SKIN PROBLEMS AND TREATMENT

5.7 Melasma

Melasma is also known as mask of pregnancy or chloasma. Melasma starts in child bearing age. It is most common acquired pigmentation. It is more common in females. In 1 /3 rd cases are idiopathic or have no exact cause. In some cases it is familial problem.

Like high blood pressure or diabetes melasma is incurable condition but it can be reduced satisfactorily& can be kept to minimum level in most of the cases, if that person keeps proper sun protection & proper long term follow up with cosmetic experts. In certain cases it may naturally reduce after age of 55 years.

Multiple factors aggravate melasma e.g. genetic, UV light, stress, endocrinal/ hormonal changes, hormonal imbalance, hormonal replacement therapy, thyroid problem, menopause, progesterone, higher level of estrogen,irregular life style. nutritional deficiencies, Vitamin B12 deficiency, Diabetes mellitus, acanthosis nigricans, use of certain cosmetics and medicated creams, certain drugs, antiepilepsy drugs (like hydantoin, dilantin) etc. Ultraviolet rays in sun light and higher level of estrogen are biggest culprit. So, it often occurs during pregnancy & use of oral contraceptive. Even if the person is not exposed to sunlight, occasional exposure to strong sunlight for short duration e.g. procession of marriage without protection of the face in sunlight can also be strong provocative factor. It increases during reproductive age. Dark skin persons are more likely to develop.

Facial melanosis, due to other causes may be present simultaneously.

Clinical features of melasma : Melasma has irregular shape and has blotches of light to dark brown pigmentation. Skin texture in that area become more rough and thickness reduces in some areas due to atrophic scar like changes or loss of superficial layer of epidermis. Some times on some part of the surface on the disease patch one may see some mixture of areas of pigmented thickened layers and/or thin atrophic (depressed) spots.

It often starts as very mild condition. It increases slowly, so most of person neglects it initially. Melasma usually develops on cheek, nose, forehead, chin, upper lip& sometimes in neck. It may develop on the nipples & around the external genitalia.

Treatment: The behavior of the melasma is erratic & response to any treatment is always uncertain. So also follow up treatment is taken by that person irregularly and erratically Most of the person fails to take active treatment of expert during initial period of disease. They often try home treatment or advertised products which slowly aggravate this problem. They do not give concurrent protection from sunlight or strong artificial light. Valuable time for taking effective treatment during initial phase of disease is wasted in self-medication by most of the persons.

Management of melasma is like high blood pressure or diabetes. As it is incurable disease in most of the persons the aim of treatment is to reduce it and to keep it at minimum possible level. It can be reduced to minimum if person takes regular treatment & keep long term follow up under expert care. It needs maintenance treatment at certain interval to keep pigmentation under control. Melasma is not just local disease on the face but it is general problem affecting locally on the face. So just doing local treatment is not enough. Depending on various precipitating factors in particular case precaution should be observed. Avoid over expectation. Over expectation-often leads to mistakes in management of treatments e.g. approach for treatment, failure to keep follow up, changing doctor frequently, using same medicine for long period, using some medicine which was prescribed some times in past etc. These factors make disease strong and resistant to treatment. Treatment response is often uncertain. It varies from person to person. So person should not keep high expectation just because he is taking expert treatment.

Initial treatment of melasma: Treatment is always started in mild doses which is increased gradually. Then addition of drugs may be done later on after observing response to initial treatment. Thus initially person may not see beneficial effects for few weeks but slowly improvement takes place. Some persons insist on cosmetic expert for instant results from first day onwards. In such approach initially steroid is added in cream but as soon as cream is stopped there is recurrence of melasma. So person should keep patience & should continue sincere follow up. Response to treatment vary from case to case, response is often unpredictable throughout the treatment. It may unexpectedly increase suddenly during treatment inspite of initial phase of reduction, so patient should keep time to time communication with doctor if any unfavorable change happens. One should not do hurry to change doctor but person needs to make changes in treatment. If one develops redness, itching, more darkness after local application of medicine. Stop medicine and consult your cosmetic physician. Local application of top flat beam of Q Switch Nd:YAG laser reaches at greater depth safely in comparison to chemical peels and local application of medicine. Medicine may not reach to deep level in sufficient concentration. This specially happens in chronic cases & advanced cases. If disease is located in dermis, patient needs stronger treatment like deep chemical peels & Q switch Nd: YAG laser treatment. Challenge in treatment of melasma is to treat not only pigmentation but also to improve texture of the skin in that area.

