The Dr Louise Newson Podcast - 211 - Melasma: keeping hyperpigmentation at bay in the summer

Episode Date: July 4, 2023

Consultant dermatologist Dr Sajjad Rajpar returns to the podcast this week for a special summer episode about melasma, a condition that leads to darkening or brown patches developing on the skin. Up to 85% of those affected by melasma are women – and there is a connection between this condition and female hormones. Dr Sajjad and Dr Louise delve into what is known about this chronic complex condition, why it is crucial to protect your skin from the sun and the wide range of treatment options available, including topical treatments and laser therapy. Dr Sajjad’s three top tips on what to do if you suspect you have melasma, plus advice on self-management: Educate yourself on how to tell the difference between melasma and freckles – look at the areas of the face where it occurs. Family history and background may mean you are more susceptible. Sun protection is crucial in managing melasma. This means being really disciplined with using sunscreen, and seeking out a tinted version that will block visible as well as ultraviolet light. There are a wide range of active skin ingredients that can help with melasma; Dr Sajjad suggests starting with azelaic acid or arbutin to treat your condition. For more information about Dr Sajjad, visit www.midlandskin.co.uk  

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based, information and advice about both the perimenopause and the menopause. So today I'm delighted to introduce to you again to the studio, Dr. Sad Rajpah, who hopefully some of you have heard before, and I don't think this is going to be the last

podcast I do with him, because there's so much to talk about when it comes to skin. And Sad is my go-to dermatologist, not just for me, but for my patients as well, because he's so knowledgeable and so calm and actually, I just love the way he explains things to people as well. So welcome back today, Serge. Thanks for joining me. Thanks, Louise. It's always a pleasure to come on. So yeah, it's interesting, isn't it? So I wanted to do dermatology for a little while. I wanted to do oncology initially, study of cancer, and I'm quite geeky. I like pathology. I like disease. Well, I don't like disease. That's silly. I like learning about diseases, how they work, what happens, what goes wrong with the body,

know, right down to a molecular basis. And when I did an oncology job, I just decided I didn't want to do it because it was all about trials. It was all about putting people into chemotherapy trials. And somehow the sort of sensitivity of the patient was lost. They were on a bit of a conveyor belt. And I really liked me very personal with my patients and working out the best consultation for them at the best time for them and sharing all the decisions.

So I decided it wasn't for me, but I was already on a medical rotation. So I would did lots of other jobs. And then I was in Manchester. And Manchester's got a really good dermatology unit. And I thought, well, I've done my BSC, I did a pathology degree. And I did that in looking at systemic sclerosis skin. So I was looking at type 4 collagen in systemic sclerosis skin, the basement membrane. And, you know, it's very interesting when you look at how active the skin is and all these

cells and all the activity in the skin. And I thought, wow, actually, this is really interesting. and then I'm not very good with names and I couldn't remember all the Latin, all these very long names that you give for all these conditions. And I thought, I'm going to be so worried about the diagnosis and the names that I'll forget about the patient

and it just didn't quite feel right. And I did actually, it was the only job that I'd never got was I applied for a job as a registrar in dermatology on a rotation and I didn't get it because they didn't have enough experience. And actually it was probably the best thing that happened to me because I would have been a really bad dermatologist. I think you would have been an absolutely excellent dermatologist Louise and I've just learned something new about you so I can send all my collagen questions to you

because I had absolutely no idea and that your intercalation was in prosology and systemic cirrhosis that's absolutely fascinating yeah it's interesting how life does these circles but with menopause and perimenopause skin really really changes and I hadn't realized how much skin changed until I started to see the volume of women I did. And it really varies from dry, itchy skin of probably the commonest skin complaints. But people notice the texture of their skin changes, not just on their face, but on their body as well. They often become more sensitive to products.

But also associated with skin as hair, hair changes can be really common. People find their hair becomes more straw-like, drier, more brittle. doesn't grow the same way it can fall out. All these things really can affect us and that's without thinking of all the other symptoms and I know when I first saw some ladies who had skin problems that I couldn't even with my dermatological knowledge couldn't manage and treat them. I was wanted to find a good dermatologist and no disrespect to dermatologists. It's quite hard to find people who are general dermatologists. Often they specialize or now there's a huge move to cosmetic dermatology which has a role, but actually for problems and diseases, I needed a really good dermatologist.

