Recently, Mrs Tan came to consult me, looking very upset. The brown spots on her cheeks and forehead had got darker after a week at the beach.
She had been applying her skincare products and sunscreen regularly and yet her melasma had worsened. As she had an important social event in three weeks' time, she was desperate to get her skin cleared up.
Melasma is a common skin pigmentation that usually presents as brown spots on the cheeks. It can also be seen on the forehead, nose, upper lips, chin and, occasionally, on the arms.
Although it is mainly a cosmetic problem, most people are troubled by it and will go to great lengths to have it treated.
This is especially so in Asia, where melasma is common and where most women - and some men - value fair and clear skin.
Unfortunately, melasma cannot be cured. The causes are multifactorial and dependent on one's age.
It starts during the mid-30s, or earlier in some darker-skinned people, and can continue until the person is 60 years old and beyond.
Family history is a contributing factor, with Latin Americans and Asians generally at higher risk.
Melasma tends to get worse when the skin is exposed to the sun. And in women, hormones also influence melasma - the condition may flare up when a woman is pregnant or on oral contraceptives.
While melasma arises from an increase in melanin formation in the skin, recent studies have shown that the non-pigment producing cells, called keratinocytes, as well as the blood vessels, also play a role in melasma. This means treatment requires a multi-targeted approach.
Unfortunately, melasma cannot be cured. The causes are multifactorial and dependent on one’s age. It starts during the mid-30s, or earlier in some darker-skinned people, and can continue until the person is 60 years old and beyond.
For Mrs Tan, the immediate solutions aren't many.
Topical creams, while effective, will not be able to get rid of her melasma or make the brown spots less visible within three weeks.
She will need light treatment either in the form of intense pulse light (IPL) or laser light to disperse the pigments.
CREAMS, LASERS AND MEDICATION
Light or laser treatments are not the first-line treatment for melasma as they cannot prevent the formation of new pigments.
However, they can disperse some of the accumulated pigments which can be shed or removed by the skin cells. The brown hue will thus look lighter.
Another option is to remove some of the pigments through a chemical peel. A chemical solution is applied on clean skin to create a "controlled chemical burn", which will remove some of the pigments.
After that, Mrs Tan will have to continue with treatment to prevent melasma from recurring and to further lighten existing pigmentation.
Sunscreen is important too. It must be able to block both types of ultraviolet (UV) rays - UVA and UVB - as well as infra-red (IR) rays.
For most people, creams form the mainstay of melasma treatment.
Such creams target the various pathways of melanin production. For instance, they reduce pigment production by melanocytes, prevent the transfer of formed pigments into skin cells and exfoliate the skin cells.
An effective combination cream would contain hydroquinone, a skin lightener, tretinion and a mild corticosteroid. Doctors use different variations of this combination.
For people who use such a cream, the melasma will be considerably cleared within eight weeks.
While hydroquinone is effective, it can cause minor skin irritation. Many of the side effects attributed to this ingredient, which can be found online, are not proven.
Doctors are generally confident in using hydroquinone as it is effective and has been used for many decades with minimal or no side effects.
There are non-hydroquinone skin lighteners for melasma, although they are not as effective.
These are often found in cosmetic skin lighteners and include arbutin, kojic acid, liquorice, azelaic acid and fruit or plant extracts.
These are gentle on the skin.
Meanwhile, creams that can prevent the transfer of pigments contain ingredients like niacinamide, soya and retinol.
Given that we know oxidative stress can trigger melasma, the treatment regimen often includes antioxidants such as vitamin C and fruit and plant extracts. These are often incorporated into moisturisers as "skin lighteners" .
In some people, some fine blood vessels or a red hue can be observed among the melasma pigments.
Under this subset of melasma - which can be confirmed with a skin examination called dermatoscope - the blood vessels can be eliminated with a specific type of laser. Patients may also be given oral medication.
For melasma, only two types of oral medication have been reported in scientific literature to be effective - tranexamic acid and an oral sunblock containing the fern extract, polypodiun leucotomas.
Tranexamic acid inhibits the plasminogen activator and helps prevent pigment formation.
This is usually given for a short period of time.
Recent studies suggest that visible light may be a causative factor too. Unfortunately, there is no sunscreen product commercially available that blocks off visible light.
This is where the oral sunblock comes in. The medication has been shown to improve melasma.
Though Mrs Tan does not need oral medication yet, she must continue with the topical creams, including skin lighteners, sunscreen and antioxidants, to keep the melasma under control.
She will have to make sure she reapplies sunscreen every four hours and take other sun-protection measures like wearing a hat and sunglasses.
•Dr Joyce Lim Teng Ee is a dermatologist at Joyce Lim Skin and Laser Clinic at Paragon Medical. She has a special interest in pigmentary skin problems, laser surgery and injectables.