The following is an excerpt from the Glow Journal podcast. To listen to the full interview, subscribe now on iTunes or Spotify
In this instalment of our Ask An Expert series with our friends at Candela Medical, we’re taking YOUR questions on melasma to Dr Danae Lim. A cosmetic physician with over 14 years medical experience, Dr Lim is an undisputed skin expert and also has a background in emergency, so her approach to skin is vigilant, safe and well-rounded, with a deep understanding that the health of the skin goes well beyond its appearance.
Away from our regular brand founder conversations, I am frequently asked so many highly specific questions about the skin. Given that I am an educated consumer and by no means an expert, it would be extremely unethical for me to even attempt to address your skin concerns- which is why I insist on taking those questions to a medical doctor. That’s why I truly love producing this Ask An Expert series with Candela. Although the series itself is sponsored, doctors legally and ethically have to remain completely objective in interviews like this. For this reason, this series is the single most authentic way for me to integrate branded content into the podcast because it’s giving you, the listeners, completely unbiased expert answers to your most specific skin questions.
GLOW JOURNAL: Firstly- what is melasma?
DR DANAE LIM: Melasma is a chronic and acquired disorder of skin pigmentation. Melas means “black” in Greek, and if you go far back enough you will find that melasma is commonly known as the mask of pregnancy. Melasma is usually characterised by dark and well defined areas of pigment in darker skintypes- mainly because there are more active and bigger pigment cells. These patches occur in sun exposed areas, typically on the face, but can occur on the body. It is also a recurring condition, meaning it comes back after exposure to its triggers. It can be controlled but not cured.
And what causes it?
We don’t know exactly what causes melasma but there appears a genetic component. Many who suffer from melasma will find that they have family members who also have it, particularly in female relatives. Men can also suffer from melasma. We do know the triggers that make it worse. Think of it as having pigment cells that react disproportionately to a stimulus – most notably sun exposure, hormones, physical trauma, stress, chronic illness and even dietary changes. It actually varies greatly across individuals.
How can we differentiate between “regular” redness or sensitivity and melasma?
Skin conditions occur on a continuum, some with overlap in the characteristics, but melasma is predominantly a pigmentation disorder, so there has to be the hallmark patches of pigment on sun-exposed skin for diagnosis. With regards redness and sensitivity, we know that melasma has an inflammatory component – the skin barrier is often damaged with inflammed blood vessels in addition to making too much pigment after exposure to triggers that make it worse. What means that people who have melasma may also be quite red in the same areas, but ultimately there has to be the classic pigment changes to be diagnosed as melasma. Other conditions like dermatitis, rosacea or just highly reactive blood vessels have different underlying processes and we treat those accordingly. Skin sensitivity may be due to genetics and dryness, but do not typically give rise to pigment.
Before we get into treatments- is there any way we can prevent melasma occurring?
As melasma is highly dependent on genetics and lifestyle, the best way to prevent this would be to have a good skincare routine that builds up the health of the skin, tones down inflammation from sun and environmental damage, and absolutely meticulous sun protection. This will reduce the severity of melasma, but ultimately may not be avoidable. Most people actually don’t know if they have melasma until they experience major stress or pregnancy – that’s why it’s an acquired disease despite having a strong genetic influence – you are not born with it.
Very top level, but can you talk me through some of the most common and readily available treatment options?
Contrary to popular belief, laser is not the first line treatment and can in fact cause problems when used inappropriately. With melasma we have to be very careful and build it up from the basics. As mentioned before, a good skincare routine and meticulous suncare are the absolute minimum. The healthier the skin, the easier it is to even think about stronger skincare products as those may irritate the skin. Medical treatment is firstline. This usually means prescription strength treatments with pigment correctors, medical grade peels or even prescription oral tablets to lighten the pigment, but you must see a professional in order to decide what is right for you.
Other treatments include laser and microneedling, all with varying degrees of success at control. Often changing the treatments every few months or combination treatment is required as melasma is very complex and different aspects need to be targeted for best results – the ultimate aim is to reduce the severity and frequency of recurrence.
And what would you suggest is the most economical option- not necessarily up front, but taking into account things like repeat visits?
Good skincare is actually the most cost-effective for treating most skin conditions, whether it be melasma, sun damage or acne. A good routine which incorporates the basic anti-aging ingredients like vitamins A, B and C can slough of excess pigment, repair skin damage. protect against excessive UV exposure and calm the skin. Adding pigment correctors on top of that enhances the results. Good hydration is also very understated – hydrated skin is less likely to be irritated. This all has to be balanced with skin sensitivity and whether it’s used consistently.
