Treatment-resistant melasma in darker skin
Dr. Jason Rivers on treatment options and avoiding unwanted pigment changes while managing melasma (450 words, 3 minutes)
Editors’ note: We’re excited to launch the preview episode of the Skin Spectrum Podcast. In this Forerunner Edition of the newest podcast series from the Chronicle Podcast Network, Dr. Julia Carroll, Founder of Compass Dermatology, speaks with Wade Hull, Vice President of Research and Development at Crescita Therapeutics, about managing patients pain and maintaining their comfort during routine office surgical procedures. They discuss pain management tactics and the current PSI-CAP real-world study. Listen here. And watch for the first episode in our regular season beginning June 26th.
For patients with melasma that does not respond to first- and second-line treatments, lasers and other energy devices may lead to improvement, Dr. Jason Rivers reported at the 2020 virtual Skin Spectrum Summit. However, he noted that there is a significant risk of post-inflammatory hyper- or hypopigmentation with this approach, especially for patients with darker skin types.
“Lasers that reduce vascularity may play a role [in reducing melasma] though some studies have suggested the opposite,” he said.
Dr. Rivers is a dermatologist in practice in Vancouver, B.C. and is the President of the Canadian Dermatology Association.
Newer energy devices such as picosecond pulse lasers or fractional radiofrequency (RF) devices and laser-assisted medication delivery are promising new modalities for treating refractory melasma in darker skin, Dr. Rivers said.
He presented a case example of one of his melasma patients treated with a 755 nm picosecond alexandrite laser using a diffractive lens array. That patient experienced significant improvement after one treatment.
“However, it is interesting that a recent study has suggested that whether or not you use a diffractive lens on the picosecond alexandrite laser, you will get similar results,” Dr. Rivers said, referring to a paper in Lasers in Surgery and Medicine (Special issue: Dermatology / Plastic Surgery, Jan. 2021; 53(1):95-103).
The cornerstone of melasma treatment in all patients is sun protection, Dr. Rivers emphasized, regardless of how much protection an individual's skin tone naturally provides. “Year-round [sun protection]. That is every day of the year.”
For topical sunscreens, “The SPF should be high, that is over 30,” he said. “And for many of my patients, I suggest they use at least a 60. The sunscreen should be broad-spectrum, that is covering both UVB and UVA. And also, I think something that should be kept in mind is that we should look for sunscreens that also block visible light because this may be playing a role in the formation of melasma as well. Agents that can block visible light include iron oxides.”
Other treatment approaches include:
Hydroquinone—still the gold standard, often used in conjunction with tretinoin or a topical steroid
Tranexamic acid—can be used topically or orally, but there are coagulation-related contraindications
Other topical agents including Kojic acid, arbutin, retinoids, nicotinamide, vitamin C, and glycolic acid in the form of peels
Other systemic agents, including Polypodium leucotomos and glutathione
Bottom line: While melasma patients with dark skin can improve their condition by being treated with energy devices such as lasers, consideration should be taken for their elevated risk of unwanted pigment changes from these approaches. Sun protection, used year-round, should still be part of their treatment regimen.
From the literature on melasma:
Randomized, double-blinded, split-face study comparing the efficacy and tolerability of two topical products for melasma
This study compared topical hydroquinone 4% to a hydroquinone-free, retinol-free cosmetic topical brightener for treating moderate facial melasma in patients with Fitzpatrick skin types III-VI. The two treatments were comparable for most clinical endpoints, though the hydroquinone arm showed statistically significant improvements in Melasma Severity Rating Scale measures at 12 weeks.
Fractional 1064 nm picosecond laser in treatment of melasma and skin rejuvenation in Asians, a prospective study
Twenty patients with Fitzpatrick skin types III and IV seeking treatment for melasma and skin rejuvenation were included in this study. Each received up to nine laser treatments at four to six-week intervals with a fractionated nonablative 1064 nm picosecond laser. In all cases, the treatment was safe, well-tolerated, and effective, with no reported hyper- or hypopigmentation.
Intradermal tranexamic acid (TA) injection for the treatment of melasma: a pilot study with 48-week follow-up
This small study examined the effectiveness of a program of 4 mg/mL intradermal TA injections on the face every two weeks for seven sessions for treating melasma. The injections were supported with a sunscreen prescription. The five participants were followed out to 48 weeks. Significant efficacy was seen from the treatment at week 16, but 60% of the participants had melasma recurrence in the follow-up period.
Synbiotics supplement is effective for melasma improvement
A placebo-controlled trial of a synbiotic (prebiotic plus probiotic) supplement for managing melasma has shown significantly better results with the supplement than the placebo after 12 weeks. A total of 57 Thai participants, aged 30 to 50 years old, with Fitzpatrick skin types III-VI and facial melasma on both sides of the face participated.
VIDEO: A new understanding of how facial melasma affects QoL
From the intersection of skin and society
Winnipeg hosted its first Asian film festival May 29-31, showcasing Asian filmmakers and stars from across North America.
Called the FascinAsian Film Festival, the event was held virtually due to the pandemic.
All of the festival’s live-streamed events, including director interviews, are now available on Facebook and YouTube for free. The films will be available to watch on-demand.
CBC News reported that the festival’s president and co-founder, Alan Wong, said that representation of Asian people in the film had improved a bit, but there is still work to do. That, he said, is why the film festival is important.
“Until we get to a point where we can stop talking about it, then it still needs to be talked about. But at the same time, we're just really happy to celebrate Asian heritage and Asian contributions to Canadian culture,” Wong told the CBC.
The festival featured 21 films—18 shorts and three feature-length projects. Wong said the three longer projects included a crime caper, a drama and a documentary.
FascinAsian joins a robust family of Canadian Asian film festivals, including the Vancouver Asian Film Festival and the Toronto Reel Asian Film Festival.
Details on the festival and links to video streams are available on the festival's website at https://fascinasian.ca/.
More on this story here.
This Week
June 16 is International Day of the African Child
June 19 is Juneteenth in the United States
June is Canadian Men's Health Month
Something to think about in the week ahead
Next week
Dr. Danielle Marcoux on pediatric skincare in skin of colour. Questions, comments or observations about ethnodermatology? Send them to us at health@chronicle.org. Have a great week, everyone.
