Melasma: keeping hyperpigmentation at bay in the summer
Consultant dermatologist Dr Sajjad Rajpar returns to the podcast this week in a special summer episode to talk about melasma, a condition that leads to darkening or brown patches developing on the skin.
Up to 85% of those affected by melasma are women – and there is a connection between this condition and female hormones.
Dr Sajjad and Dr Louise delve into what is known about this chronic complex condition, why it is crucial to protect your skin from the sun and the wide range of treatment options available, including topical treatments and laser therapy.
Dr Sajjad’s three top tips on what to do if you suspect you have melasma, plus advice on self-management:
1. Educate yourself on how to tell the difference between melasma and freckles – look at the areas of the face where it occurs. Family history and background may mean you are more susceptible.
2. Sun protection is crucial in managing melasma. This means being really disciplined with using sun screen, and seeking out a tinted version that will block visible as well as ultraviolet light.
3. There are a wide range of active skin ingredients that can help with melasma; Dr Sajjad suggests starting with azelaic acid or arbutin to treat your condition.
For more information about Dr Sajjad, visit www.midlandskin.co.uk
And you can read more about melasma and the menopause in this balance article.
Transcript
Dr Louise Newson: [00:00:09] Hello, I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of the Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause.
So today I’m delighted to introduce to you again to the studio Dr Sajjad Rajpar, who hopefully some of you have heard before, and I don’t think this is going to be the last podcast I do with him because there’s so much to talk about when it comes to skin and Saj is my go to dermatologist, not just for me but for my patients as well, because he’s so knowledgeable and so calm. And actually I just love the way he explains things to people as well. So welcome back today, Saj. Thanks for joining me.
Dr Rajpar: [00:01:15] Thanks, Louise. It’s always a pleasure to come on.
Dr Newson: [00:01:18] So, yeah, it’s interesting. So I wanted to do dermatology for a little while. I wanted to do oncology initially, the study of cancer. And I’m quite geeky. I like pathology, I like disease. I don’t like disease – that’s silly – I like learning about diseases, how they work, what happens, what goes wrong with the body, you know, right down to a molecular basis. And when I did an oncology job, I just decided I didn’t want to do it because it was all about trials. It was all about putting people into chemotherapy trials. And somehow the sort of sensitivity of the patient was lost, the were on a bit of a conveyor belt. And I really like being very personal with my patients and working out the best consultation for them at the best time for them and sharing all the decisions. So I decided it wasn’t for me, but I was already on a medical rotation, so I did lots of other jobs. And then I was in Manchester and Manchester’s got a really good dermatology unit and I thought, well, I’ve done my BSc, I did a pathology degree and I did that in looking at systemic sclerosis skin. So I was looking at type four collagen in systemic sclerosis skin, the base membrane. And, you know, it’s very interesting when you look at how active the skin is and all these cells and all the activity in the skin. And I thought, wow, actually this is really interesting. And then I’m not very good with names. And I couldn’t remember all the Latin, all these very long names that you give for all these conditions. And I thought, I’m going to be so worried about the diagnosis and the names that I’ll forget about the patients. And it just didn’t quite feel right. And I did, actually it was the only job I’d never got, was I applied for a job as a registrar in dermatology on a rotation, and I didn’t get it because I didn’t have enough experience. And actually it was probably the best thing that happened to me because I would have been a really bad dermatologist.
Dr Rajpar: [00:03:09] So I think you would have been an absolutely excellent dermatologist, Louise, and I’ve just learnt something new about you, so I can send all my collagen questions to you, because I had absolutely no idea that your intercalation was in pathology, in systemic sclerosis. That’s absolutely fascinating.
