PEEL IT: TREATING MELASMA WITH ACIDS

Although a benign skin condition, melasma can have serious impact on the self-esteem and confidence of a patient. Dr Rinky Kapoor, Consultant Dermatologist, Cosmetic Dermatologist, The Esthetic Clinics explains how right skincare can help overcome this skin condition.

A symmetrical acquired hypermelanosis known as melasma is characterised by well-defined, light-to-dark brown patches and macules on sun-exposed areas. While the precise etiology of the pigmentation is unknown, some etiological reasons such as genetic influences, ultraviolet (UV) radiation, pregnancy, hormone therapy, cosmetics, phototoxic pharmaceuticals and antiseizure medications, are proposed. Despite melasma being a benign skin condition, some individuals find it to be a bothersome issue and seek treatment, only to be disappointed in most cases. Given the complexity of the pigment, a combination strategy is needed to avoid regression. The Esthetic Clinics in Mumbai has developed a specialised combination therapy to treat such facial pigmentation.

Case report

A 48-year-old woman with obesity suffered from pigmentation on her face for more than 15 years. She informed us that during her second pregnancy, the pigmentation across her cheekbones had become apparent, and it had gradually spread over her forehead, nose and the area above the upper lips. She confirmed that her mother had similar pigmentation, but to a much milder extent for a long time. The patient was on oral contraceptive pills earlier and her history of hypothyroidism dated back roughly 15 years. However, her hypothyroidism was now in control with regular medication. She was now menopausal since the past three years. According to the patient, she was not diagnosed with polycystic ovarian syndrome. She also did not have long hours of sun exposure.

The patient underwent a number of therapies, including topical hydroquinone application, several peels, Q switched laser therapy and sun protection, all of which proved ineffective and unsatisfactory for the patient. It was challenging to pinpoint the precise cause of the pigmentation because of its ambiguous and complex nature. The condition had immensely affected the patient’s self-esteem and confidence, and she had come to The Esthetic clinics as her last resort before she would decide to give up.

At Esthetic Clinics, we approach pigmentation by understanding its complexity. We suggested the patient our combination therapy for melasma, which has shown to have noticeably improved outcomes.

This process requires two sessions, with the first session involving applying an alpha hydroxyl acid peel for few minutes to the face and neck, after degreasing the face. The first treatment session serves as a skin preparatory treatment for the second peel.

The second session is performed two weeks after the first session. Here, the doctor applied a combination peeling agent that involved azelaic acid, kojic acid, arbutine, phytic acid, ascorbic acid on the patient’s face, which is left on for 10 hours before washing it off. The patients are fully warned during this session that visible peeling of the skin, erthyema, extreme dryness, and facial irritation may happen for up to a week. After the procedure, we advised the patient to moisturise the area thrice a day with a thick moisturiser. Patients are instructed to start using a regular maintainance cream (kojic acid, phytic acid, ascorbic acid, retinyl palmitate) that works as a moderate peeling agent every night, a week after the treatment, followed by a moisturiser if the skin feels very dry. Patients are given oral antioxidants, tranexamic acid, and daily topical application of sunscreen (SPF 50) as an adjuvant. Regression of the pigment to a significant extent is achieved by this peel and medication combination.

Conclusion

Although melasma does not lead to mortality, the cosmetic and psychological impact it has on the lives, is immense. It can be challenging to come up with a treatment that actually shows good results. The recommended current guidelines suggest sunscreens, hydroquinone, tretinoin, and fluocinolone and their various combinations as the first-line treatments. Lasers and chemical peels are the procedures that are also suggested. However, these can produce unpredictable outcomes and have side effects include scars, postinflammatory hyperpigmentation, and skin hypersensitivity, in addition to unsatisfactory improvement in pigmentation.

In our experience, The Esthetic Clinics has formed a combination treatment protocol that has shown fantastic outcomes in more than 500 cases of melasma. The disadvantages are the downtime of one to two weeks after the second session, and the cost of the sessions to the patient is higher than simple peels or laser sessions. The advantages of the protocol being, two sessions only needed for the treatment, very simple to perform, economical for patients as well as the dermatologist in terms of time required and investment needed, practically devoid of side effects and we have noted the best results in melasma control with this therapy than with any other currently available modalities of therapy. The two peeling sessions may be repeated again after a year if required.