Is your natural beauty hidden behind a mask of melasma? While best known as the "mask of pregnancy," melasma literally means dark skin. You don't have to be pregnant (or even a woman!) to develop melasma. And if you think you're silently suffering alone, think again. An estimated six million women throughout the U.S. are currently affected by this distressing, albeit cosmetic concern.

Here A Spot, There A Spot, Everywhere A Spot, Spot...

Melasma is a darkening of the facial skin, commonly affecting the apples of the cheeks, the mid forehead, jawline and areas around the mouth. Overachieving melanocytes are to blame. These pigment producing cells become stimulated to produce extra unwanted melanin resulting in patchy discoloration. Triggers include estrogen supplements, birth control pills, pregnancy, cellular hypersensitivity to normal estrogen levels and sun exposure.

Don't Give Up

Certainly it seems that some women simply cannot avoid developing melasma when on oral estrogens. However, experiencing melasma does not automatically dictate having to discontinue the pill. I've even had patients say they don't want to consider getting pregnant again if it means they'll develop melasma! Having melasma doesn't mean you have to go off the pill or use this as a reason for family planning. Highly effective melasma therapy and a well thought out maintenance plan to prevent recurrences are your best revenge.

No Sun, Period

All the estrogen in the world won't make your melasma more noticeable if you don't get some sun exposure. Sunlight dramatically darkens pale pools of pigment in as little as a day at the beach. The single most important first step is avoid sun exposure at all costs! This means both UVA and UVB. Absolutely, positively apply a true broad spectrum SPF 30 like DERMAdoctor Body Guard Exquisitely Light SPF 30 For Face & Body daily. Even better, apply Total Block Clear SPF 65 which blocks both UV and visible light. Put on a wide brimmed hat or sun protective extra-long billed hat like Physician Endorsed Naples - Khaki. Wear your favorite glamour extra-large sunglasses (think Garbo). Then minimize your sun exposure.

Whether or not a bleach contains SPF, I still maintain that all over use of a sunscreen is important to help with the bleaching process and to prevent the development of new areas. Consider SPF in your skin care products and color cosmetics as "icing on the cake". Makes for added pleasure and protection, but doesn't hold up alone.

All's Fair In Love And Bleaching

When it comes to trying to lighten those bits of brown, "the more the merrier" has become bleaching mantra. In the dark ages of bleaching (no pun intended), single ingredient products ruled. Now combination specialty formulas spar for the best synergy. Hydroquinone, kojic acid, glycolic acid, vitamin A/retinol/tretinoin, azeleic acid, ascorbic acid, lactic acid, salicylic acid, steroids and sunscreen are all used in endless variations on a theme. The use of hydroquinone above 2%, tretinoin, and azeleic acid 20% automatically place a bleach into the prescription category.

Here are the list of the multitalented players:

• Lustra: Contains 4% hydroquinone, 4% glycolic acid.
• Lustra AF: Contains 4% hydroquinone, 4% glycolic acid plus SPF 15.
• Alustra: Contains 4% hydroquinone and retinol.
• Glyquin: Contains 4% hydroquinone, 10% glycolic acid, SPF 15 and is sodium metabisulfite free.
• Tri-Luma: Contains 4% hydroquinone, 0.05% tretinoin and 0.01% fluocinolone acetonide.
• Obagi: The prescription portion of this physician directed bleaching routine is made up of generic tretinoin cream and a generic 4% hydroquinone.

Manage A Trios

A prescription combination trio, Tri-Luma manufactured by Galderma, is the FDA approved version of what dermatologists have long referred to as Kligman's Formula. (Dr. Kligman has long been a proponent of mixing tretinoin, hydroquinone and a steroid for melasma therapy). Tri-Luma contains the active trio of 0.5% tretinoin (the active agent in Retin A), 4% hydroquinone and a potent topical steroid, fluocinolone acetonide 0.01%.

A one-step bedtime cream, I consider Tri-Luma a kick-start to melasma management. It is applied every night for no more than 8 weeks. The reason for this is the presence of the high potency topical steroid which if used for a longer period of time may result in skin atrophy. The manufacturer has performed studies showing the product is safe and dramatically effective.

Tri-Luma is quite new and anecdotal reports are circulating about dermatologists placing patients on all types of on-again, off again regimens to eradicate the melasma while trying to avoid thinning of the skin.

Anything new in the treatment of melasma is always welcome, but it is very important to understand this is NOT a product to receive from your doctor and go off and use on your own for long periods of time particularly unsupervised. If you find you develop spider veins, thin skin, loss of skin color and even stretch marks as side effects to abuse of Tri-Luma, you will be even unhappier than the discoloration you set out to treat.

If you aren't participating in a supervised on again, off again routine, and still require further treatment, some non-steroid based method of bleaching needs to be continued after stopping Tri-Luma. Either switching to one of the other combination products to finish up the job or adding some super separates such as Retin A or Tazorac (they will help your skin rejuvenation and any acne, too), perhaps some Azelex (the acne med that helps with reducing unwanted skin discoloration) and of course a good primary bleaching ingredient can help complete the process.

