I use many of the best cutting edge lasers and light devices in my office every day. However, I am the first person to talk my melasma patients out of using these devices, and opting for less expensive options instead. This blog focuses on why! 

If you have melasma, when you first get a laser or light based treatment, you might see the brown patches turn into a coffee ground material, and then slough off. At first, the results look great! However, the next time you go in the sun, you might notice your melasma comes back with a vengeance. I can’t tell you how many patients have come to me in tears after getting a series of laser or IPL (intense pulsed light) treatments at a spa, and realizing that they spent thousands of dollars only to find that their melasma is worse than it ever was.  

Here’s why that happens. We know that melanocytes, the pigment producing cells, are exquisitely sensitive to both heat and light. Consequently, it seems as though most laser and light devices, even used at very low/gentle settings, prime or sensitize the melanocytes. The next time these cells are exposed to sunlight or heat, they work overtime to pump out more pigment. As a dermatologist, on behalf of my patients, I’d rather be safe than sorry. Although every melasma patient would love a quick fix, and laser before and after photos can provide that WOW they are looking for, I strongly urge you to see a provider who takes a more conservative (and often less expensive) route.  

Now if you have sun damage, and your brown spots are lentigos, or sun spots, and NOT melasma, that’s a whole different story! Bring on the lasers and lights! In those cases, I absolutely love using lasers like the Fraxel laser to brighten dark spots from the sun. So, the very first and more important step is to make sure the person deciding on your treatment plan has a very good eye and knows how to diagnose disorders of pigmentation.

I’m sharing so much on melasma right here for you guys and I love the questions you have been asking. Check out my latest posts on my favorite skincare ingredients and products to address melasma and my thoughts on the safety of hydroquinone, a topical treatment often used to treat melasma.

Dr. Whitney

I’ve been getting so many questions about which skincare ingredients are most effective when dealing with melasma, or the type of hyperpigmentation known as the “pregnancy mask.” 

Overall, the strategic combination of complementary ingredients to target different aspects of melasma is, in my opinion, the best approach. Here’s why: some ingredients slow down pigment production, while others stop the transfer of pigment from the melanin producing cells to the other cells in the skin. Other ingredients help exfoliate away the uppermost layers of pigment-stained skin, and others act as antioxidants, neutralizing the free radicals and oxidative stress that makes melasma worse. So, combinations are going to be more effective than single modalities.

But, it’s a delicate balance because we don’t want to overdo it with potentially irritating ingredients. If you cause too much irritation in the skin, this can make melasma worse. 

In this post, I’ll cover both products you can get online or in stores, and ingredients that come in prescription strength, through your doctor. I’ve put together a list of the ingredients I find most effective in addressing melasma, and of course, I’ve added products in each category that I love to use:

Glycolic acid and/or lactic acid: 

While in office peels are going to get you more dramatic results more quickly, you can absolutely see improvements using at home peels if you use them right! 

First, look for ingredients like glycolic acid and lactic acid. If you have oily skin, you might enjoy a peel with salicylic acid, but that can be drying in more sensitive, dry skin types.

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.

Despite what the instructions say, the first time you use one of these at home peels, consider leaving it on for 5 minutes and then rinsing off, and immediately applying a moisturizer – this is the recommendation I make to my patients. This short exposure is a “test run” for your skin to see how you tolerate that peel. Another good rule of thumb is that tingling is ok, but stinging/burning is NOT ok.  If you feel anything more than a tingle, then wash it off immediately and apply a nourishing moisturizer. Burning does NOT mean it’s working- it means it’s triggering too much inflammation in your skin and that can make your melanocytes react by pumping out MORE pigment.  

If your skin feels healthy and you don’t experience any stinging/burning or red blotches in the days following the first peel trial, then you can consider leaving the product on the skin either for 10 minutes, or even overnight, depending on the strength of the product and how sensitive your skin tends to be. The goal is to try to work your way up to using one of these products twice a week at night, with each application spaced 3-4 nights apart.  

