MELASMA –A NEW UNDERSTANDING
Dr.Sly Nedic emphasizes the importance of patient education in the successful treatment of this common skin disorder.
Melasma is a commonly acquired condition, occurring mainly in women, which symmetrically affects the skin’s photo-exposed area. It is a chronic and relapsing disorder, despite treatment. It has a significant impact on a patient’s social, family and professional life, and a huge impact on an individual’s self-confidence.
Treating melasma is especially challenging, as it presents many obstacles for physicians and patients, including:
- poor understanding of the causes
- current, one-dimensional conventional treatment concentrates mostly on the skin itself, rather than understanding the internal contributing causes
- lack of patient education on the complexity of the condition
- lack of patient compliance and determination in sticking to prescribed procedures.
After trying numerous treatments with no visible improvements, melasma patients end up going from doctor to doctor, vainly hoping to find a miracle cure in the form of a single product or procedure.
Back to basics: Understanding the cause
From functional and integrative medical perspectives, we need to fully understand the cause of melasma so that we can treat it and its root causes, instead of only treating symptomatically.
Melasma is traditionally referred to as “the mask of pregnancy”, due to its frequent appearance during pregnancy. It also predominantly affects women with Fitzpatrick III to VI (darker) skin types, in areas where UV radiation is highest. Hormonal changes are known to play a role here, as melasma is frequently found in women taking contraceptive pills. However, what happens in cases where no pregnancy or contraceptive pill use are present or where male patients are affected?
Intriguingly enough, melasma runs in families irrespective of whether a man or woman gets the condition. The study showed that 70% of Latino men with melasma also had a family member with this condition.
Melanin fabrication in the skin is influenced by various internal and external factors that are more prevalent in certain genetically predisposed individuals. In addition to UVR, hormones and inflammatory signals can stimulate the melanocyte to either increase melanin production or increase transfer of melanin to keratinocytes. In men,the source of excessive hormonal influence is often different from that in women (like xenoestrogens, internal estrogen from aromatisation, etc.)
Our skin, especially the epidermis and keratinocytes, contains β-receptors (ER-β), which are highly sensitive to signaling from 17β-estradiol. This is the usual form of estrogen in reproductive women. Incorrect signaling, especially enhanced under UV radiation,upregulates the transcription factors that cause inflammation and increase melanin production.
However, there are more forms of estrogen, such as estriol (in pregnant women), non-bioidentical estrogen (in contraceptive pills), xenoestrogen (from environmental toxicity, cosmetics, etc.), and estrone(delivered by aromatisation). These forms can also have a higher binding affinity towards β-receptors than 17β-estradiol, explaining why Melasma is more prevalent under these circumstances.
One study showed a higher protein expression of β-receptors in the melasma-affected skin, which suggests estrogen participation in the pathogenesis of this disease, despite normal hormone levels in the blood.
Simply explained: estrogen under UV influence creates melasma in genetically predisposed individuals.
Since our environment is cluttered with xenoestrogens (phthalates, parabens, PCBs, BPN, preservatives, etc.) controlling melisma by only using products or procedures locally on the skin will inevitably lead to an unsuccessful outcome. Helping patients to understand this is of vital importance, as it will be reinforced during the integrative management of melasma. Patient compliance in avoiding xenoestrogens and detoxifying them is a big task but necessary!
Another important hormone in melasma pathology is cortisol. During persistent stress, cortisol –which is an anti-inflammatory hormone under normal circumstances – changes the immune response, allowing uncontrolled inflammation. Substantial evidence shows that melasma gets worse during stressful events and that inflammation also plays a role in melasma-affected areas. Inflammation is likely to play a big role in the sun-exposed skin because UVstimulates inflammatory signals, cytokines and the α-MSH hormone.This can also trigger melanin production and hyperpigmentation. Teaching patients how to control stress in order to help with melasma improvement is another big challenge for the integrative practitioner.
Melasma usually appears in sun-exposed areas, where UVR has either initiated or worsened pigmentation.It is interesting that melasma-affected skin shows signs of photodamage, when viewed under a microscope. With UV exposure, there is a direct and indirect way of stimulating the melanocyte to produce more pigment through inflammation and β-receptor signaling. Since this is so important, educating the patient on proper sun protection as part of their regular skincare regime is the most crucial step to diminishing melasma.
Patients need to understand that melasma is an incurable yet manageable condition. Management does not depend solely on prescribed local treatments or procedures – although they do play a significant part. Moreover, patients’ compliance in avoiding sun exposure, as well as avoiding undesirable estrogen and xenoestrogens from the environment is essential for a more effective outcome. Regular detoxification, more organic food, and organic skincare would make a substantial difference; however, many patients are reluctant to implement these changes.
The integrative medical approach will include some oral supplements known as β-receptoragonists that, in a way, compete with harmful xenoestrogens. Persistence and dedication to receiving regular local treatments are also important, as one treatment is usually not enough. However, patient education and compliance are fundamental for effective results.