Non-Prescription Hydroquinone Options

• ScarGuard Scarlight MD: Contains 2% hydroquinone, kojic acid, azelaic acid & retinoic acid.

Hydroquinone Hard Knocks

A highly unusual side effect caused by hydroquine is called ochronosis. Treatment with the active ingredient can in fact darken the treated area or create a bluish cast to the skin. Again, don't plan on being the unlucky soul, this is very atypical. Certainly, if there seems to be some darkening, discontinue use of that agent and check with a dermatologist.

For some reason there is an urban myth circulating about the supposed hazards of long term hydroquinone use. I am unaware of any health risks associated with long term use of hydroquinone and completely at a loss as to where this myth came from.

Au Natural

OK, sometimes hydroquinone just isn't in the cards. Maybe you're sensitive or allergic to it. Perhaps you're pregnant, nursing or concerned about ochronosis. Whatever the reason, a Japanese bleaching ingredient has great usefulness for melasma. Kojic acid is derived from various fungal and organic plant materials. Kojic acid helps reduce melanin formation. It is particularly popular for use in Asian and ethnic bleaching products.

Kojic acid, like hydroquinone, can again be combined with a variety of other ingredients (including hydroquinone!) to help hasten improvement.

Botanicals thought to have skin brightening qualities include bearberry extract and licorice extract. Vitamin C , particularly in the form of 10% magnesium ascorbyl phosphate, is also considered highly effective. Hints of newer "smart" ingredients coming onto the market for skin brightening continue to make this a promising field of cosmeceuticals.

Natural Options:

• PRIORI CoffeeBerry Brightening Facial Complex: Contains coffeeberry, lactic acid and retinyl palmitate.
• DERMAdoctor Immaculate Correction Potent Hydroquinone-Free Skin Brightener: Contains the new and amazing mitracarpus scaber extract, azelaic acid, bearberry extract, licorice extract & beta carotene.
• MD Formulations Vit-A-Plus Illuminating Serum: Contains buffered glycolic acid, retinol, mulberry and licorice extracts.
• Cellex-C Fade Away Gel for Sun and Age Spots: Contains neither hydroquinone nor kojic acid. Rather it contains a natural blend of ascorbic acid, tyrosine, green tea, zinc sulfate, sodium hyaluronate, cucumber and thyme extract.

Paint Within The Lines

No matter what you're using to treat your skin discoloration, bleaches can't tell the difference between normal and abnormal skin tone, so you need to apply the bleach only to the abnormal color. As this can be difficult at times, I don't recommend that you try to bleach every last miniscule freckle. Stay with the larger, well-defined sites. Bleaches are usually applied twice daily.

Bleaching is not a fast process. Depending upon how dark the area is compared to the normal skin tone, it can take as along as one year or sometimes longer.

Because of the prolonged time frame for bleaching, I think the combination approach is best. If you aren't already using a combination product, try adding other active ingredients including glycolic acid skin care such as MD Formulations, retinols like Replenix All-Trans-Retinol Smoothing Serum 10x, Afirm, DERMAdoctor Poetry In Lotion intensive retinol 1.0 or prescription Vitamin A creams and perhaps Azelex.

Glycolic acid is a wonderful base to apply prior to the bleach as it helps draw the bleach into the skin better. I also try to add in a Vitamin A cream every other night (solo) such as Replenix All-Trans-Retinol Smoothing Serum 10x, Afirm, Retin-A, Renova or Tazorac. These products help erradicate blotchy discoloration on their own as well as exfoliate the discolored skin. Azelex cream was developed for acne, but it is an acid base and actually helps bleach discolored skin.

Peel Power

Exfoliation can be a useful tool in hastening the resolution of melasma. It works to remove superficial pigmented skin cells and also eases penetration of bleaching agents. A variety of means can be used, both mechanical and chemical. Whatever your weapon of choice, a fine line exists between exfoliation and excessive inflammation. The unwanted outcome of too much irritation can be an increase in skin pigmentation also known as post inflammatory hyperpigmentation.

Three main methods are used: chemical peels (glycolic, TCA, or home use, DERMAdoctor Physical Chemistry facial microdermabrasion + multiacid chemical peel or Dr. Dennis Gross use); microdermabrasion (physician/esthetician performed or home DermaNew use); and a light freezing of the skin with liquid nitrogen. I have seen several patients who've undergone the latter procedure present to me with a darkening of the treated area, so this is a treatment I prefer to avoid. As for spot laser resurfacing, a truly skilled laser surgeon may be able to improve melasma but personally I would use this as method of last resort.

The Post Game Wrap-Up

When it comes to treating melasma, remember to stick with your program for the long haul. When you have achieved your desired results, stop your bleach but continue your sun protection. You may even want to continue your glycolic acid and Vitamin A creams. The low pH of Vitamin C (such as Ascorderm Contouring Serum PLUS or Cellex-C High Potency Serum) in your skin rejuvenation routine can also help lighten the skin. Using an ongoing skin rejuvenation program can help prevent recurrences as well as give you a head start on keeping fine lines at bay. Should you find you are experiencing early recurrence of the discoloration, restart your bleach before the problem gets out of control.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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