Why are Non-Prescription Options increasingly used for melasma?

I think that it comes down to an issue of access. Consumers have some responsibility for managing common conditions and appreciate being able to obtain something readily that is safe and effective. This concept is relevant for melasma, acne, very mild forms of eczema, and dry skin. Given the increasing complexities of the healthcare system, access to a dermatologist may not be readily available.

Melasma is a very common condition. It’s a global condition. Many patients have mild involvement. I think for those individuals who have more moderate to severe disease, dermatologic intervention is probably going to be the path. But for individuals with mild disease that we can target early, access to something over the counter that’s efficacious and well tolerated would be optimal. Given the fact that we think melasma is a form of photodamage, early intervention may be key.

How does our expanding understanding of melasma pathogenesis influence your management approach?

Melasma is far more complex than we’ve ever realized. We know that melanocytes in the epidermis are not increased in most cases. Our work suggests that the melanocytes respond to a variety of stimuli, including growth factors, keratinocytes in the epidermis, and fibroblasts in the dermis. Sunlight stimulates the release of cytokines that upregulate pigment production and deposition. We know that lipids are abnormal; the barrier is abnormal. In the dermis, elastosis is increased.

We also now know that there is a cohort of patients in whom vascular endothelial growth factor is increased. If you look clinically, they can have an increase in blood vessels.

In addition to sun exposure, hormones are a factor—pregnancy can be a trigger.

The ideal approach to melasma would be to prevent it in the first place. For patients who already have melasma, clearing it up and preventing a relapse is key. Relapse is one of the major reasons melasma is so challenging.

Sun protection and antioxidant use are absolutely key. We know that the barrier is abnormal and lipids are abnormal in melasma, so appropriate hydration of the skin is important.

Melasma may be a case where less is more for patients. We want to decrease the excess pigment that has been produced to get it closer to normal skin. We know that exfoliants can help. My approach includes sunscreens, hyperpigmentation therapies, antioxidants, exfoliators, and moisturization. These are the therapeutic arms of a four-prong prevent, correct, protect, and perfect approach.

Are there specific ingredients that you recommend?

I vary my skincare recommendations on a patient-to-patient basis, but there are some ingredients that I tend to favor. Broad spectrum sun protection is vital to prevent recurrence of hyperpigmentation. There are products containing the physical sunscreens titanium dioxide and zinc oxide that are cosmetically acceptable for use on skin of color.

Antioxidants can help protect the skin from UV-induced damage by neutralizing free radicals. Mulberry extract is one example. Alpha hydroxy acid—especially glycolic acid—and/or retinol can assist with exfoliation to support more even skin tone. It is important to avoid products that may increase skin irritation.

Is there a role for corrective cosmetics?

In addition to ultraviolet light, scientific data suggests that the visible light component of sunlight is a key trigger for hyperpigmentation. While we have a number of good UV protecting sunscreens, we unfortunately have a lack of good visible light protectors. Studies suggest that iron oxide is a good absorber of visible light, but the effective use level in tinted sun protection products is not clear.

Dermablend Flawless Creator is a lightweight foundation containing iron oxide, available in many different shades to suit a variety of skin tones. While this product is not an SPF, it was found in a clinical study to help protect against pigmentation caused by visible light, which a standard mineral SPF formula could not prevent.¹

This data suggests that foundations containing a significant level of iron oxides can complement SPF products to help provide daily protection beyond the UV spectrum.

If patients use an iron oxide-containing foundaton, I suggest layering it over a tinted sunscreen for the full broad spectrum of protection.

Some male patients push back at the idea of using a foundation, but if I can convince them to use a little bit, they ultimately get onboard.

We do have quality of life data that suggests that corrective cosmetics can make a difference as we manage patients with pigmentary concerns, working toward a more lasting improvement for what we’re treating medically.

PRODUCT SPOTLIGHT

3-Step System for Discoloration

SkinCeuticals Discoloration Defense Serum

• 3% Tranexamic acid
• Niacinamide
• Kojic acid
• HEPES

SkinCeuticals Physical Fusion UV Defense SPF 50

• 100% mineral filters
• Translucent color spheres
• Artemia salina, a plankton extract

Dermablend Flawless Creator

• Liquid foundation
• Features iron oxide

1. Dumbuya H, Grimes PE, Lynch S, et al. Impact of iron-oxide containing formulations against visible light-induced skin pigmentation in skin of color individuals. J Drugs Dermatol. 2020; 19 (In press).