Dr Newson: [00:03:27] Yeah, it’s interesting how life does these circles. But with the menopause and perimenopause, skin really, really changes. And I hadn’t realised how much skin changed until I started to see the volume of women I did. And it really varies. Dry, itchy skin are probably the commonest skin complaints. But people notice the texture of their skin changes, not just on their face, but on their body as well. They often become more sensitive to products, but also associated with skin is hair. Hair changes can be really common and people find their hair becomes more straW -like, drier, more brittle, doesn’t grow the same way, it can fall out. All these things really can affect us. And that’s without thinking about the other symptoms. And I know when I first saw some ladies who had skin problems that I couldn’t even with my dermatological knowledge, couldn’t manage and treat them, I wanted to find a good dermatologist. And no disrespect to dermatologists, it’s quite hard to find people who are general dermatologists. Often they specialise or now there’s a huge move to cosmetic dermatology, which has a role, but actually for problems and diseases, I needed a really good dermatologist and I can’t remember how we connected. I think you’d written, you’d seen one of my patients and you’d written this amazing letter and I think I just reached out to you, didn’t I? Is that how it happened?
Dr Rajpar: [00:04:53] Yeah, it was through a patient, actually, who I think attended for hair loss and went back to you. And I think we shared her care for a number of months and then, yeah, you made contact. And it was really great because at that stage I myself hadn’t connected the dots between the oestrogen deficiency and all the things I was seeing in my clinic. It’s something that we were not trained in dermatology specialist training You’ve mentioned many times it’s something that you’ve never been trained in, in your medical training. It’s something you’ve had to work out yourself and get specialist training and knowledge of. And it was only once we had connected and we started looking at other patients that you had referred and you’re like, actually there is a lot of similarity and homology here and, really, the skin is an important organ that is affected during the perimenopause and menopause.
Dr Newson: [00:05:53] And there’s so much we don’t know. We still don’t know enough about it. But there’s lots of very obvious things that we do know that are often missed, like there are a lot in menopause. But one of the conditions we want to talk to about today was something called melasma, which is I can remember, that’s not too long a Latin name, but it must derive from something. So can you explain what the word is and what it means Saj.
Dr Newson: [00:07:01] And we see it quite a lot in different stages of a woman’s life actually. And it seems to be more with I mean, this is a generalisation, of course people can get it without knowing any triggers, but people on the contraceptive pill can get it, people who are pregnant can get it, sometimes people on HRT. So even if I didn’t know anything about it, I might presume that there might be a hormonal component to it. Is that right?
Dr Rajpar: [00:07:26] Yeah, There’s definitely a relationship between hormones and melasma. So there are sort of three main causes of melasma, genetics, sun and hormones, and we really don’t understand the exact hormonal relationship. Is it oestrogen, is it progesterone? You know, what levels are required? Does it come about anyway? Because as I mentioned, men get it who don’t have elevated levels of estrogen or any progesterone. So we don’t really know what the exact mechanism that hormones affect the skin are, but as you say, some people will be triggered from taking the pill. Some people will find that they get pigmentation during pregnancy and sometimes that’s called the mask of pregnancy. And some people will find that if they commence HRT that they develop melasma pigmentation.
Dr Newson: [00:08:20] Yes. And obviously with the oral contraceptive, the type of hormone is quite different because it’s all synthetic, as you know. But actually the dose is higher than with HRT as well. We don’t know whether it’s a dose dependent thing. If it is related to hormones, then is it going to be worse with higher doses? So, for example, in pregnancy, people can have very high levels of estrogen in their blood, can’t they?
Dr Rajpar: [00:08:46] Yeah, I certainly think that it is to a degree a dose relationship because the majority of people that I see where an identifiable trigger is found it is women on the contraceptive pill and for women who have recently been pregnant. So I think those extreme high levels are much, much more likely to cause melasma because that’s the group that present themselves with melasma to me than people with what we would call physiological levels of estrogen. So they’re not terribly high, they’re just in the normal range just ticking over and what they should be for the normal physiological functioning of the body. So I think we do need to make a distinction between those elevated states. And as you say, the combined contraceptive pill is quite a high dose, isn’t it of estrogen all dropped into the body all at once.
