Wednesday, August 1, 2012

What are the brown spots on my face?

What are the brown spots on my face?
The brown spots are called melasma. Melasma is a relatively common disorder of hyperpigmentation (dark discoloration) that affects sun-exposed areas of the skin, most commonly the face.

Who gets melasma?
Melasma is a very common skin disorder. Though it can affect anyone, young women with brownish skin tones are at greatest risk.

What causes melasma?
The precise cause of melasma has not been determined. Multiple factors including pregnancy, birth control pills (oral contraceptives), genetics, sun-exposure, cosmetic use, thyroid dysfunction, and anti-epileptic medications have been identified. Sun exposure is a strong risk factor for melasma. This condition is particularly common in tropical climates.  Melasma is probably the most cosmetically disturbing pigmentary change associated with pregnancy, occurring up to 75 percent of pregnant women. Female hormones are the factors contributing to these pigmentary problems. Melasma in men, shares the same clinical and histologic features, but not clear if it’s affected by female hormones.

What are the symptoms?

Melasma doesn't cause any other symptoms besides skin discoloration but may be of great cosmetic concern. A uniform brown color is usually seen over the cheeks, forehead, nose, or upper lip. It is most often symmetrical (matching on both sides of the face).

What are the simple tests to diagnose melasma?
Melasma can be easily diagnosed based upon the appearance of your skin. A closer examination using a Wood's lamp will be helpful to guide your treatment.

How can my brown spots be treated?
Treatment of melasma can be challenging because of the chronic and persistent nature of this condition.
Long-term topical cream use and strict sun protection is very important to control the disease. Chemical peeling are most often recommended for the treatment of melasma.

1. Topical cream
Creams used for whitening and pigmentation treatments usually contain hydroquinone, tretinoin, kojic acid, and azelaic acid. These are common bleaching agents which have been shown to improve the appearance of melasma.

- blocks formation of pigments by inhibition of enzyme tyrosinase.
- apply twice daily for up to 3-4 months with subsequent tapering
- normally 2-4% is used, but higher concentration yield better results
- complications: allergies, contact dermatitis, hypopigmentation of surrounding skin
- efficacy can be improved by combining with glycolic acid or tretinoin.

Azelaic acid
- Inhibits tyrosinase just like hydroquinone
- Used twice daily
- Adverse reactions: redness, scaling, itchiness, and burning

Tretinoin (Retin-A)
-  Tretinoin is a derivative of vitamin A. Tretinoin increase the turnover of cells. It is used for acne skin, where new cells replace the cells of existing pimples, and the rapid turnover of cells prevents new pimples from forming. By a similar mechanism, tretinoin reducewrinkles, areas of darkened skin (hyperpigmentation), and rough areas of skin, all of which occur in sun-damaged skin. Improvement in the skin usually are seen within the first 3 to 4 weeks of treatment. Brown spots begin to fade after 6 to 8 weeks. Wrinkles decrease or disappear after three to six months. Following application to the skin, a minimal amount of drug is absorbed into the body.
Combination of topical creams are widely used these days.

2. Chemical peels
Chemical peels in indicated for patients with moderate to severe melasma, especially those who did not respond to bleaching agents (topical creams).
Chemical peeling uses fruit acids that is applied on the surface of the skin, to create smooth, rejuvenated skin by way of organized repair process and exfoliation.

Few types of chemical peels exists:

Mild peeling
Mild peelers includes Alpha hydroxy acids (AHAs) and Beta hydroxy acids (BHAs)
Alpha hydroxy acids (AHAs) are usually fruit acids: citric acids, glycolic acid, lactic acid, malic acid and tartaric acid.
Beta hydroxy acids (BHAs) such as salicylic acid are normally better for oily and acne-prone skin type.

Intermediate to deep peeling
Trichloroacetic acid (TCA) is used as an intermediate to deep peeling agent in concentrations ranging from 20-50%. Depth of penetration is increased as concentration increases, with 50% TCA penetrating into the reticular dermis. Concentrations higher than 35% are not recommended because of the high risk of scarring.
Trichloroacetic acid peels smooth out fine surface wrinkles, remove superficial blemishes, correct skin pigment problems and normally require repeat treatment to maintain results. After peeling, use of sunblock for several months is a must.

3. Lasers
A wide variey of light -emitting devices are useful for the treatment of melasma. Q-switched lasers (QS) are currently the gold standard for treating pigmentation/melasma.
QS lasers deliver exceptionally high energy laser pulses with pulse durations in nanoseconds, creating acoustic shock waves within melanosomes, thus removes melanin.
Ablative and nonablative lasers work similarly like chemical peeling, inducing skin resurfacing and skin cells turnover.
Light therapy such as Intense Pulse Light is currently no longer a good modality for pigmentation treatments.

4. Sun protection

Regardless of the method chosen, therapy must be combined with use of broad spectrum sunscreens, preferably more than SPF35.
Clothing and hats should be also used.
Daily sunscreen use not only helps prevent melasma but is crucial in the prevention of skin cancer and wrinkles.

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