Laser treatment: Treatment with Top Flat beam of Q-switch Nd: YAG laser toning provides good improvement after 7-15 sittings. The results of such treatment tend so last longer. Top flat wave beam of Q switch Nd: YAG laser is quite safe in comparison to gaussian wave beam of Q switch Nd: YAG laser. In selective cases Ultra-Pulse® fractional CO2 laser skin resurfacing is done on affected irregularly thickened areas or rough areas to make surface more smooth and to reduce thickened tissues. In some cases there is temporary aggravation of mellasma after this procedure. Such aggravation reduces dramatically after 3-4 weeks with continued treatment of Q Switch Nd: YAG laser. With continuation of such treatment 50% persons have very satisfactory improvement. In spite of taking treatment sincerely, regularly & for longer period under expert care, this disease may aggravate at anytime in future.In such situation person may think that doctor has failed to treat problem. So they may change doctor or reverse back in use of steroid containing bleaching cream or advertised products as self-medication. So it leads to mismanagement of treatment & poor results. Recurrence of this disease is not failure of treatment or failure of doctor but it indicates that such problem needs more effective management & treatment to achieve long term results.

Recurrence of this disease is common in spite of good treatment taken for sufficient period. This is characteristic of this disease; Stress, incidental exposure to ultraviolet rays in strong sunlight or TV/ Computer, irregular life style, lack of rest, discontinuing use of sunscreen, insufficient use of sunscreen aggravate severity of melasma during treatment.

Doctor may start with one medicine product and go on adding other products. But there are chances of recurrence if maintenance doses are not continued. Use it in night. During day use sunscreen. Some creams may cause irritation & produce redness, burning, swelling. It may happen at any time during treatment. In such situation stop these bleaching creams & report to your doctor. Such situation is due to chemical irritation and sensitivity of the skin. In some cases the problem may increase in spite of good treatment during initial period. In such situation discuss with cosmetic physician & make necessary changes in treatment.

Melasma of epidermal presentation respond to treatment but that of dermal presentation does not respond to treatment.

Facts about melasma: Melasma can not be eradicated completely. One can reduce its darker colour tone. It has tendency to recur and sometimes may get aggravated even during treatment period. Such recurrence of mellasma or increase in dark colour tone of mellasma does not mean that treatment is wrong but it means at this stage that person has more sensitive skin & so he needs more careful management & changes in life style. Stress, sunlight/ TV/ computer exposure tend to aggravate. It may respond after 6-10 treatment sessions of Q switch Nd: YAG laser. After complete course of treatment it may improve further upto after 2-8 months. In spite of good response, the person needs preventive treatment or maintenance treatment to improve further and to maintain results. Occasionally in some persons aggravation of melasma occurs in spite of careful maintenance care. They often think, why to take continued treatment? If they are not getting response why to keep follow up for such a long time. It is futile to keep follow up. These patient must continue to use sun screen, protection of the skin & care of the skin. Although this disease appears locally multiple general factors affect its prognosis like stress, sunlight, hormonal disturbances, health status, oral contraceptives lack of rest, late hours sleep in night etc.

A. Avoid sunlight, Use UVA screen for car & home windows. Use protective cloth & hat. UVA can penetrate glass. So, use proper glasses.

B. Use good high SPF sunscreen having broad spectrum coverage. No sunscreen offers full protection. So, best is to avoid sunlight.

C. Use medicine regularly. Q Switch Nd: YAG laser with top flat beam in mild doses slowly improve the pigmentation.

Follow up management and treatment of melasma : It can be kept under control with medicine but one needs to take treatment at regular interval as suggested by expert & then one need maintenance care of the skin.

Recurrence after treatment is common. 40% patients respond satisfactorily, 40% show partial response, 20% cases do not show response. Intermittent touch up session of Q-Switch Nd :YAG laser is required after every 6-8 months to prevent increase in severity, Most of patient do not keep proper follow up because response is slow and patient have over expectations or patient tend to use previously prescribed medication. Due to poor response or less than expected response to treatment & due to tendency of disease to recur it may aggravate in spite of effective treatment. Due to such multiple reasons, persons tend to loose faith on available medical treatment. These person are often confused & frustrated on issue of treatment. In such situation they tend to mismanage treatment Initially most of patients try to manage this disease by home remedy or self medication. Due to advertisement most of person know various bleaching agents or fairness creams. Such self medication or mismanagement in treatment make the problem more resistant to routine line of treatment. Such attempts of self management delay in consulting expert & delay in starting right medical treatment. In such cases severity of disease aggravates slowly & may become incurable.

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