Hormonal Pigmentation / Melasma

The short answer is that melanin -- its amount, quality, and distribution -- creates human skin color. The slightly longer answer is that melanin is produced within melanosomes, organelles located in the cytoplasm of melanocytes (skin cells in the basal layer of your epidermis). The number of melanocytes in human skin is the same in people of all races; in darker-skinned individuals, though, the melanosomes are larger and contain more melanin. Once melanin is produced, melanosomes migrate to the melanocytes' dendrite tips, where they come into contact with keratinocytes, skin cells closer to the surface of the epidermis. The final stage of the pigmentation process, however, wherein melanin is transferred from the melanocytes to keratinocytes, is still poorly understood.

• UVA rays are a stimulant for melanin (brown pigmentation) to develop on the skin, and unfortunately can even penetrate through car window glass.
• Any change in hormonal status with higher levels of estrogen is thought to trigger and aggravate the condition (i.e. birth control pills and pregnancy).Discontinuing the use of contraceptives rarely clears the pigmentation and it may last for many years after discontinuation.
• After pregnancy Melasma (chloasma) or pigmentation usually clears within a few months of delivery but may persist indefinitely
• However many women without these risk factors also develop melasma
• any activities that cause Intense heat to the face( from steam showers, hot closed environments, sitting on the beach even under cover and with full sun protection, etc) cause inflammation which is a powerful stimulator of melanin
• It is more prevalent in darker-complexioned individuals though persons of any race can be affected due to the intense sun exposure in South Africa.
• Melasma is seen most frequently in young women but can be seen in men

• Centro Facial (forehead)
• Malar (cheekbones)
• Mandibular (jawline)

• Epidermal melasma is the most common form and is easily treated with a combination of superficial chemical peels, Limelight or Photo Genesis procedures
• Dermal melasma : If the melanin has leached into the dermis, this is known as dermal melasma .The deeper the pigment is and the more difficult it is to treat. Dermalmelasmais not treated with superficial peels and is best treated with mid dermal peels such as a Skin Renewal's 3 D peel , Cosmelan, Dermamelan or injected mesotherapy with Tranexamic acid to penetrate into the dermis to reach the pigment.
• Mixed Epidermal-Dermal melasma is a combination of the above and is treated the same way as dermal melasma

One should consult with Skin Renewal doctor to rule out the possibility of a systemic health disorder or a cancerous lesion that requires medical treatment. Your Skin Renewal doctor will conduct a physical examination, examining the location, distribution, color, and appearance of the areas of increased pigmentation. Ask your Skin Renewal doctor to look at your skin with a Wood's light - a type of black light - which is available at all Skin Renewal clinics or the Visia Complexion analyser.

Additionally, your Skin Renewal doctor will assess the history of the condition, which will help determine whether the disorder may be due to a developmentally programmed, congenital, or acquired cause.

Your Skin Renewal doctor will also evaluate whether external factors, such as hormones, medications, chemical exposure, or other environmental influences could have contributed to the increased deposition of pigment in the skin. Furthermore, the practitioner will make note of any prior history of pigmentation disorder and its treatment

Melasma, also known as hormonal pigmentation, is a considerable problem for South African women. It is a chronic skin condition that occurs on the face in the form of brown patches and is a dynamic (active) condition that needs lifelong management. Its incidence is much higher in Asian and darker-skinned individuals than in fair-skinned people

Pigmentation disorders such as melasma or chloasma (during pregnancy) arise from increased melanin in the lower layers of the skin and increased free melanin in the skin. Hormonal pigmentation is usually brown with a non-distinct border, and is usually found symmetrically on the face or jawline. Melasma can appear on the central facial areas such as the cheeks, moustache, and forehead areas. Melasma affects both men and women, though it is more frequent in women (up to 30% may be affected) and usually starts to appear from the age of 28 years onwards.

