by Dr Rataporn Ungpakorn
Skin tone is one of the most visible indicators of human individuality. Genetics are key, but other factors can affect skin tone, like environmental factors or, even in some cases, cosmetic procedures. Dark or light, skin tone may be altered (think Michael Jackson!).
The science behind skin tone is defined by the pigment (melanin) in the skin. Formed by pigment-producing cells called melanocytes, melanin is the substance that gives the skin its natural colour. People with darker skin have higher amounts of melanin, and those with less melanin have lighter or fairer skin tone.
Most commonly, chronic pigmentary skin problems occur as a result of increased melanin production. This creates a darker skin tone that may be blotchy and uneven. Though causes of skin pigmentation can range from auto-immune conditions to drug reactions or genetic predisposition, sun damage is probably the leading cause of most skin pigmentation problems.
Thousands of women battle skin pigmentary problems related to sun exposure and hormonal changes. One of the most common and under-diagnosed skin or facial skin discolouration problems in Asian skin is melasma. Surprisingly, many do not know its causes, and even more are unaware of how to manage it. In fact, most people may not have heard of melasma and accept the condition unknowingly.
Is It Just Dark Spots?
The irony is while melasma is largely unfamiliar and unheard of, it is a very common facial pigmentary disorder. In the US, there are about 5 to 6 million sufferers, but only about half a million patient visits a year are recorded.
To some, it may be just tiny brown patches on the cheeks, while to others it may be the ultimate facial disfigurement. With an estimated 40% prevalence in females and 20% in males, melasma largely affects women and it is more apparent among darker-skinned people, and it is a fairly common disorder in South-East Asia.
Generally identified by irregular light-brown to grey-brown patches on sun-exposed areas of the skin, like on the forehead, cheeks, upper lips, nose and chin, experts believe that the primary culprit for the initiation and exacerbation of melasma is exposure to ultraviolet (UV) light from the sun. Current statistics suggest that melasma emerges during the adolescent years due to genetic predisposition, aggravated by high exposure to strong sunlight and the damage is carried through adult life.
Melasma is also commonly associated with hormonal changes. Most women may find their melasma tends to worsen during the second and third trimester in pregnancy or when taking oral contraceptives or hormone replacement therapy.
As such, women who are on contraceptives and hormone replacement therapy may need to discuss with their gynaecologists their choice of therapy, with reduced oestrogen or progesterone concentrations most likely.
Other contributing factors to melasma include thyroid dysfunction and certain cosmetics, phototoxic drugs and anti-seizure medication.
Melasma is usually diagnosed by clinical means - a detailed personal and family history and clinical examination in most cases leads to the diagnosis. Skin biopsy is necessary only to differentiate it from other similar pigmentary disorders.
Although not life-threatening, melasma has a profound psychological, social and emotional impact on a patient. Having a reputation for being the most recalcitrant of pigmentary disorders, melasma cannot be permanently cured. It can only be controlled through protection against sunlight, and effective long-term maintenance treatment can improve quality of life.
Malaysians are exposed to many hours of UV radiation during daily activities. The majority of people are unaware of the need for protection against sunlight, both indoors and outdoors. In fact, a recent survey from the American Academy of Dermatology reports that almost 86% of Americans do not realise that they need to wear sunblock every day, all year round.
The basic, and probably the most important, way to control melasma is sun protection. Minimising sunlight exposure during everyday activities can help prevent further darkening of existing melasma as well as the formation of new patches. This is vital, as melasma is a chronic condition and can recur, especially with unprotected sun exposure, even after being successfully treated.
Simple steps such as using a sunblock that protects against both UV radiation A and B (look for UVA & UVB protection on the bottles) keeps the skin well-guarded. Other easy steps include the use of umbrellas when strolling down the street, donning a hat when out in the garden (preferably with an eight-inch wide brim) or even wearing sunglasses when out jogging – all help play a part in the control of melasma.
Another effective method in the management of melasma is using topical creams, and this still remains the first-line treatment. Topical creams are usually preferred to peeling agents, light and laser technology because the latter group carries a higher risk of making the affected skin area darker in colour.
Multiple clinical studies have proven that the most effective topical solution is a triple fixed combination cream with the concentration of hydroquinone 4%, tretinoin 0.05% and fluocinolone acetonide 0.01%. Irrespective of the severity of the condition, this treatment is found to be effective in the clearing of melasma after a compulsory and active eight-week preliminary course.
It is suitable for most women, but not during pregnancy or while breastfeeding.
Melasma can only be controlled, but not totally removed, through long-term maintenance treatment and protection against sunlight, as it tends to reappear several months later, especially after sun exposure. Women with melasma should seek advice from their skin specialist to find out how best to manage and treat their condition.
Fortunately, women do not have to be self-conscious, as there are ways to control and treat this condition and reduce it substantially. Over the years, melasma management strategies have evolved, all with a view to provide fast, safe and effective treatments for people to control and relieve their symptoms. With better management, women will never need to lose face over melasma.
More info on MELASMA here.