The majority of our audience has asked the same question- is laser the solution?
Interestingly no. Even with laser I would still opt to prepare the skin and make sure it is strong enough to take the relatively high energy required to reduce pigmentation.
Hypothetically, what kind of laser treatment would we be looking at? How does it work?
The most common lasers for treating melasma would be the Q-switched laser and picosecond lasers. These are considered high energy lasers that have a short pulse duration, meaning a lot of energy is targeted at the pigmentation to either heat it up and vaporise it, or shatter the pigment into small fragments. The body then mops up the residual fragments over time. This has to be titrated very carefully such that only the pigment is destroyed without harming surrounding tissues, otherwise you get burnt, or the skin makes more pigment in response to the damage.
One listener has asked how they can treat their melasma when they also have post- inflammatory hyperpigmentation.
Post-inflammatory hyperpigmentation usually occurs after some kind of trauma which can occur after skin inflammation, sunburn or laser treatments. It is not that different to melasma except the pigment is likely more superficial, and treatment still starts with application of the correct skin care products, reviewing skin sensitivity then deciding whether peels, laser or microneedling is more appropriate.
I’ve touched on this in previous episodes, but it’s worth discussing again as I know many people are still a bit fearful of lasers- what is the effect of heat on melasma?
There are no studies that demonstrate the effect of heat on melasma, but I have had many patients say their melasma flares up in summer even if they have stayed indoors and avoided the sun completely. I do believe that heat can make melasma flare up. As we just mentioned lasers work either by destroying the pigment with heat or shattering it into smaller fragments mechanically. There is always some heat produced with both cases, and my preference is a faster picosecond laser that produces minimal heat compared to conventional lasers for my own peace of mind.
Are these treatments permanent? Or will the client need to come back for maintenance?
The skin is the biggest organ of the human body and it reacts to the environment we live in. Melasma is a recurring condition, so for best results patients do need to maintain a very strict skincare routine and sun avoidance. The good news is, the better this is done, the less frequent maintenance treatments need to be.
Is there a difference in the way you would approach melasma on the face, as opposed to the body?
The face is exposed to more sun as the body can be covered up, so I would be very stringent on sun protection. If the body is covered, I may opt to treat with prescription pigment lighteners as it is also more difficult to apply consistently. Treatment on the face however is likely to work faster due to the better blood circulation and faster skin turnover compared to other parts of the body.
A lot of people had questions about peels, and how they might compare to a laser treatment. Can a great peel work to fade melasma?
Yes, a peel (when done properly can fade melasma). This has to be balanced with skin sensitivity as stronger peels can “burn” the skin can cause rebound pigmentation from the “trauma”.
What about a combination of treatments?
That is the ideal plan – to use different treatments at a lower intensity and get results without severe side effects. Often medical treatments plateau after a while. A clinical treatment can then be performed boost the results to the next level, and products can be switched around to target other aspects of the condition.
Something that a few people asked about was Hydroquinone, which I believe is a topical bleaching agent. Is this at all effective in treating melasma?
Hydroquinone is actually one of the best topical agents for treating melasma, but again needs to be balanced with skin sensitivity. It can cause hypopigmentation if used for a long period of time in darker skin types, so make sure to see a professional.
If we aren’t looking to go down a professional treatment route, are there any products we can use to treat melasma at home? Or does it need laser or similar?
Laser is not my first treatment of choice for melasma. For melasma that is not severe, I have not found laser to be particularly effective as laser recognises colour – the stronger the colour the better it works. In a few of my patients, the topical products did appear to be more effective after I have performed laser possibly because the pigment particles were smaller and easier for the body to remove.
And if we have had a treatment in-salon, are there any products (or even specific ingredients) we should be using to maintain those results?
There are several ingredients that come to mind – apart from hydroquinone, vitamin A derivatives, arbutin, kojic acid, niacinamide and vitamin C, just to name a few. Best to see a professional as the concentration of the ingredients do matter and everyone’s skin sensitivity is different.
Another thing I was asked about on the home care front was diet. Is it at all possible to improve the appearance of melasma through dietary changes?
Again, large scale studies have not been done on diet affecting melasma so I am basing it on my patient experiences. Some of my patients actively avoid processed sugar and gluten, and it has made a difference. Whether it’s the actual food or that certain food intolerances causes the body to be more “pro-inflammatory” I do not know. Maybe switch to dark chocolate if you are worried!