• The pathophysiology of melasma is uncertain. In many cases, a direct relationship with female hormonal activity appears to be present because it occurs with pregnancy and with the use of oral contraceptive pills and HRT/ hormone replacement therapy
• After pregnancy Melasma (chloasma) or pigmentation usually clears within a few months of delivery but may persist indefinitely
• Any change in hormonal status with higher levels of estrogen is thought to trigger and aggravate the condition (i.e. birth control pills and pregnancy).Discontinuing the use of contraceptives rarely clears the pigmentation and it may last for many years after discontinuation.
• However many women without these risk factors also develop
• Other factors that may be implicated are progesterone ( the Mirena) ,
• photosensitizing medications such as tetracyclines or anti psychotic medication or medical conditions such as mild ovarian or thyroid dysfunction
• thus it is important to consult with a Skin Renewal doctor to diagnose the cause of Hormonal pigmentation/ Melasma
• Other possible causes could probably include genetic predisposition and exposure to ultraviolet light , visible light which emits infra red A ( computer screens, hair dryers, clay ovens) and excessive heat which causes inflammation ( such as saunas and steam baths)
• Stress may also produce certain hormones that worsen melasma.
• UVA rays are a stimulant for melanin (brown pigmentation) to develop on the skin, and unfortunately can even penetrate through car window glass.
• Any activities that cause intense heat to the face ( from steam showers, hot closed environments, sitting on the beach even under cover and with full sun protection, etc) causes inflammation which is a powerful stimulator of melanin
• Melasma is more prevalent in darker-complexioned individuals though persons of any race can be affected due to the intense sun exposure in South Africa.
• Melasma is seen most frequently in young women from the age of 28 years but can be also be seen in men.

Make an appointment to consult with your Skin Renewal Doctor and he/ she will assist you in determining your risk factors for pigmentation and how best to prevent any problems or conditions that you may be susceptible to.

• Hormonal pigmentation/ Melasma is a dynamic, chronic condition which has to have ongoing management by applying a pigment inhibitor daily. We have numerous Prescription and non prescription topical Brightening / pigmentation products at Skin Renewal
• Without the strict avoidance of sunlight and the continued use of home topicals mentioned above to downregulate the enzymes responsible for making pigment , potentially successful treatments for melasma and pigmentation are doomed to fail.
• To prevent increased Hormonal Pigmentation and PIH (Post inflammatory Hyperpigmentation) before and after any peel or IPL procedure, pretreatment for a period of 2 to 4 weeks is recommended to downregulate the enzymes responsible for making pigment
• Our superficial peeling treatment of choice at Skin Renewal is the Beta Melanostop peel which is a 4 peeling combination of salicylic acid, rescorcinol, phytic and azelaic acid combined with a transdermal brightening mesotherapy
• Prescription skin-bleaching agents are extremely helpful in lightening melasma and maintaining skin-lightening improvements and may be prescribed by our Skin Renewal doctors
• In addition, THE CONTINUED USE OF RECOMMENDED PIGMENTATION PRODUCTS IS MANDATORY AFTER ANY PEEL / IPL procedure .
• SPF of 50 MUST be applied twice daily
• Any laser procedure such as fractional laser that causes excessive redness and inflammation should be avoided as there may be aggressive rebound hormonal pigmentation a few weeks/ months later especially if NOpost treatment depigmentation products are prescribed
• At Body Renewal we recommend that you avoid hot baths,Bikram Yoga, steam saunas, tanning beds and dry saunas as they can cause excessive inflammation and may aggravate hormonal pigmentation
• At Body Renewal we are pleased to introduce Skin Brightening IV infusions for pigmentation..

The initial medical consultation at Skin Renewal will be approximately 30 minutes. If you think you're unaffected by pigmentation, ask your Skin Renewal doctor to look at your skin with a Wood's light -- a type of black light -which is available at all Skin Renewal clinics - or the Visia Complexion analyser. Our patients are always shocked by the as-yet-invisible dark spots that these lamps reveal. The Skin Renewal doctor will decide on a treatment plan or depending on :

• how long you have had hormonal pigmentation?
• If the Hormonal pigmentation/ melasma has been present or more than 2 years it may be more difficult to improve
• what medications you are taking
• previous treatment failures or successes
• whether dermal pigment is present .
• After the Woods lamp analysis, deeper dermal pigment can be identified and an appropriate treatment schedule can be prescribed
• your Skin type. Deeper/more aggressive skin peels and IPL/Lime Light procedures cannot be done on darker skin types 5 and 6
• your expectations and budget restraints
• your occupation/sporting/ recreational activities

Many all-natural, topical skin-lightening agents have been found to be quite beneficial in lightening hyperpigmented areas of the skin. These include alpha arbutin, as well as kojic acid, azelaic acid nicotinamide and Liquorice root( Glycyrrhiza glabra )

Topical applications of natural, fruit-derived alpha-hydroxy acids, including glycolic acid, have been extremely beneficial in combination with the aforementioned bleaching agents. For enhanced results, these products should be used in conjunction with exfoliation treatments such as peels and transdermal pigment lightening Mesotherapy .

