Melasma is an acquired facial pigmentation skin disease that occurs mostly on the face of women with darker skin who are frequently exposed to ultraviolet rays. Female patients account for 90% of all cases, and the incidence rate in Asian women of childbearing age is as high as 30%. The course of the disease is recurrent and can last for several years. It is easy to relapse, which seriously affects the patient's appearance and self-confidence. Male patients account for about 10%, and some studies believe that the incidence of males is related to genetics. In general: it is not easy to treat!

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Clinical manifestations of melasma

Melasma is manifested as light brown or dark brown patches symmetrically distributed on the face, with different sizes, irregular shapes, and clear or blurred edges. Commonly found in the central area of the face, such as the forehead, nose, cheeks, upper lip and chin, and sometimes in areas exposed to the sun, such as the neck and forearms. It gets worse after sun exposure, and the symptoms are more obvious in summer, but may be alleviated in winter. Generally, there are no subjective symptoms, and it mainly affects the appearance.

Clinical classification of melasma

1. Stages

Active stage: The lesion area has recently expanded, the color has deepened, the lesion has become red, and the lesion has become red after scratching. Most of the lesions have faded after glass slide pressure diagnosis.

Stable stage: The lesion area has not expanded recently, the color has not deepened, the lesion has not become red, the lesion has not become red after scratching, and most of the lesions have not faded after glass slide pressure diagnosis.

2. Classification

Based on the involvement of blood vessels, it is divided into 2 types:

Simple pigment type (M type): The lesions do not fade when the slide is pressed, and the color contrast between the lesion area and the non-lesion area increases under the Wood lamp.

Pigmented combined with vascular type (M+V type): The lesions partially fade when the slide is pressed, and the color contrast between the lesion area and the non-lesion area under the Wood lamp is not significantly increased.

Based on the location of the pigment, it is divided into 2 types:

Epidermal type: The pigment is mainly located in the epidermis.

Mixed type: The pigment is located in the epidermis and the superficial dermis.

Based on the location of the lesions, it is divided into 3 types:

Central facial type: The lesions are mainly distributed on the forehead, cheeks on both sides, lips, and nose.

Cheek type: Lesions are widely distributed on the cheeks and nose.

Mandibular type: Lesions are mainly distributed on the mandibular area.

Treatment of melasma

First, avoid the causes. Avoid excessive sun exposure, reduce cooking or occupational heat exposure, avoid using inferior cosmetics with excessive mercury and lead content, avoid taking drugs that cause changes in sex hormone levels, and maintain a good mood and mentality.

Second, pay attention to sun protection. Sun protection is the primary prerequisite for treating melasma and should be carried out throughout the entire treatment process. It is recommended to use both soft sun protection (such as sunscreen) and hard sun protection (such as parasols, sun hats, and sun protection clothing). When applying sunscreen, apply it in sufficient amount.

In addition, repairing the skin barrier is crucial for patients with melasma, as many patients with melasma have damaged skin barriers. In daily skin care, it is recommended to use functional skin care products containing ingredients such as hyaluronic acid, ceramide, cholesterol and free fatty acids. These ingredients help maintain the structure and function of the skin barrier and enhance the skin's moisturizing and protective abilities.

1. Treatment in the active phase

Treatment of melasma in the active phase mainly focuses on basic treatment and systemic drug treatment, avoiding the use of phototherapy and chemical peeling.

Systemic treatment includes: tranexamic acid, glycyrrhizic acid, vitamin C, vitamin E, and glutathione.

• Tranexamic acid: It can competitively inhibit tyrosinase, reduce melanin synthesis, inhibit angiogenesis, and reduce erythema. It is usually taken orally, 250-500 mg/time, 12 times a day, and it is recommended to use it continuously for 3 to 6 months.

• Glycyrrhizic acid: It has anti-inflammatory effects and can be intravenously dripped.

• Vitamin C and Vitamin E: Vitamin C can prevent DOPA oxidation and inhibit melanin synthesis, and Vitamin E has an antioxidant effect. The combined use of the two can enhance the therapeutic effect.

2. Topical drugs:

Topical drugs are widely used to treat melasma, which can effectively reduce the score of melasma and have relatively high safety.

• Hydroquinone and its derivatives: They are the first-line topical treatment drugs for melasma, with a common concentration of 2%~5%, used once a night, and there will be obvious effects after 2~4 weeks of treatment, and the best effect is 6~10 weeks.

• Retinoic acid: 0.05%~0.1% retinoic acid ointment or gel is commonly used in clinical practice, once a night, and the course of treatment is about 6 months. It can promote epidermal renewal and reduce pigmentation.

3. Treatment in the stable period

Combined with photoelectric and other comprehensive treatments based on systemic treatment and topical drug treatment. Photoelectric treatment includes photorejuvenation, picosecond laser, non-ablative fractional, etc.

·IPL Intense Pulsed Light·

Intense pulsed light, commonly known as "photorejuvenation", if laser is a single wavelength monochromatic light, intense pulsed light is a wide spectrum composite light in a certain wavelength range, so it is also called composite color light. Like: phototherapy miracle egg, AOPT, DPL, BB light, CC light, etc. are all intense pulsed light.

In the stable period, for simple pigment type (M type) and pigment combined with vascular type (M+V type) melasma, different filter bands are selected for treatment. The filters of different instruments will also be different, and the technical requirements of the operator are relatively high. For patients with pigment combined with vascular type (M+V type) melasma, 585nm or 595nm pulsed dye laser and 500-1200nm intense pulsed light (IPL) can be used. These treatment methods can selectively act on capillaries and inhibit vascular proliferation while targeting pigments.

·Picosecond laser·

Compared with Q-switched laser, picosecond laser has shorter pulse width and higher peak power. It acts on pigment particles mainly through photomechanical effect rather than thermal effect, thus avoiding the risk of pigment rebound caused by thermal stimulation of traditional laser. The 755nm picosecond alexandrite laser can not only effectively remove spots, but also form a laser-induced photodestructive effect on the epidermis, stimulate collagen synthesis, and improve photoaging. The 1064nm picosecond laser uses a large spot and low energy flat scanning treatment mode, and has low adverse reactions after treatment. Like the 755nm alexandrite picosecond laser, it is currently an ideal choice for the treatment of melasma.

·Non-ablative fractional laser·

Common wavelengths include 1540 nm, 1550 nm and 1565 nm lasers, which can selectively inhibit pigment synthesis and increase skin collagen, which can brighten the skin tone overall.

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