Dr Newson: [00:09:40] And someone said to me ages ago that it can occur in skin that is sun damaged so you’re less likely to get melasma if you’ve always use good quality sunblock or stayed out of the sun. Is that right?
Dr Rajpar: [00:09:53] I think there is some plausibility to that. Melasma is not just a skin discolouration problem. It’s a really complex, chronic, inflammatory, serious skin condition. And I say serious because it really affects the quality of life of the people who develop melasma and it can really, really cause impairment in social comfort because of the appearance of it. And it is really important. And when I see patients with melasma I try and explain that, you know, it is not like a tan, it’s not like your skin is going a bit dark. If you just stay out of the sun, you’re fine, it’ll just fade off. It is this thing that keeps wanting to come back and persist.And when you look down the microscope, if you take a biopsy from melasma you do see more solar elasticity, more sun damage in that area than you do in adjacent skin that doesn’t have melasma. So there’s something about the collagen producing cells which are called fibroblasts that is not absolutely right in those areas. You also see more inflammation, you see more white cells, you see more mast cells, which is the type of white cell. You see slightly bigger pigment producing cells and you see more blood vessels. There are actually more cytokines, or proteins that are produced that produce new blood vessels in the area. So when you look closely at Melasma, it’s not just a brown colouration. There’s often some degree of redness as well. So it is absolutely fair to say that sunlight can aggravate melasma. Some people say that melasma is a form of sun damage on the skin and it is possible that if somebody never got any sun exposure ever, that they may never get melasma. It is possible. It’s plausible. We haven’t proven that. But it is a complex condition and sun is just one factor.
Dr Newson: [00:11:57] Yeah, so it’s a bit different to just freckles, isn’t it? Because some people think, oh, it’s just large freckles but it’s not.
Dr Rajpar: [00:12:04] It’s absolutely not large freckles. It’s a completely different entity of its own. And as I say, when you look at the skin of it, there are multiple components. There’s an issue with the blood vessels, there’s new blood vessels being formed in that area. There’s an issue with inflammation and there’s an issue with pigment production. And we don’t really know how the blood vessel cells, the pigment producing cells and the collagen producing cells all talk to each other. But the way they are talking to each other is slightly dysfunctional and it’s causing this appearance to form.
Dr Rajpar: [00:12:48] So most often it’s possible to make that diagnosis by examining somebody’s skin and often they will have brown or dark brown or grey patches of pigmentation, often on the cheeks, on the central and upper outer cheeks, on the central forehead and on the upper lip. And often they will say it’s a lot worse when they’ve been in the sun. So the majority of my melasma consultations will be from April till July. So when the sun first comes out, the melasma is often aggravated. So it’s not caused by the sun, it’s aggravated in this instance, it’s being revealed, it’s being worsened and people will then realise that something’s not quite right and want an assessment. Now, not all melasma is in that typical distribution. Sometimes melasma can be different, sometimes it can be on the outer parts of the face, it can be on the outer temples and the outside parts of the cheek. And that is actually not that uncommon and very uncommonly that you can actually even get melasma on the body. I’ve seen it on the forearms, I’ve seen it on the neck. So it’s not just that typical distribution. But it is really important for a doctor to take a history. And we both have agreed previously that much of a diagnosis is ascertained from just detailed history taking, just understanding what’s going on. And you know, about 60% of people with melasma will have a relative that has melasma as well. So there’s a massive genetic component and there’s a racial diversity with melasma that you are much more likely to develop melasma, if you are of a darker skin colour. So we see melasma much more commonly in those of an Asian or Afro-Caribbean descent.
Dr Newson: [00:14:36] Interesting. And is there any reason why?
Dr Rajpar: [00:14:38] It may be related to sun exposure? But we don’t know. There’s definitely a discrete genetic component that is bringing about more melasma in these racial groups.
Dr Newson: [00:14:50] So once it’s been diagnosed, it sounds like once people have melasma, obviously we should use sunblock, but that’s not going to stop it being there, is it? So what can we do to treat it?