The following is a list of skin care ingredients to AVOID due to worsening melasma pigmentation and dark spots.

oestradiol, oestrogen, genistein ,black cohosh, chasteberry, hops, red clever, soy, wild yams.

• Pigmentation present for more than 2 years may be more resistant to treatment as dermal pigment may be present and this may need transdermal therapy with TA ( Tranexamic acid) or deeper peels Cosmelan or Dermamelan depigmentation treatments which are suitable or all Skin types
• Dermal pigment is caused by the melanocyte distributing pigment/ melanin into the dermis instead of the epidermis.
• This dermal pigment may take longer to resolve than epidermal pigment . The source of the dermal pigment is the epidermis so if the epidermis can be prevented from making melanin for long periods with home topicals and peel/ depigmentation treatments such as a series of superficial peels, Cosmelan and Dermamelan , the dermal pigment will not replenish and will slowly resolve..but this may take months
• Normal SPF sunblock protect against UVA and UVB but NOT AGAINST infra red A. see below
• Without the strict avoidance of sunlight and the continued use of home topicals mentioned above to downregulate the enzymes responsible for making pigment , potentially successful treatments for melasma and pigmentation are doomed to fail.

• Infra red A , a relatively new discovery, is a deep dermal ray which causes accelerated ageing
• Infra red A is found in ANY visible light that emits heat such as sunlight, computer screens, fluorescent lights, heaters and even hair dryers
• Normal SPF 50 sunblock protects against UVA and UVB but does NOT protect AGAINST infra red A.
• One is only 56 % protected with a good SPF 50 sunblock
• If one applies a topical anti oxidant such a Vit C, Vit E , Ferulic and Phloretin, 96 % sun protection can be achieved
• Only topical antioxidants such as Vit C, Vit E , Ferulic and Phloretin can protect against infra red A

• For continued sun protection and to maintain results, oral supplements such as Ovelle (Pycnogenol®) or Heliocare (Polypodium Leucotomas) together with MSM with Vit C can be taken orally to increase ones resistance to the sun
• In addition Pycnogenol and Polypodium Leucotomas are powerful anti oxidants that stop the enzyme that breaks down collagen (MMP) and protect against infra red A, which is present in the light from sun exposure, computer screens, fluorescent lights etc

• After a series of 4 to 6 in office medical peel treatments combined with home topicals, the topical products need to be applied indefinitely and one of the above mentioned topicals is recommended. These can be alternated over time .
• If there no improvement after the 6th treatment then we usually recommend that a Health Renewal consult with one of our integrative doctors to exclude medical causes of pigmentation. This may also include a course of Skin Renewal lightening intra venous infusions with Glutathione Skin Brightening IV Infusion
• In addition, if there no improvement after the 6th treatment of superficial peels and topical products, Cosmelan or Dermamelan or Injected Tranexamic acid mesotherapy treatments are recommended to treat dermal melasma and PIH which has been present for more than 2 yrs
• If the melanin has leached into the dermis, this is known as dermal melasma
• The Laser Genesis procedure can be done in all skin types as it targets dermal pigment by heating up the melanophage ( which contains the melanin) trapped in the and aids the "release" of the trapped dermal pigment so it can move up to the epidermis where it can be exfoliated with normal epidermal renewal. Laser genesis also "polishes" the skin and improves fine lines, wrinkles , pores and texture
• For all peels prescription creams such as Retin A or retinols must be stopped stop 3 days before each treatment and restarted 3 days after the peeling process.
• At Body Renewal we are pleased to announce our new breakthrough in skin Whitening and Cellular Defense: An intra venous infusion of a combination of powerful anti-oxidants such as glutathione delivered with vitamins and fluids to hydrate the skin and reduce melanin production in all our pigmentation afflicted patients . After a series of treatments a lighter fairer skin tone may result. Glutathione is an extremely effective antioxidant comprised of three essential amino acids. It plays a major role in helping your liver detoxify harmful chemicals by binding to the toxins, facilitating their easy elimination. The body produces glutathione naturally, and research has shown healthy intake of Vitamin C boosts its production. If glutathione levels are normal, the body’s ability to fight neurological disorders like Parkinson’s disease is strong. If they are low, you are susceptible to a revolving door of conditions.

