ALL ABOUT HYPERPIGMENTATION!

Shriyal Sethumadhavan delves in to the consultation process and treatment for patients conditioned to hyperpigmentation.

H yperpigmentation refers to darkening of affected area when compared with the adjacent surrounding areas due to excess melanin pigment that gives skin its colour. This can be seen in various forms like freckles, lentigines, melasma, post-inflammatory hyperpigmentation, and lichen planus pigmentosus, to name a few. Out of this, melasma is known for its stubborn pigmentation. Melasma is most commonly associated with hormonal fluctuations which is why it commonly seen during pregnancy. Melasma may also occur when you start hormonal contraception including birth control pills or when you take hormone replacement therapy. Common triggers are radiation (ultraviolet, visible light, or infrared) genetics, hypothyroidism and use of certain drugs.

When a patient comes in for consultation, least would they always know for sure that what they are conditioned to is hyperpigmentation. Here a dermatologist has a crucial role to play in consulting and planning the right treatment approach.

THE CONSULTATION

Every skin is different from the other, and therefore a detailed history and a close-up look to the skin by specialised devices like a wood’s lamp or dermatoscope is done, says Dr Sonia Tekchandani, Consultant Dermatologist, Tender Skin International. “These devices help us to evaluate the depth of pigments, diagnosis, prescription and number of in-clinic treatment sessions.”

For Dr Ami Shah, Dermatologist, Shah Skin and Cosmetic Laser Clinic, a patient who comes with melasma is counselled depending on the severity, the number of how deep the melasma is and for how long has he/she been conditioned to it. “Generally, we tell the patient that this is a hormonal condition and stays for a long time. While this condition cannot be controlled directly, modern treatments and options with lasers and other procedures at the clinic lead to a satisfactory outcome.” But since the basic nature of this condition is to reoccur, one needs to be careful and ensure absolute maintenance in terms of using sunscreens, and following-up with the doctors on a regular basis.

TREATMENT AND DEVICES

After the first visit, generally the patient is put on certain medicines that are available for melasma and oral anti-oxidants, oral tranexamic acid, and topical creams that contain depigmenting agents, says Dr Shah. The clinical response for this is observed for a few weeks, and the patient is also counselled about the treatment options. Dr Shah mentions her favourite treatment as intense

pulse light (IPL) to resolve the vascularity and hyperpigmentation associated with melasma, along with glycolic peel. “When I use Q-switch laser, especially the fractional mode, it works well on melasma,” she adds. “Nowadays, we have got excellent difference in the results when we use growth factor concentrate wherein a patient’s blood is extracted and a superior form of PRP, which is GFC, is extracted from the patient’s blood and delivered to the patient’s skin suffering from melasma by either using a dermapen or an insulin syringe.” She also mentions that these have definitely given promising results when used in combination with IPL, especially in patients who don’t respond to the medical line of treatment.

In most cases of melasma, combination therapy is advised, says Dr Tekchandani. “The most common standard combination therapy comprises of hydroquinone with retinoid that increases skin cell turnover and a steroid that decreases skin inflammation. Oral medications, including tranexamic acid, are usually considered in severe melasma.” She adds that if melasma does not respond to conventional therapy or if the patient is looking for faster results, in-clinic treatments should be added to their treatment regimen. Also, adding procedures such as chemical peels and lasers are beneficial. Speaking of chemical peels, she adds, “Glycolic acid, alpha-hydroxy acids, salicylic acid, retinol and no down time TCA helps to remove the superficial layer of the skin that contains excess pigment thus lightening the existing pigments.” The doctor adds, “Laser therapies can destroy pigment cells located in deeper layers. Lasers such as Pico, fractional, IPL, Q-switch are helpful. Some newer treatments like non-ablative fractional lasers, GFC, PRP and laser toning are also gaining a lot of attention due to minimal downtime and better results.”

However, in the case of melasma there is considerable risk of relapse post-treatment. Therefore, Dr Tekchandani suggests that after achieving improvement, daily usage of sunscreen and maintenance therapy is a must along with avoiding other triggers such as hormonal medications when possible. Skin lighteners other than hydroquinone like kojic, alpha arbutin, niacinamide, liquorice, undecylenoyl phenylalanine, n-butylresorcinol, various antioxidants and botanicals can be used.

SUCCESS STORY

Sharing one of her successful case studies, Dr Tekchandani, says: A patient aged 57 came to us with postmenopausal melasma. Vitamin C serum followed by sunscreen was prescribed in the morning and a combination of alpha arbutin, niacinamide and undecylnoyl phenylalanine at night. Combination approach of peels and laser was opted for her in the clinic treatments. A series of glycolic peel, retinol peel, no down time TCA peel and laser toning was advised. After three months she was suggested vitamin C serum, sunscreen and niacinamide as maintenance therapy.

Going by experience, there are many patients who have been responding to Dr Shah’s treatments. Some show a good response, a fast one, long-term; and some are stuck for a long time but still continue because there is a difference – it may not be 100 per cent but there is a partial improvement, which gives them satisfaction. She shares a case, “One patient, aged 48, came to us with a long, chronic melasma. She was fair-skinned with dark brown patches on the skin. We put her on oral tranexamic acid and some topical depigmenting creams with sunscreens. I also advised her for some sessions of IPL. After the first session, when she came for her next visit, it was almost 50 per cent clear, and the next time she visited, it was all clear. Her melasma being cleared in two or three sessions was satisfying. Such interesting cases do happen. She still continues with her maintenance treatment once in four months.

Do you have an interesting approach to treating hyperpigmentation / melasma or an interesting case study to share, do write in to shriyal.s@ideas-exchange.in