Dr Rajpar: [00:15:02] Yeah, sunblock is really crucial and for some people, sunblock may be enough. So meticulous sun protection, and I do mean meticulous, sun protection. This is one of those instances where 30 seconds of UV exposure can undo six months of fantastic skin care.
Dr Newson: [00:15:21] 30 seconds!
Dr Rajpar: [00:15:23] 30 seconds. UV is extremely intense at stimulating melasma and pigment production. So you want to do your very best at using a broad spectrum sunblock. And it is now being understood that it’s not just ultraviolet light. That a number of melasma patients may also be sensitive to visible light, and often it’s the sort of blue end of the spectrum. So my advice now to my patients with melasma is to use a broad spectrum sunblock that is tinted – tinted sunblocks have got iron oxide in them and iron oxide blocks visible light as well. So if you can block that spectrum, you’re better off.
Dr Newson: [00:16:11] Oh, very clever. I didn’t know that at all. So that makes sense. And then what other treatments are available?
Dr Rajpar: [00:16:18] Yeah. So then we go down the sort of products that reduce melanin production, and the most common prescription product is something called hydroquinone. And hydroquinone is mixed together with a retinoid-like tretinoin and a steroid. And that’s called the triple formula in the world of dermatology, or Kligman’s formula. And that’s a prescription product that dermatologists will frequently use for controlling melasma and it’s used for about 12 to 16 weeks. It’s not something that can be used for the long term because it can cause side effects, it can actually cause paradoxical pigmentation that can be permanent. So it’s not something that somebody can be on life long. It is highly effective. And 60 to 70% of people will say, you know what, I think this is really working and I’m really happy with it. But what we know is when they stop, the pigment is likely to want to come back. So what we then do is switch over to something for maintenance. And there are a number of maintenance products out there. My favourite is something called azelaic acid, and we’ve spoken about azelaic acid in the balance app in the context of acne because it’s got acne properties, we’ve even spoken about it in the context of rosacea because it can help control rosacea, but this particular product can also help control melasma and it’s something that you can buy over the counter. So azelaic acid is a fantastic maintenance treatment for melasma. Another new kid on the block is called cysteamine and this is another molecule that helps block the production of melanin and it’s also an antioxidant. And we think that there is oxidative damage That means that sun and genetic factors are causing these oxygen species in the skin that are just damaging the pigment producing cells and causing them to create more pigment. And so cysteamine has got these antioxidant properties as well, and that’s something that somebody would apply on their skin for five to 15 minutes a day and then they would wash it off and they can use that as a maintenance treatment as well. And there’s also a heap of botanical products, products that are derived from plants that can have anti-pigmentary effects, things like soy, liquorice. Arbutin is probably one of the most common ingredients found in skincare regimes. Coffee berry, mulberry, rumex, niacinamide, the list goes on. There’s millions and millions and it can actually get quite confusing, but those can also be tried. But in my experience, they’re not as effective or as powerful as your hydroquinone, your azelaic acid and your cystaemine. And I would say that’s my triad, that’s my top three when it comes to topical skin care.
Dr Newson: [00:19:10] So certainly it’s worth seeing a specialist to find the best treatment for you. And it might be trying more than one treatment from the sounds of it as well.
