July 25, 2018Skincare

Melasma 103: Q & A with Dr. Whitney Bowe

You guys asked so many insightful questions about this subject, so I am answering a number of them here and then, we will also have another post, Melasma 104, in order to address the broader questions.

This Q & A is intended to empower you with knowledge and information to discuss with your physician. Without seeing each and every one of you in my office as a patient, I cannot provide personal medical advice. Instead, my goal is to share my knowledge and experience in order to serve as a guide for you – arming you with the knowledge you need to help make excellent medical decisions with your personal doctor.

Here goes!

Q: Which peels, lasers, etc would be safe for a patient with Melasma.

Dr. Whitney Bowe: I will address this question from an in-office and an at home perspective.

I offer superficial, medium and deep peels in my office. The depth of the peel plus the combination of ingredients has a major impact on which skin issues the peel addresses as well as how much downtime/recovery is involved post-peel. Many of my patients come into my office recounting the Sex and the City episode where Samantha had that horrendous chemical peel. As I tell my patients, not all peels are created equal, so you really want to be sure that you are in very experienced hands when it comes to these types of peels, particularly if you have Melasma.

Over the years, I’ve found that the best in office “peel recipe” for Melasma is a series of at least 10 monthly superficial peels. Superficial peels don’t penetrate too deeply into the skin, and the cumulative effect of these peels is more effective AND results in fewer side effects than a smaller # of medium or deep peels.

If someone with Melasma also has acne prone skin, or the type of rosacea that leads to swollen looking pores (what I call a peau d’orange, or orange peel appearance to the skin), then I begin with salicylic acid peels. Salicylic acid is incredibly effective at dialing down redness in the skin. It’s very closely related to aspirin on a molecular level, and we know aspirin is an amazing anti-inflammatory. My patients note that salicylic acid peels tend to be very calming and anti-inflammatory. These peels also typically don’t make you more sensitive to the sun, so these are my go-to peels all summer long.

If a patient presents with dry skin, and isn’t struggling with redness, then I might start with a series of glycolic acid peels. There’s a major misconception that the higher the percentage, the stronger the peel. However, it’s not just percentage that matters . . . it’s also the pH of the peel, and whether the peel is buffered or not. So you might go to a spa where an aesthetician is using a 70% glycolic peel on your skin, but that peel is very buffered and hence much weaker than a 30% peel I use in my office!

If you’re thinking about starting a series of peels with your practitioner—a few things to keep in mind and to discuss with your doctor:

  • I recommend that my patients refrain from using anything that could irritate your skin in the days leading up to the peel. I have my patients stop using any products containing retinoids or benzoyl peroxide four nights prior to peels in my office
  • Your skin should be prepped prior to the peel, to ensure it penetrates evenly. This step “degreases” the skin, so it removes any built up oils or sebum on the skin that might affect the peel’s ability to penetrate evenly.
  • My staff uses a barrier ointment to protect the delicate areas on the face where the acid can pool. They paint it on using a Q-tip.
  • Some peels are re activated by exposure to water, so be sure to ask how long to wait before sweating or exercising or washing your face again.

The peels you purchase online or over the counter, that are meant for at home use, tend to be much weaker than in office peels. However, you can still run into trouble. At home peels contain many of the same ingredients as in-office peels, so they do come with a risk of burn or skin irritation if used improperly. One at home salicylic acid peel that has consistently been given rave reviews by my patients is the Exuviance Performance Peel AP25. The ease of use is definitely a key feature of this peel, as you are using pads rather than a dropper. I often recommend that my patients start off trying these once per week to determine their skin sensitivity and to assess whether there is any reaction. Follow with a moisturizer, as these peels can be drying.

Q: What makeup is best to cover melasma? I noticed a lot of makeup brands sit on top and do not help cover.

Dr. Whitney Bowe: My patients with Melasma consistently love a product called Dermablend.

I also regularly recommend the Bobbi brown color corrector. I actually use this to cover up both uneven pigment AND broken blood vessels or red areas. Pat, don’t rub, onto spots that require coverage. Then use your regular foundation all over on top. I use this like a concealer/spot corrector.

And, here are a few makeup tips which I share with my Melasma patients: Always begin by using a moisturizing sunscreen underneath your foundation! Studies show that people use about 1/7th of the powder or foundation they need to get the SPF on the label – meaning, you would need to apply 7 coats of the makeup/powder you would normally use to get the SPF you think you’re getting. This is not true of moisturizing sunscreen/moisturizer with SPF so, I recommend beginning with this type of product, allowing it to absorb, and then applying your makeup on top. If your makeup also includes SPF, this would be icing on the cake.
Never rub your foundation. Instead, pat or blot it on with a sponge or fingertips. Rubbing can actually irritate/inflame your skin, which can make Melasma worse.

Q: I have heard microdermabrasion is helpful. Do you think so or could it make it worse?

Dr. Whitney Bowe: In my experience, Microdermabrasion can make Melasma worse, so I tend to avoid it in my Melasma patients.

Q: What is your recommended skincare routine, including ingredients, for patients with Melasma?

Dr. Whitney Bowe:

MORNING:

I always recommend that my Melasma patients begin with a Heliocare supplement every morning. Heliocare has been studied in patients with Melasma and a recent study (http://jcadonline.com/effectiveness-polypodium-leucotomos-extract-melasma-asian-skin/) demonstrated its efficacy when used in combination with sunscreen and hydroquinone.  Subjects who also took Heliocare, along with those other measures, actually had a faster response and accelerated brightening of their dark spots compared to those who took a placebo. Slow response to treatment is one of the most frustrating aspects of Melasma, so anything that is proven to safely speed along the progress is key!

In addition to taking a Heliocare supplement, I recommend that in the morning, my Melasma patients cleanse their skin with a gentle cleanser (ex: LRP) using fingertips only. Pat your skin dry (don’t rub). Next, you can add a couple of drops of your favorite Vitamin C Serum (see those listed below) into your moisturizer with SPF, or you can use a layering approach – apply your antioxidant serum first and then layer your moisturizer with SPF on top of it.  Follow with makeup per my description.

For my sun hat and lifestyle recommendations for patients with Melasma, please check out Melasma 101 and 102.

EVENING:

In the evening, I recommend that my Melasma patients alternate between an antioxidant serum like La Roche-Posay’s CE Ferulic or Dermalogica biolumin c serum and a retinol-containing product like dermalogica’s overnight retinol repair or one prescribed by your doctor.

Also, I usually prescribe a Melasma Emulsion – which my patients often mention on social media — or a BLEND of ingredients to use a few nights a week- talk to your derm about getting one customized to meet your needs. I choose from ingredients like HQ, kojic acid, tretinoin and hydrocortisone. I do not sell this emulsion on my website. This is an in-office customized prescription.

Dr. Whitney