And I can't remember how we connected. I think you'd written, you'd seen one of my patients and you'd written this amazing letter. And I think I just reached out to you, didn't I? Was that how it happened? Yeah, it was through a patient, actually, who I think attended for hair loss and went back to you. And I think we shared her care for a number of months. And then, yeah, you made contact. and it was really great because at that stage,

I myself hadn't connected the dots between estrogen deficiency and all the things I was seeing in my clinic. It's something that we were not trained in dermatology specialist training. You've mentioned many times it's something that you've never been trained in in your medical training. It's something you've had to work out yourself and get specialist training and knowledge of. And it was only once, you know, we had connected and we had connected, and we started looking at, you know, other patients that you had referred.

And we're like, actually, there's a lot of similarity in homology here. And really, the skin is an important organ that is affected during the perimenopause and menopause. And there's so much we don't know. We still don't know enough about it. But there's lots of very obvious things that we do know that have often missed, like there are a lot in menopause. But one of the conditions we wanted to talk to about today was something called melasma, which is, I can remember that.

It's not too long a Latin name, but it must derive from something. So can you explain what the word is and what it means, SAD? Yeah, so the word melasma originates from a Greek word called malaz, which means dark or black, and it reflects the darkening or brown coloring of the skin that occurs with this condition. So melasma is a skin condition in which brown patches develop. They develop on the cheeks, on the upper lip, on the forehead, but they can occur anywhere on the face. And the majority of people with melasma, so about 80 or 85% of people with melasma, are women.

So it's not to say that it's only women that get it. So 15% of people with melasma are actually men, but it's much, much more common with it. women. And we see it quite a lot in different stages of a woman's life, actually, and it seems to be more with, I mean, this is a generalisation, of course, people can get it without knowing any triggers, but people on the contraceptive pill can get it, people who are pregnant can get it, sometimes people on HRT. So even if I didn't know anything about it, I might presume that there might be a hormonal component to it. Is that right? Yeah, no, there's definitely a relationship between hormones and melasma. So there are sort of three main causes of melasma, genetics, sun,

and hormones. And we really don't understand the exact hormonal relationship. Is it estrogen? Is it progesterone? You know, what levels are required? Does it come about anyway? Because as I mentioned, men get it who don't have, you know, elevated levels of estrogen or any progesterone. So we don't really know what the exact mechanism that hormones affect the same. skin are. But as you say, some people will be triggered from taking the pill. Some people will find that they get pigmentation during pregnancy. And sometimes that's called the mask of pregnancy. And some people will find that if they commence HRT, that they develop melasma pigmentation. Yes. And obviously, with the oral contraceptive, the type of hormone is quite different actually because it's all synthetic,

as you know, but actually the dose is higher than with HRT as well. We don't know whether it's a dose dependent thing. If it is related to hormones, then is it going to be worse with higher doses? So for example, in pregnancy, people can have very high levels of estrogen in their blood, can't they? Yeah, I certainly think there is to a degree a dose relationship because the majority of people that I see where a identifiable trigger is found, it is women. on the contraceptive pill and or women who have recently been pregnant. So I think those extreme high levels are much, much more likely to cause malasma because that's the group that present themselves with malasma to me

than people with what we would call physiological levels of estrogen. So they're not terribly high. They're just in the normal range just ticking over and what they should be for the normal physiological functioning of the body. So I think we do need to make a distinction between those elevated states. And as you say, the combined contraceptive pill is quite a high dose, isn't it, of estrogen, all dropped into the body all at once. And someone said to me ages ago that it can occur in skin that is sun damaged.

So you're less likely to get melasma if you've always used good quality sun block or stayed out of the sun. Is that right? I think there is some plausibility to that. Malasma is not just a skin discoloration problem. It's a really complex, chronic, inflammatory, serious skin condition. And I say serious because it really affects the quality of life of the people who develop melasma.

And it can really, really cause impairment in social comfort because of the appearance of it. And it is really important. And when I see patients with malasma, I try and explain that, you know, it is not like a tan. It's not like, oh, your skin's gone a bit dark. If you just stay out of the sun, you know, you're fine. It'll just fade off.

It is this thing that, you know, keeps wanting to come back and persist. And when you look down the microscope, so if you take a biopsy from malasma, you do see more solar elastosis, more sun damage in that area than you do in adjacent skin that doesn't have malasma. So there's something about the collagen producing cells, which are called fibroblasts, that is not absolutely right in those areas. You also see more inflammation. You see more white cells.