Dr Rajpar: [00:19:19] Yeah, absolutely. It can be that you need to combine treatments because melasma can be complicated, resistant and difficult for some people. And if the skin lightening treatments are not effective on their own, then it is possible to add in in-clinic treatments as well. And one of the treatments that we do is a laser toning treatment, which is where we use laser in very low energy to try and help break down that pigment. Again, it’s not a cure. It’s to help control the pigmentation and to help reduce the intensity of pigmentation. And often we run it concurrently with mixtures of topical treatments. One of the new things that’s being used a lot now for melasma is an oral medication that you’ll probably be familiar with called tranexamic acid. And tranexamic acid is used for the control of heavy periods, but in lower doses it can help reduce melasma. And what it does is it stops this substance called plasminogen from turning into plasmin in the bloodstream, and plasmin seems to be aggravating inflammation in the skin. It causes prostaglandins to be released and other chemicals like VEGF 1 that stimulates blood vessels and pigmentation. So melasma is a complex chronic inflammatory disorder that we’re just learning all these different mechanisms, this interplaying mechanisms of. But I have actually found that tranexamic acid can be really helpful as part of a multi-pronged approach. One of the things with tranexamic acid is that you can’t really have it if you’re prone to DVT, if you’re a smoker, if you’ve got a history of ischaemic heart disease. So you do need to talk to the doctor about whether it’s suitable or not. The biggest point to mention is its off label. That means it’s an unlicensed indication. So that means there are no big studies and you’re familiar with, we are challenged with doing the best for our patients and managing these unlicensed medications.
Dr Newson: [00:21:29] And it’s interesting, isn’t it, when we talk about using things in an off-label way. So, the products have been around for many years. I mean, tranexamic acid has been around for donkey’s years. But this is using it for a different indication. So it’s still licensed. So that’s why you’re saying off label. But actually, a lot of what we prescribe in medicine is off label. And some studies have shown it’s about 10 to 20% of medications that GPs prescribe. In paediatrics for children it’s a lot higher because they don’t have the license, and they probably will never get it because to get the license you have to do big studies with the indication, usually randomised control studies, that’s a lot of money, lots of time, something like tranexamic acid is as cheap as chips and not going to be able to have the funding to do the study, but we know it’s safe. So prescribing off-license doesn’t mean it’s not safe. And with a lot of these things, it’s worth trying if we know that it’s a safe product or medication to use. So you mentioned lasers as well. Does that hurt having lasers on your face around your melasma?
Dr Rajpar: [00:22:34] That’s a good question. It sounds like it should hurt, but because it’s low energy and this is the thing with melasma is you do not want to put too much heat on the skin. You do not want to put too much energy in the skin because it’s one of those conditions that can improve and then rebound very quickly because of that extra heat energy. So, it’s actually a reasonably comfortable treatment that’s done every couple of weeks because it’s low energy and it’s diffusely given over the face. One other type of laser that we use also for melasma is something called fractional laser. That’s where, and this does sound a little bit scary, where we drill very tiny microscopic holes, again with low energy, through the skin with the laser to stimulate the fibroblasts. And when we stimulate the fibroblasts, it seems like the melasma can improve as well. And this is bringing about this really unknown connection between the fibroblasts, the blood vessels and the melanocytes, the melanin producing cells. So even sort of stimulating those fibroblasts that have gone quiet, they’re not producing good quality collagen just in those areas, can actually improve melasma.
Dr Newson: [00:23:48] So there’s different types of laser treatment.
Dr Rajpar: [00:23:50] Yeah, there are two main laser types of treatments that we would use. One is called laser toning, which is a low energy laser to help just gently break away the pigment. And then there’s fractional resurfacing, which is also done at low energies to stimulate the collagen machinery in the skin, which can then, as a bystander effect, also improve melasma. Often lasers are done alongside optimising topical treatments, optimising sun protection and thinking about things like tranexamic acid. So it’s one cog in the wheel, you would never just only do laser treatment. It’s really best done as part of a proper treatment plan.
Dr Newson: [00:24:35] And I think that’s really important to state or really overstate as well, because there’s a lot of laser sort of cosmetic treatments that are available. There’s all sorts of things. Laser is just a word, but there are so many different types and done for different indications, aren’t there? So you do have to be really careful and not just think, oh, I’ve had a laser treatment and it hasn’t worked. Therefore nothing is going to work for my melasma.
