Melasma frequent in skin of colour
Sun protection, including blocking visible light, remains vital, and changes may be coming to the treatment armamentarium (1,470 words, 7 minutes 20 seconds)
Sun protection remains key in managing melasma in darker skin types, including by blocking visible light, said Dr. Jason Rivers, speaking at the 7th annual Skin Spectrum Summit on Nov. 4. In addition to sun protection, Dr. Rivers detailed some emerging changes in therapeutic options for the pigmentary condition.
Dr. Rivers is a clinical professor of dermatology at the University of British Columbia and the medical director at Pacific Derm in Vancouver.
People with skin of colour are at elevated risk of developing melasma, he noted.
“[Melasma] prevalence has been reported to be as high as one per cent of the general population, and nine to 50 per cent in higher-risk groups including pregnant women, people of colour and those with a lot of ultraviolet exposure,” said Dr. Rivers. “This is probably still an underrepresentation, not including those who don't go to physicians or who aren't reported in clinical trials.”
Dr. Rivers said that while melasma can be treated, it is important to inform patients that there is no cure. As a result, sun protection year-round is crucial to prevent the development of pigment changes. Sunscreen must be a high SPF value, at least 30, and must be broad-spectrum, covering both UVA and UVB, he said.
“For people of colour, especially, visible light-blocking agents should be considered,” Dr. Rivers said. Dense, opaque sun protection formulations containing zinc and titanium will effectively block visible light, and the addition of iron oxide is also important in patients with skin of colour.
Dr. Rivers also noted some shifts occurring in the melasma treatment landscape:
Hydroquinone remains a gold standard of treatment, and Dr. Rivers said that it continues to be his top choice for starting melasma treatment, often in combination with tretinoin. However, he noted some nations have placed additional restrictions on hydroquinone due to its nature as a benzene derivative.
Oral tranexamic acid has been a ‘gamechanger’ in melasma treatment since its introduction for this indication, Dr. Rivers said. However, he said it is crucial to ensure patients do not have a history of pulmonary embolisms, deep vein thromboses or coagulation issues. In his practice Dr. Rivers treats patients with this agent through the summer months and has them stop treatment during the winter when sunlight exposure is lower. He notes patients can experience some recurrence of melasma as they come off the medication for the winter, but the return of pigment change is not sudden.
While melasma recurrence can be as high as 50% with laser and other energy-based treatments, picosecond lasers are being considered as a treatment option for melasma that may reduce pigmentation and minimize the risk of post-inflammatory hyperpigmentation.
Bottom Line: There is no cure for melasma, but it can be controlled by reducing exposure to both ultraviolet light and visible light through proper sunscreens that will cover both the UV and visible light spectrum. Sunscreens need to be used daily year-round because even skipping one or two days can cause a recurrence of their pigmentation. Tranexamic acid offers a new treatment if there are no contraindications. Finally, lasers may play a role for select individuals.
From the literature on melasma in skin of colour
Clinical evaluation of safety and efficacy of a 670-nm picosecond laser for treatment of benign pigmented lesions in Asians
This study evaluated the efficacy and safety of a novel 670 nm picosecond laser for treating benign pigmented lesions in 22 subjects with Fitzpatrick skin types III and IV. Of those, 15 had solar lentigines and seven had acquired bilateral nevus of Ota-like macules (ABNOMs). Each individual received a single treatment with the laser.
All of the subjects with lentigines had complete clearance (95%-100%) of lesions during three-month follow-up. Among those with ABNOMs, 75% noted fair lightning (25%-49%) of lesions. Mild hypopigmentation and hyperpigmentation were observed in 9% and 14% of the subjects, respectively, which resolved within three months after the treatment.
Postinflammatory and rebound hyperpigmentation as a complication after treatment efficacy of telangiectatic melasma with 585 nanometers Q-switched Nd: YAG laser and 4% hydroquinone cream in skin phototypes III-V
In this split-face study of 21 Thai female patients—Fitzpatrick skin types III-V—with telangiectatic melasma, each patient received five treatments with a 585 nm Q-switched Nd: YAG laser to half of their face at two-week intervals. In addition to the laser treatment, each patient was directed to apply 4% hydroquinone cream to both sides of their face daily at night for 10 weeks and to use a broad-spectrum sunscreen for the study period.