You see more mast cells, which is a type of white cell. You see slightly bigger pigment-producing cells. And you see more blood vessels. There are actually more cytokines or proteins that are produced that produce new blood vessels in the area. So when you look close, mostly at malasma, it's not just a brown coloration, there's often some degree of redness as well. So it is absolutely fair to say that sunlight can aggravate malasma. Some people say that malasma is a form of sun damage on the skin.

And it is possible that if somebody never got any sun exposure ever, that they may never get malasma. It is possible. It's plausible. We haven't proven that. but it is a complex condition and sun is just one factor. Yeah, so it's a bit different to just freckles, isn't it? Because some people think, oh, it's just large freckles, but it's not.

It's absolutely not large freckles. It's a completely different entity of its own. And as I say, when you look at the skin of it, there are multiple components. There's an issue with the blood vessels. There's new blood vessels being formed in that area. there's an issue with inflammation and there's an issue with pigment production. And we don't really know how the blood vessel cells, the pigment producing cells and the collagen producing cells all talk to each other.

But the way they are talking to each other is slightly dysfunctional and it's causing this appearance to form. So how do you diagnose it then if you saw somebody with presumed menazma, how do you make the diagnosis? So most often it's possible to make that diagnosis by examining somebody's skin. And often they will have brown or dark brown or grey patches of pigmentation, often on the cheeks, on the central and upper outer cheeks, on the central forehead and on the upper lip. And often they will say it's a lot worse when they've been in the sun.

So the majority of my melasma consultations will be from April till July. So when the sun first comes out, the malasma is often aggravated. So it's not caused by the sun. It's aggravated in this instance. It's being revealed. It's being worsened. And people will then sort of realize that something's not quite right and wants an assessment. Now, not all melasma is in that typical distribution.

Sometimes melasma can be different. Sometimes it can be on the outer parts of the face. It can be on the outer temples and the outside parts of the cheek. And that is actually not that uncommon. And very uncommonly, you can actually even get melasma on the body. You can get melasma. I've seen it on the forearms. I've seen it on the neck.

So it's not just that typical distribution. Yeah. But it is really important for a doctor to take a history. And we both have agreed previously that, you know, much of a diagnosis is acetain from just detailed history. taking, just understanding what's going on. And, you know, about 60% of people with melasma will have a relative that has malasma as well. So there's a massive genetic component. And there's a racial diversity with melasma that you're much more likely to develop melasma if you're off a darker skin color. So we see molasma much more commonly in those of an Asian or Afro-Caribbean descent.

Interesting. And is there any reason why? No, it may be related to sun exposure, but we don't know. There's definitely a discrete genetic component that is bringing about more molasma in these racial groups. So once it's being diagnosed, it sounds like once people have malasma, obviously we should use sunblock, but that's not going to stop it being there, is it? So what can we do to treat it? Yeah, sunblock is really crucial. And for some people, sunblock may be enough. So meticulous sun protection. And I do mean meticulous sun protection.

This is one of those instances where 30 seconds of UV exposure can undo six months of fantastic skincare. 30 seconds. 30 seconds. UV is extremely intense at stimulating melasma and pigment production. So you want to do your very best at using a broad spectrum sunblock. And it is now being understood that it's not just ultraviolet light. that a number of malasma patients may also be sensitive to visible light. And often it's the sort of blue end of the spectrum.

So my advice now to my patients with malasma is to use a broad spectrum sunblock that is tinted. Tinted sunblocks have got iron oxide in them and iron oxide blocks visible light as well. So if you can block that spectrum, you're better off. Oh, very clever. Didn't know that at all. So that makes sense. And then what other treatments are available? Yeah. So then we go down the sort of products that reduce melanin production. And the most common prescription product is something called hydroquinone. And hydroquinone is mixed together with a retinoid like retinone and a steroid. And that's called the triple formula in the world of dermatology. Or Kligmund's form. And that's a prescription product that dermatologists will frequently use for controlling

malasma. And it's used for about 12 to 16 weeks. It's not something that can be used for the long term because it can cause side effects. It can actually cause paradoxical pigmentation that can be permanent. So it's not something that somebody can be on lifelong. It is highly effective. And, you know, 60 to 70% of people will say, you know what? I think this is really working.

I'm really happy with it. But what we know is when they stop, the pigment is likely to want to come back. So what we then do is switch over to something for maintenance. And there are a number of maintenance products out there. My favorite is something called azaleic acid. And we've spoken about azaleic acid in the balance app in the context of acne because it's got acne properties.

We've even spoken it about in the context of Rosacea because it can help control Rosacea. but this particular product can also help control melasma. And it's something that you can buy over the counter. So azaleic acid is a fantastic maintenance treatments for melasma. Another new kid on the block is called cystamine. And this is another molecule that helps block the production of melanin. And it's also an antioxidant.

