Uneven Pigmentation & Melasma

Uneven pigmentation is one of the most common skin complaints that we see at Facial Artistry. There are a number of causes leading to the development of uneven pigmentation of the facial skin. These include sun damage, melasma (hormone induced), post-inflammatory hyperpigmentation, skin cancers, and other less common causes.

Sun damage

We are a sun-loving nation and most of us have spent too much time in the sun. Unfortunately, this leads to changes in the skin, causing brown areas and brown spots to appear on the skin. These brown spots can be of several pathological entities, including ephilis (freckle), lentigo simplex (flat brown marks), seborrhoeic keratosis (age spot), and actinic keratosis (sun spot). Occasionally serious pathologies such as melanoma may be present.

With Dr Bernard Leung’s dermatology training, he adopts a different approach to uneven pigmentation compared to a non medically trained therapist. The first and most important step is to make a precise diagnosis of the pathological entities. This will involve taking a history, performing a careful examination and inspection, as well as a more detailed examination with a dermatoscope (epiluminescence microscopy). Occasionally it may be necessary to perform a skin biopsy to ascertain the diagnosis. Only when the diagnosis is confirmed, can a treatment plan be instituted.

There are several options to treat the conditions that lead to uneven pigmentation of the skin. These include chemical peels, cryotherapy (freezing with liquid nitrogen), intense pulse light (such as Limelight), confluent laser resurfacing (such as Pearl or 3D photorejuvenation) and surgical excision. The treatment of skin cancers usually requires surgical excision.

Sun avoidance and the use of a broad spectrum sunscreen is equally important, particularly as these entities have a tendency to recur or that more will develop. The use of topical creams containing alpha hydroxy acids (AHA), retinoids, vitamin C amongst others will help to lighten brown spots and to prevent new spots from forming.

Case study

This lady presented with a couple of brown spots on her face. These have not responded to pulse light treatments at two different laser clinics. The brown spot on the left of the photo was a malignant melanoma, whilst the one on the right of the photo was a lentigo simplex. The former required a wide surgical excision and the latter was treated wtih cryotherapy. Fortunately the melanoma was a good prognosis tumour. This case highlights the importance of careful clinical assessment and diagnosis prior to undertaking treatment.

Site Images / Melanoma face (medium)

Melasma

Melasma, sometimes called chloasma, appears as a symmetrical blotchy, brownish pigmentation on the face. The pigmentation is due to overproduction of melanin by the pigment cells, melanocytes. It can lead to considerable embarassment and distress.

The cause of melasma is complex. There is often a genetic predisposition to melasma, with at least one-third of patients reporting other family members to be affected. In most people melasma is a chronic disorder.

There are several known triggers for melasma.

  • Sun exposure – this is the most important avoidable risk factor.
  • Pregnancy may provoke melasma – in affected women, the pigment often fades a few months after delivery.
  • Hormone treatments seem to be a factor in about a quarter of affected women,  oral contraceptive pills containing oestrogen and/or progesterone, and hormone replacement therapy are most commonly implicated. But in other women, hormonal factors do not appear important.
  • Scented or deodorant soaps, toiletries and cosmetics may cause a phototoxic reaction triggering melasma that may then persist long-term.
  • A phototoxic reaction to certain medications may also trigger melasma.
  • Melasma has been associated with hypothyroidism (low levels of thyroid hormone).

More commonly, it arises in apparently healthy, normal, non-pregnant adults and persists for decades. Exposure to ultraviolet radiation (UVR) deepens the pigmentation because it activates the melanocytes

Melasma is usually very slow to respond to treatment, so it is important to be patient. Start gently, especially if you have sensitive skin. Harsh treatments may result in an irritant contact dermatitis, and this can result in post inflamatory hyperpigmentation.

General measures

  • Discontinue hormonal contraception.
  • Year-round sun protection or sun avoidance. Use broad-spectrum very high protection factor sunscreen of reflectant type and apply it to the whole face every day. Reapply every 2 hours if outdoors during the summer months. Alternatively or as well, use a make-up that contains sunscreen. Wear a broad-brimmed hat.
  • Use a mild cleanser, and if the skin is dry, a light moisturiser. This may not be suitable for those with acne.

Topical therapy

Topical creams containing tyrosinase inhibitors are the mainstay of treatment. The aim is to prevent new pigment formation by inhibiting formation of melanin by the melanocytes. As we are a medical clinic, Dr Leung often prescribes special formulations prepared by compounding pharmacist for the best results.

Superficial or epidermal pigment can be peeled off. Peeling can also allow tyrosinase inhibitors to penetrate more effectively.

Currently, the most successful formulation has been a combination of hydroquinone, tretinoin, and moderate potency topical corticosteroid, which has been found to result in improvement or clearance in up to 60-80% of those treated. It is prescription only. Many other combinations of topical agents are in common use, as they are more effective than any one alone.

In addition to topical therapy, gentle treatment such as microdermabrasion with sonophoresis (Microplus+) helps to lift epidermal pigment found in certain types of melasma. The advantage of microdermabrasion is that it is unlikely to cause any post inflammatory hyperpigmentation, and that it can be repeated regularly for incremental improvement.

Laser therapy

Intense pulse light (such as Limelight) and chemical peels may be effective against the epidermal type of melasma. However, the results are usually disappointing against the dermal type of pigmentation. In any case, these treatment may paradoxical worsen melasma or cause post inflammatory hyperpigmentation. It is usually necessary to use the topical treatments described above before and after treatments.

Please click on the following link to read more about Cutera LimeLight.

To request an appointment with Dr Bernard Leung please email us or call us on 02 6255 8988.