Investigators found more significant improvement in the sides treated with the laser. However, nearly one in five patients developed postinflammatory hyperpigmentation on the laser-treated side, especially among those with skin phototypes IV and V. Rebound hyperpigmentation was also seen on the laser-treated sides.
The study authors conclude that this laser treatment should be cautiously applied in individuals with darker skin types.
Prospective study of growth factor concentrate therapy for treatment of melasma
This study examined the efficacy of a therapeutic approach involving the injection of autologous growth factors derived from a patient’s platelets as a treatment for melasma.
Some 30 subjects with Fitzpatrick skin types IV-V were included. Each patient received three sessions of the new treatment as monotherapy at one-month intervals.
All participants had significant improvements in modified Melasma Area and Severity Index (mMASI) scores at all visits compared to baseline. Roughly two-thirds of those with severe melasma experienced improvement to the mild or moderate categories, and a significant improvement in mean mMASI score was seen in those who had mild to moderate disease at baseline. Some 88.5% of subjects reported aesthetic improvement. Overall side-effects were mild.
Chinese women with melasma exhibit a low minimal erythema dose to both UVA and UVB
This study compared minimal erythema dose to ultraviolet A (MED-UVA) and B (MED-UVB) between female patients with melasma and healthy controls. The researchers also examined the relationship between these MED values and melasma severity.
The investigators found that compared to the control group the women with melasma had significantly lower MED-UVA and MED-UVB values. As well, they found that Melasma Area and Severity Index scores were negatively correlated with both MED values.
VIDEO: Doctor V - Tranexamic acid vs alpha arbutin for pigmentation | Skin of colour | Brown or Black skin
At the intersection of skin and society
The Canadian Journalism Foundation (CJF), which supports and facilitates excellence in journalism, is launching a new Black Journalism Fellowship in partnership with the Investigative Journalism Bureau (IJB) at the University of Toronto’s Dalla Lana School of Public Health.
According to a press release, this new award is modelled on the successful Indigenous Journalism Fellowships program, a collaboration between the CJF and the Canadian Broadcasting Corporation (CBC) that has helped foster the careers of 13 Indigenous journalists since 2014.
The CJF-IJB Black Investigative Journalism Fellowship will connect a Black journalist with one to 10 years of experience to the IJB to work for six months on an ongoing investigative journalism project. This program joins three other CJF fellowships that support up-and-coming Black journalists—the CJF-CBC/Radio-Canada Black Journalism Fellowship, the CJF-CBC/Radio-Canada Black Women’s Journalism Fellowship and the CJF-CTV News Black Journalism Fellowship.
“We are thrilled to launch a fourth fellowship opportunity in partnership with the Investigative Journalism Bureau to develop emerging investigative talent and make space for a range of voices and experiences from Canada’s diverse communities,” said Natalie Turvey, CJF President and Executive Director, in the release. “This opportunity highlights the CJF’s ongoing commitment to the development of a generation of Black media leaders and content creators across the industry.”
According to the release, each fellow will receive a full-time stipend and will write, produce or contribute to an article or series of articles during their fellowship, which will be considered for publication or broadcast by the media partner organizations.
“Approaching investigative stories from a variety of perspectives always makes the reporting richer and more resonant,” said IJB founder and director Robert Cribb, in the release. “It is an honour for IJB to be part of this fellowship program that will help us unearth new truths while fostering the next generation of investigative journalists.”
Going forward, the CJF plans to expand its Black Journalism Fellowship program with other major media outlets across the country.
Applications for the new fellowship will be accepted until Jan. 14, 2022, and can be submitted online at this link. https://cjf-fjc.ca/awards/cjf-black-journalism-fellowship-program
This week
Dec. 20 is International Human Solidarity Day
Something to think about in the week ahead…
Happy Holidays
Skin Spectrum Weekly will be taking a break for the holiday season and will return on Jan. 10, 2022, with an article on pediatric dermatology in skin of colour, based on a presentation by Dr. Danielle Marcoux.
We would like to wish all our readers and subscribers a Happy Holidays and good fortune for the coming year.
See you in 2022!