And we think that there is oxidative damage. that means that sun and genetic factors are causing these oxygen species in the skin that are just damaging the pigment producing cells and causing them to create more pigment. And so cystamine has got these antioxidant properties as well. And that's something that somebody would apply on their skin for five to 15 minutes a day and then they would wash it off. And they can use that as a maintenance treatment as well. And there's also a heap of botanical products, so products that are derived from plants that can have anti-pigmentary effects, things like soy, licorice, Arbutin is probably one of the most common ingredients found in skincare regimes, coffeeberry, mulberry, rumex, nia cinemite, the list goes on.

There's millions and millions and you actually get quite confusing. But those can also be tried. But in my experience, they're not as effective or as powerful as your hydroquinone, your azalec acid, and your cystamine. I would say that's my triad, that's my top three, when it comes to topical skincare. So certainly it's worth seeing a specialist to find the best treatment for you.

And it might be trying more than one treatment from the sounds of it as well. Yeah, absolutely. It can be that you need to combine treatments because melasma can be complicated, resistant and difficult for some people. And if the skin lightning treatments are not effective on their own,

then it is possible to add in in clinic treatments as well. And one of the treatments that we do is a laser toning treatment, which is where we use laser in very low energy to try and help break down that pigment. Again, it's not a cure. It's to help control the pigmentation and to help reduce the intensity of pigmentation. And often we run it concurrently with mixtures of topical treatments. One of the new things that's being used a lot now for melasma is an oral medication that you'll probably be familiar with called tranexamic acid,

and tranexamic acid is used for control of heavy periods. But in lower doses, it can help reduce melasma. And what it does is it stops this substance called plasminogen from turning into plasmin in the bloodstream. And plasmin seems to be aggravating inflammation in the skin. It causes prostaglandins to be released and other chemicals like VEGF1 that stimulate blood vessels and pigmentation. So, you know, melasma is a complex chronic inflammatory disorder

that we're just learning all these different mechanisms, this interplaying mechanisms of. But I have actually found that tranexanac acid can be really helpful as part of a multi-pronged approach. One of the things with trinic acid is you can't really have it if you're prone to DVTs, if you're a smug. If you've got a history of systemic heart disease. So you do need to talk to a doctor about, you know, whether it's suitable or not.

And the biggest point to mention is it's off-label. That means it's an unlicensed indication. So that means there are no big studies. And you're familiar, aren't you, Louise, we're challenged with doing the best for our patients and managing these unlicensed medications. And it's interesting, isn't it, when we talk about using things in an off-label way. So the products have been around for many years. I mean, tranaxamic acid has been around for donkeys years,

but this is using it for a different indication. So it's still licence, so that's why you're saying off-label. But actually a lot of what we prescribe in medicine is off-label. And some studies have shown it's about 10 to 20% of medications that GPs prescribe in paediatrics for children. It's a lot higher because they don't have the licence. And they probably will never get it, because to get the licence, you have to do big studies with the indication,

usually randomised control studies, that's a lot of money, a lot of time. Something like trinoxamic acid is as cheap as chip, so you're not going to be able to have the funding to do the study. But we know it's safe. So prescribing off licence doesn't mean it's not safe. And with a lot of these things, it's worth trying if we know that it's a safe product or medication to use. So you mentioned lasers as well.

Does that hurt having lasers on your face or on your melasma? That's a good question. It sounds like it should hurt, but because it's low energy, and this is a thing with melasma, is you do not want to put too much heat on the skin. You do not want to put too much energy in the skin because it's one of those conditions that can improve and then rebound very quickly because of that extra heat energy. So it's actually a reasonably comfortable treatment that's done every couple of weeks because it's low energy and it's diffusely given over the face.

And one other type of laser that we use also for melasma is something called fractional laser. That's where, and this does sound a little bit scary, where we drill very tiny microscopic holes, again with low energy through the skin with the laser to stimulate the fibroblasts. And when we stimulate the fibroblasts, it seems like the melasma can improve as well. And this is bringing about this really unknown connection between the fibroblasts, the blood vessels and the melanocytes, the melanin-producing cells. So even sort of stimulating those fibroblasts that have gone quiet, they're not producing good quality collagen just in those areas,

can actually improve melasma. So there's different types of laser treatment then? Yeah. There are two main laser types of treatments that we would use. One is called laser toning, which is a low-energy laser to help just gently, break away the pigment, and then there's fractional resurfacing, which is also done at low energies to stimulate the collagen machinery in the skin, which can then, as a bystander effect,