Some of my favorite at home peels are:

Moon Juice Acid Potion Resurfacing Exfoliator: (glycolic, lactic and salicylic acid)

Skin Fix Correct+ Dark Spot Corrector: (glycolic acid and lactic acid) 

Herbivore Botanicals Prism 12% Exfoliating Serum: (lactic, glycolic, and malic acids)

Vit C and other antioxidants (turmeric, Vitamin E, honey)

Cover FX Brightening Booster Drops (these drops have an oil soluble derivative of vitamin C called Ascorbyl Tetraisopalmitate.  It’s one of the most stable forms of vitamin C and stability is critical for vitamin C because it is prone to oxidation)  

Skinceuticals CE Ferulic with 15% L-ascorbic acid. (Strong science behind this one, but note that it is expensive)

Bakuchiol (a retinol alternative)

Check out my full blog post on this topic HERE.

Other topical ingredients to consider: azeleic acid, kojic acid, niacinamide, licorice root extract, mulberry extract and tranexamic acid, arbutin and soy. Licorice root seems to be more soothing, while niacinamide can cause irritation in some people. Topical tranexamic acid can sometimes help, but can also cause some irritation. Topical use is much less effective than when I prescribe tranexamic acid orally (more on this immediately below).

Turning to Prescription strength topical ingredients to address melasma:

In my office, I’ll often compound or blend my own prescription strength ingredients for my melasma patients.  Oftentimes, these products combine tretinoin or tazorac (forms of prescription strength vit A) with hydroquinone. Hydroquinone is a controversial ingredient with some very real side effects, so I strongly discourage anyone from using this ingredient if they are not under the direct supervision of a dermatologist. I have an entire post on the safety of hydroquinone here.  I talk about the risks and benefits of these treatments with my patients, and customize my approach for each patient based on their pigment pattern, medical history, budget and comfort level.

For info on how to address your melasma from the inside out through diet and supplements, check back soon!

Dr. Whitney

 

Melasma, and hyperpigmentation in general, is one of the most common reasons people schedule an appointment with a dermatologist. Below, I’ll talk all about one of the most powerful topical ingredients we use to treat melasma, hydroquinone, and the safety concerns surrounding its use. 

Okay, let’s dive into the topic at hand: just how SAFE is hydroquinone?

Hydroquinone is one of the most powerful topical ingredients when it comes to brightening dark spots, treating melasma, combatting hyperpigmentation and evening out skin tone. It’s available both as a prescription, often found in combination with other prescription medications like tretinoin, and is also available in OTC (over the counter) products. While it’s an incredibly powerful ingredient, and often considered first line by most dermatologists in the treatment of melasma, there are safety concerns surrounding its use. Does it get absorbed into the bloodstream? Can it cause cancer? Can it damage your liver? Should I be afraid to use it?  Having researched this ingredient extensively, and having used it in the office for over a decade, I will give you my honest opinion here.

First, should you be afraid of systemic absorption, and possible risks associated with systemic absorption? Many people aren’t aware that they are being exposed to considerable amounts of hydroquinone in their diet every single day. Hydroquinone is found in nature as either hydroquinone or arbutin, which is converted into hydroquinone in the body.  Hydroquinone and arbutin are found in tea, coffee, pears, wheat bread and red wine. Studies show that human exposure to hydroquinone from our diet is significant https://pubmed.ncbi.nlm.nih.gov/8568910/  I personally consume coffee and tea every day, and I love enjoying a juicy, ripe pear as a healthy snack.  

Does hydroquinone cause cancer or damage the liver? Most of these studies were done in rats, and many were done on populations of rats that already had predispositions for growing certain cancers and tumors. Although I certainly am not going to ignore these concerning studies, it is very hard to make a convincing case that what we see in rats will translate into humans. As far as liver studies go, hydroquinone seems to actually have a slight protective effect when you look at risk for liver cancers in rats. So clearly, we really are not certain of the true impact that hydroquinone has on our different organs. So far, studies done in humans who are exposed to higher concentrations of hydroquinone have been reassuring. I honestly don’t know any board certified dermatologists in the US who are afraid to use this ingredient because of concerns surrounding its “toxicity” to the body, after having reviewed the literature and science extensively.

What we do know is that high concentrations of topical hydroquinone, especially used for long periods of time without a doctor’s supervision, can lead to a skin condition called exogenous ochronosis, or pseudo ochronosis.  

This is when we see a darkening of the skin, even darker than the original melasma that these creams were meant to treat!  Furthermore, it is near impossible to get these stains to disappear!  

These cases, thankfully, are quite rare in the United States, and much more commonly found in parts of the world where people are also using antimalarial medications. Antimalarials also cause pseudo ochronosis, so the combination of hydroquinone plus antimalarials are probably a major risk factor for this condition.