Overall, is there a cure for melasma? Or is it just about managing it?
There is no “cure” – it can be controlled to a manageable level but avoiding triggers maintaining a good skincare routine with sun avoidance and the occasional clinical treatment.
My audience all seemed to be pretty aware the sun exposure and melasma are inextricably linked. Why is that?
Our skin produces pigment directly in response to the sun, partly to protect it against damaging UV radiation. This process is magnified by degrees in people with melasma and sun exposure is possibly the biggest trigger for pigmentation production.
Is physical or chemical sunscreen better in managing melasma?
I definitely prefer a physical sunscreen, when applied generously, i.e.g half a teaspoon for the face and neck. Zinc oxide and titanium dioxide are the main ingredients in these. The reason being physical sunscreen forms a layer on the skin that does not allow UV radiation to penetrate if applied correctly (SPF 15% = 92% blockout … SPF 30+ = 97-98% blockout).
There are very well made chemical sunscreens and they do feel lighter on the skin, however some can still cause skin irritation as it needs to bond to the skin directly. Chemical sunscreens also work by converting UV radiation into heat, which can also exacerbate melasma so it can be a double whammy.
What is the number 1 product, outside of sunscreen, that you would recommend people use if they want to reduce the appearance of melasma?
If it is purely to reduce the appearance, I would say a cosmetic foundation like a BB cream. If we are talking reduction in the actual pigment I would have to recommend seeing a professional for prescription skin lighteners as the skin sensitivity can be a huge issue.
While we’re on sun exposure… A question only one person asked, but I’m sure a number can relate to- will my skin be okay in my 30s and 40s from all the mistakes I’ve made in my 20s?!
The skin has great regenerative capacity, but sun damage can cause DNA damage which gives rise to problems like skin cancer especially in the Australian climate. Bottomline is, it is never too late to start practising good sun care, but most likely genetics and skin type will be the main determining factors in how well someone ages. Darker skintypes have more pigment, which in this case is protective against sun damage and skin cancer. But a good skincare regime as stated above is not just for treatment of pigment – it is a good overall anti-aging routine that will help repair DNA as well. And get your mole checks regularly.
Another thing my audience link to melasma, other than sun exposure, is pregnancy and hormones. Why do so many women experience dark melasma during pregnancy?
Pregnancy is a classic trigger. Many women do not have issues until they get pregnant, or find that it worsens during pregnancy. Hormones fluctuate wildly during pregnancy, extending even to the breastfeeding period, are a powerful trigger for stimulating pigment production.
One listener who does have melasma asked if she should wait until after having children to get her melasma treated by laser, as she’s worried it might come back worse post-pregnancy and the initial treatment will have been a waste.
It all depends on how much the melasma bothers her, how many children she is planning to have and whether she is happy to wait till after she has children to have treatment. Melasma often improves after pregnancy and breastfeeding as the hormones stabilise. While some active products cannot be used during pregnancy, she can definitely still maintain it in between pregnancies until she is ready for clinical treatments including laser. Do see a professional to decide what is the safest and most suitable treatment plan.
A handful of listeners asked if their melasma might improve if they were to go off the pill?
Melasma differs in individuals and the type of pill also matters. Some pills maintain a stable hormone level, while others cause fluctuations that mimick a menstrual cycle. If melasma worsened after they got on the pill, then perhaps ask the GP to switch to another type of pill to see if it improves. Barring that alternative forms of contraception may need to be considered. That’s a difficult one because some people don’t actually take the pill for contraception and may need it to help with other medical conditions.
Pill aside, another listener asked if other contraception can affect melasma, as she thinks hers got worse after she got the Mirena?
It is possible as Mirena is a hormonal intrauterine device. A copper intrauterine device that does not release hormones into the body is a good alternative.
What treatments are safe during pregnancy and breastfeeding?
Generally vitamins B and C, as well as arbutin are quite safe during pregnancy and breastfeeding, but when in doubt please see a professional. Sun protection is also a must.
There’s so much information out there about what you should do to treat melasma- but what about what you shouldn’t do?
The general principles would be to not be in the sun as far as possible, which many melasma sufferers will instinctively do anyway. Do not to buy random products or attempt strong treatments at home without consulting a professional. Have a consult and don’t waltz into a clinic expecting to have a laser or other clinical treatment the same day. Most of these need pre-treatment with the right products.
Be patient and do it safely. Melasma is a chronic condition after all, and even in the most experienced hands unexpected things can happen.
