New therapies emerging for melasma treatment
Managing hyperpigmentation in Black and Brown skin has added challenges. New therapies may improve outcomes (620 words, 4 mins.)
Hyperpigmentation, including melasma, is a frequent complaint in Black and Brown skin due to its higher reactivity. But that same reactivity means some common treatments for hyperpigmentation can make it worse in this population. In the July 24 edition of the Skin Spectrum Summit's Summer of Dialogue podcast on dermatology concerns in Brown and Black skin, Drs. Yvette Miller-Monthrope and Vincent Richer discuss existing treatments for melasma and some new investigational agents for treating hyperpigmentation.
“Hyperpigmentation is probably one of the most common reasons for patient visits in my practice in patients with Brown or Black skin,” said Dr. Miller-Monthrope.
Dr. Miller-Monthrope is an assistant professor of medicine at the University of Toronto in the Division of Dermatology and currently works in Toronto as an academic dermatologist and dermatopathologist.
While there are good treatments for melasma, both Dr. Miller-Monthrope and Dr. Richer—a Vancouver-based medical and cosmetic dermatologist and clinical assistant professor at the University of British Columbia—noted there are areas where outcomes can be improved in patients with Brown or Black skin.
While hydroquinone has been the gold standard for pigment reduction since the 1970s, long-term use can lead to the permanent pigment change known as ochronosis, the two dermatologists noted.
Laser treatments for hyperpigmentation have an elevated risk in very dark skin, said Dr. Richer, as it can risk paradoxically making the pigment change worse.
Several new options for treating melasma and hyperpigmentation are emerging, and Dr. Miller-Monthrope said she had been trying several in her clinic in the past year, with a relatively high satisfaction rate. Some of these new approaches include:
Topical tranexamic acid 2%-5%
A new formulation of topical cysteamine cream with a more agreeable odour
Topical methimazole
Topical flutamide 1% creamTopical glutathione
Oral tranexamic acid
Bottom line:
There is room for improvement in the treatment of melasma in Brown and Black skin. Dermatologists should follow the research on new treatments being explored in this condition.
Listen to the complete Summer of Dialogue podcast episode here.
From the literature on dark skin and melasma
Microdermabrasion assisted delivery of glycolic acid 70% peel for the treatment of melasma in dark-skinned patients
This study involved 30 female melasma patients with skin types IV and V. The investigators evaluated the efficacy and safety of combining microdermabrasion with a glycolic acid 70% peel as a melasma treatment in this population, compared it to peel alone. Overall, they found the combination approach was both safer and more effective than the glycolic acid 70% peel alone.
Insurance coverage gap for treatment of melasma compared to rosacea
The authors of this paper note that rosacea and melasma share some key features. The two conditions are both common, chronic and exacerbated by sun exposure. Both are also primarily treated topically and cause measurably decreased quality of life in affected patients. However, in this paper, the investigators detail how health insurance plans differently cover the two in the U.S. They note that rosacea treatment, with 91.8% of diagnoses seen in light-skinned patients, is often covered by insurance. In contrast, while melasma is predominantly diagnosed in patients with Fitzpatrick skin types III to V, many providers consider the treatment of melasma as cosmetic and do not cover it.
Low-power fractional carbon dioxide laser followed by Jessner's Peel versus Jessner's Peel alone for the treatment of melasma
A prospective cohort of 40 Egyptian female patients with melasma was divided into two groups in this study. One group received a single session of low-power fractional CO2 (10,600 nm) laser, followed by up to six sessions of Jessner's solution peeling. The other group received the peeling alone. Both groups had statistically significant improvement in their melasma, but there was no significant difference between them. The investigators concluded that both approaches were safe and effective for treating melasma in patients with different skin types, especially in dark skin types (Fitzpatrick Skin Types III and IV).
Dual toning method with the combination of picosecond and microsecond Nd:YAG in refractory melasma unresponsive to picosecond alone
This study notes that the Q-switched toning laser is the most commonly used laser for treating moderate to severe melasma in Asia, but picosecond lasers are growing in popularity. To evaluate a multi-modal laser treatment using both laser systems, they recruited 20 Vietnamese females with Fitzpatrick skin type IV with a clinical diagnosis of severe dermal and mixed-type melasma. The investigators found that their dual-laser approach method using the 1064 nm Nd:YAG picosecond and microsecond laser was safe and effective, and well-tolerated by all patients without downtime. They note that larger studies with more objective measurement techniques are needed to confirm the results of this preliminary study.
VIDEO: How To Get Rid Of Hyperpigmentation, Melasma, Acne, Rough Texture Black Dark Skin—Chemical Peels
At the intersection of skin and society
In a recent article in the U.S. magazine Cosmopolitan (July 8, 2021), several U.S. physicians advise how individuals with dark skin can find a dermatologist who understands their skin and how to self-advocate for their own dermatologic care.
To evaluate a doctor, the article proposes a 'three strikes' approach. The three warning signs listed are: not acknowledging that different skin types behave differently; not suggesting a slower, less aggressive and potentially inflammatory treatment schedule; and not having a thorough discussion of skin cancer, including advocating sun protection.
The article offers four points of advice for self-advocacy:
Search for a physician with experience with patients who have a range of skin tones.
Many dermatologists have a web and social media presence where a prospective patient may see images of that dermatologist's other patients.
Don't be afraid to educate. If a dermatologist recommends a treatment or care regimen that is incompatible with a patient's skin type or cultural practices—such as recommending daily hair washing to someone with Afro-textured hair—a patient can explain why that option will not work and ask for alternatives.
Prospective patients can also seek out physician review sites and read about other patient's experiences with a dermatologist they are considering.
Individuals can also benefit from learning about the ingredients in common skincare products. The Cosmopolitan article suggests the Paula’s Choice online ingredient dictionary as a resource.
For prospective patients who are looking for a dermatologist who also has dark skin, another resource the article suggests is the Black Derm Directory at https://www.blackdermdirectory.com/
This Week
July 28 is World Nature Conservation Day
July 30 is World Day Against Trafficking in Persons
Aug. 1 is Emancipation Day in Canada
Something to think about in the week ahead. . .
Next Week
The Summer of Dialogue: Focus on the Black and Brown Dermatology Patient talk with Drs. Miller-Monthrope and Richer continues with a talk on keloids in Brown and Black skin.
The Summer of Dialogue is a summer-long podcast discussion series on Black skin health. In recognition of the persistent health gaps that BIPOC Canadians experience, this program will be dedicated to promoting and advancing medical knowledge and cultural competence. The podcast series will conclude with a live colloquium to be held on Aug. 21, 2021.
Registration for the colloquium and more information on the Summer of Dialogue is available at https://www.skinspectrum.ca/summer