also improve malasma. Often, you know, lasers are done alongside optimizing topical treatments, optimizing sun protection, and, you know, thinking about things like tranexamic acid. So it's one cog in the wheel. You'd never just only do laser. laser treatment, it's really best done as part of a proper treatment plan. And I think that's really important to state or really overstate as well, because there's a lot of laser sort of cosmetic treatments that are available. There's all sorts of things. Laser is just a word, but there are so many different types and done for different

indications, aren't there? So you do have to be really careful and not just think, oh, I've had a laser treatment and it hasn't worked, therefore nothing is going to work for my menazer. Yeah, I think what has happened with lasers is it's become synonymous with High Street beauty. And there is definitely a role for lasers on the high street in the beauty sector. So for things like laser hair removal, which are very protocol driven, I think that's a very safe and reliable way of delivering that treatment. I think when you're talking about a complex medical condition,

so melasma, rosacea, acne, these are complex medical inflammatory conditions that need a proper medical assessment. They often need multiple angles of treatment. I think that's when, you know, lasers need to be taken outside the context of the high street and, you know, into the medical practice. Yeah, really, really important to state because like most of the things that we talk about, it's essential that you have the right expert helping who's got the right experience. And I think as patients,

you should be able to challenge the person that you see. And I don't mind if anyone says to me, how many people have you seen similar to me? And I think that's the same, isn't it, when you see a skin freshist dermatologist, it is definitely worth asking because a lot of people will improve with first line, second line treatments.

But if they don't, you know, I know you see a lot of people and I do who feel that they've come to the end of the road, that there's nothing else. And so actually, if you see someone who is very experienced, which is always worth saying, you know, how many cases of melasma, how many difficult cases have you seen and how experienced are you using laser or do you have different types of laser? I don't think that's rude. I think it's just really important to know that you're seeing the right person, isn't it? Oh, absolutely. I think it's really important to also know that there are options out there because people can get dismayed.

And, you know, when I see patients who have struggled sometimes for decades with malasma and, you know, have really curtailed their social existence because of this. And it is, it can really, really be devastating to hear somebody's story. And while we may not have a perfect cure, there is no cure, which is fair to say, it is really worth just exploring treatment options and, you know, evaluating whether it would be something that could be considered. Yeah, I always find with patients, it's really nice for them to know that if this doesn't work, there is something else. And that's usually in medicine. There's always something else to try.

And actually, some of these things can take quite a long time to try. So patients is a virtue for our patients. But also just having time to discuss. discuss and make sure that each patient is comfortable with every treatment that's being offered and know the pros and cons. So very common condition that is really under-treated, like a lot of dermatological conditions actually. So before I finish, Sat, three take-home tips, as you know. So three things. So if people think they might just have some preckles or they've got some pigmentation on their skin, they've got no idea whether it's malasma. So three things that you

think they should do to try and help them get the diagnosis and just on the road for getting some proper treatment? Okay, so I think you can differentiate freckles from melasma by the look of it. If you've got these large areas that blend into each other on the upper outer cheeks and especially the upper lip, you don't usually see freckles on the upper lip, then think more malasma. If you've got a family history or you've got Mediterranean or Asian ancestry, you're more at risk of malasma. So think of it. And then the second thing would be if you think you might have malasma, you may well be able to control it with meticulous sun protection. And as I said before, meticulous in this condition really, really is meticulous. And try and

use a product that also blocks the visible spectrum of light. So that's something that's tinted. Try and get something that matches your skin tone and looks natural. There are some brilliant sunstreams out there now that are tinted. But you will get that extra layer of protection. And then number three, there are skincare active ingredients that you can buy and obtain yourself without needing to see a doctor that you could try. And I think I would go down the azaleic acid root probably. Arbutin is another one. You could give those a go. So those are your sort of three self-help tips. And I think, you know, a number of people will actually find they're able to manage their skin with that. Brilliant. So as usual, thank you so much for imparting some of

your superb knowledge and experience and look forward to you coming back onto the podcast. There's a whole plethora of topics that I want to talk about. And if any of you want any specific topics for Saj to talk about then just put them in the review section of the podcast and we'll pick them up. So thank you ever so much again for your time today, Saj. Thanks, Louise. It's always a pleasure. For more information about the perimenopause and menopause, please visit my website, balance, balance, or you can download the free balance app, which is available to download from the app store or from Google Play.