The main risks seem to be: 

using concentrations higher than 4%

using hydroquinone for years at a time without breaks, and

combining hydroquinone with other ingredients such as oral antimalarial medications.  

We also know that many “bleaching” and “whitening” creams that you can find online or in other countries are contaminated with mercury and high potency steroids like clobetasol https://www.sciencedirect.com/science/article/abs/pii/S0013935116302651

Ok, so how do I approach hydroquinone in my office with my patients.  Here are my take homes:

  • Hydroquinone should only be used under the very strict supervision of a dermatologist
  • Each patient needs to weigh pros and cons, risks and benefits of using hydroquinone vs using other treatment modalities.  In cases where melasma is severe and affecting someone’s quality of life, the benefits may outweigh the risks. It’s a personal decision between that patient and the treating physician.
  • If you have been prescribed a hydroquinone containing prescription from your dermatologist, you MUST follow up carefully. Most derms will rotate you off of hydroquinone every few months, to make sure you get prolonged breaks between uses.
  • If you have used hydroquinone, or are using it, under the close supervision of a dermatologist, don’t lose sleep over it! Remember, everyone who is drinking coffee or tea, or eating pears or sipping on red wine, is also being exposed to hydroquinone.
  • Do NOT try to get hydroquinone containing products online or through online pharmacies.  If a friend brings you an extra “magic cream” across the border and swears by it, PASS!  Warn your friend about mercury and clobetasol and other risks she/he might not even know about.

For more recommendations and discussions surrounding melasma and hyperpigmentation, check out my IGTV and YouTube channels.

Dr. Whitney

 

 

Now that the warm summer months are becoming a distant memory for many of us, one major focus in my office is on hyperpigmentation that’s still lingering on my patients’ skin into the winter months. Specifically, melasma, also called the “pregnancy mask”, is common and can be incredibly frustrating. 

Melasma is a type of hyperpigmentation which is characterized by dark brown or gray-brown patches of skin on your cheeks, forehead, upper lip, or along the lower cheeks and jawline. My patients often describe it as having the appearance of “paint splatter” on their skin.  The excess pigment can be in the upper layers of your skin, or the deeper layers, or both. If you have excess pigment in the deeper layers, that can be much more challenging to treat.

A question I’ve been getting all the time on this subject is: Should I use retinol or bakuchiol if I have melasma?

Whereas retinol can be a bit of a diva in that it can be an irritant. Anyone who has tried a retinol has been there: you use it liberally for a few nights in a row and think: “No big deal! What’s all the fuss? My skin is doing fine.”  Then, about 4-5 days in, you find your regular moisturizer that you use all the time is making you red, blotchy and stings like crazy when you apply it. Then, you start to see the flakes, and you officially have a full blown case of “retinoid dermatitis!”

The new kid on the block, bakuchiol, is not irritating in the same way, and has been found to actually help soothe irritated skin!  When compared to retinol, bakuchiol is also very effective at reducing hyperpigmentation. This is so important because we know that irritation can actually exacerbate your melasma, making it worse. So although retinoids are so great at lightning the skin, it was always a delicate balance between getting the benefits without creating inflammation which we know could set melasma patients back.  

Now, we don’t have the same mountain of evidence for bakuchiol as we do for retinol because bakuchiol is so new on the scene, but the studies I’ve seen have been very, very promising and exciting on this front.

Also, bakuchiol is a great option for hyperpigmentation/melasma patients because it is not photosensitizing, meaning it won’t make your skin more susceptible to sun damage. Many retinol products, in contrast, are best used at night because they can make your skin more sensitive to the sun. 

Third, bakuchiol acts as an antioxidant, which is very beneficial for melasma patients given that oxidative stress and free radicals contribute to melasma. 

Finally, pregnancy and nursing often coincide with melasma (also known as the “pregnancy mask”), but we do not recommend use of retinol if you are pregnant or nursing. So, bakuchiol is a great option to help dial down melasma while you are pregnant or nursing. 

Here are some of my favorite bakuchiol products: 

Herbivore Botanicals Bakuchiol Retinol Alternative Serum-very lightweight, easily layers under your moisturizer.

Beauty Counter Countertime Tripeptide Radiance Serum 

You guys have asked so many great questions about melasma, so keep ‘em coming!

 

Dr. Whitney

@DrWhitneyBowe

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