MSM is a powerful activator of the powerful anti oxidant Glutathione. MSM may facilitate the break up of pigmentation in the skin/ dermis as it a natural detoxifier. MSM contains sulphur which is necessary for the production of new cells and plays an essential part in the synthesis of collagen and keratin, vital protein substances that are needed to make and maintain hair, nails and skin. Hair and nails grow faster and stronger with good levels of sulphur. This compound is also responsible for the flexible bonds between cells and helps to block the cross-linking of collagen, an effect responsible for the appearance of wrinkles and aging skin.

Sulfur helps the body to form keratin, the protein that makes up the main part of the outermost layers of your hair and nails. It is a tough, fibrous protein that is very resilient to the effects of damaging chemicals and other harmful agents. Each strand of hair has its own keratin supply, which is stored in the root. Sulfur is also contained in biotin, a B vitamin that is essential for shiny hair and strong nails. You may be interested to know that the natural inclination of hair to be straight or curly is maintained in part by the sulfur amino acids. MSM benefits dry scalp and hair and improves nail growth and benefits your cuticles and nails.

Acne, including rosacea has been shown to respond favourably to MSM in studies, sulphur has also been found to enhance wound repair. MSM acts to keep the skin's cells and the tissue soft. Keeping the skin soft ensures that it remains elastic enough to allow stretching and movement without damage. Smooth, flexible skin is less prone to wrinkles and dry flakiness. It even helps stretch marks. MSM benefits the skin and internal organs.

• Avoid sun exposure and wear a protective hat when outdoors for extended periods to further block these rays.
• Use a broad-spectrum sunscreen with SPF 30+ to block the UVA rays every day to help prevent melasma.
• In addition your sunscreen you should also apply an anti oxidants such as Vit C, Vit E , Ferulic and Phloretin to protect against infra red A
• At least 5 mls / 1 teadpoon of sunscreen should be applied daily to the face and neck twice a day to prevent melasma/ hormonal pigmentation
• Taking an oral anti oxidant supplement such as Ovelle or Heliocare daily is clinically proven to raise one's level of resistance to the sun and also helps to reduce the melanin content in the skin down the line.
• As melasma is a dynamic condition and needs to be managed daily and indefinitely, one day of unintentional sun burn can set you back.
• At Skin Renewal we recommend that you avoid hot baths, Bikram Yoga, steam saunas, tanning beds and dry saunas as they can cause excessive inflammation and may aggravate hormonal pigmentation

The most common localized pigmentation disorder affecting the skin are ephelides, more commonly known as freckles. Freckles appear as flat brown pigmentation in sun-exposed areas, usually on the face. They are much more common in fair-skinned individuals, and a propensity to have freckles is an inheritable condition. The degree of pigmentation in the skin changes according to the amount of ultraviolet light exposure, so that freckles usually darken in the summer and lighten in the winter.

Another very common skin disorder is known Post Inflammatory Hyperpigmentation PIH. The underlying mechanism is unclear, but may involve inflammatory mediators such as prostaglandins and leukotrienes. While the causes and clinical presentation of post-inflammatory hyperpigmentation can vary, they are usually secondary to a traumatic incident to the affected area of the skin such as acne, dermatitis, eczema or any form of inflammation of the skin. Sun exposure can worsen this condition. Topical therapies and treatments as mentioned above in combination with sunblock may help this condition

Solar lentigos / sun spots appear as brown lesions (about 1 centimeter in diameter), typically on the face and hands. Both acute and chronic UV exposure can cause lentigos. While they rarely appear on patients under fifty, they are not caused by age -- sun-protected skin is not affected, even in elderly patients. Solar lentigos are completely preventable with sun avoidance and daily sunscreen use. Finally, whether solar lentigos are treated or untreated, patients should undergo routine skin exams, as they may be at greater risk for skin cancer.