Dr Rajpar: [00:25:01] I think what has happened with lasers is it’s become synonymous with high street beauty and there is definitely a role for lasers on the high street in the beauty sector. So for things like laser hair removal, which are very protocol driven, I think that’s a very safe and reliable way of delivering that treatment. I think when you’re talking about a complex medical condition so melasma, rosacea, acne, these are complex medical inflammatory conditions that need a proper medical assessment. They often need multiple angles of treatment. I think that’s when lasers need to be taken outside the context of the high street and into the medical practice.
Dr Newson: [00:25:56] Yeah, really, really important to state because like most of the things that we talk about, it’s essential that you have the right expert helping who’s got the right experience. And, you know, and I think as patients, you should be able to challenge the person that you see. And I don’t mind if anyone says to me, you know, how many people have you seen similar to me? And I think that’s the same, isn’t it? When you see a skin specialist, a dermatologist, it is definitely worth asking because a lot of people will improve with first line, second line treatments. But if they don’t, you know, I know you see a lot of people and I do, who feel that they’ve come to the end of the road, that there’s nothing else. And so actually, if you see someone who is very experienced, it is always worth saying, you know, how many cases of melasma how many difficult cases have you seen and how experience are you using laser or do you have different types of laser? I don’t think that’s rude. I think it’s just really important to know that you’re seeing the right person, isn’t it?
Dr Rajpar: [00:26:52] Oh, absolutely. I think it’s really important to also know that there are options out there because people can get dismayed. And, you know, when I see patients who’ve struggled sometimes for decades with melasma and have really curtailed their social existence because of this, and it can really, really be devastating to hear somebody’s story. And while we may not have a perfect cure, there is no cure, which is fair to say. It is really worth just exploring treatment options and evaluating whether it would be something that could be considered.
Dr Newson: [00:27:34] Yeah, I always find with patients it’s really nice for them to know that if this doesn’t work, there is something else and that’s usually a medicine. There’s always something else to try. And actually some of these things can take quite a long time to try. So patience is a virtue for our patients, but also just having time to discuss and make sure that each patient is comfortable with every treatment that’s being offered and knows the pros and cons. So a very common condition that is really undertreated like a lot of dermatological conditions actually. So before I finish, Saj, three take home tips as you know, so three things. So if people think they might just have some freckles or they’ve got some pigmentation on their skin, they’ve got no idea whether it’s melasma. So three things that you think they should do to try and help them get the diagnosis and just on the road for getting some proper treatment.
Dr Rajpar: [00:28:28] Okay. So I think you can differentiate freckles from melasma by the look of it. If you’ve got these large areas that blend into each other on the upper outer cheeks and especially the upper lip, you don’t usually see freckles on the upper lip then think more melasma. If you’ve got a family history or you’ve got Mediterranean or Asian ancestry, you’re more at risk of melasma. So think of it. And then the second thing would be if you think you might have melasma, you may well be able to control it with meticulous sun protection. And as I said before, meticulous in this condition really, really is meticulous and try and use a product that also blocks the visible spectrum of light. So that’s something that’s tinted. Try and get something that matches your skin tone and looks natural. There are some brilliant sunscreens out there now that are tinted, but you will get that extra layer of protection. And then number three, there are skincare active ingredients that you can buy and obtain yourself without needing to see a doctor that you could try. And I think I would go down the as the azelaic acid route probably, arbutin is another one. You could give those a go. So those are your sort of three self-help tips. And I think, you know, a number of people will actually find they’re able to manage their skin with that.
Dr Newson: [00:30:03] So, as usual, thank you so much for imparting some of your superb knowledge and experience and look forward to you coming back onto the podcast. There’s a whole plethora of topics I want to talk about, and if any of you want any specific topics for Saj to talk about, then just put them in the review section of the podcast and we’ll pick them up. So thank you ever so much again for your time today.
Dr Rajpar: [00:30:27] Such thanks, Louise. It’s always a pleasure.
Dr Newson: [00:30:32] For more information about the perimenopause and menopause, please visit my website www.balance-menopause.com. Or you can download the free balance app, which is available to download from the App Store or from Google Play.
END.
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