Tackling the complexities of chronic hyperpigmentation

October 8, 2024
Healthcaretoday, AMSC, Aesthetic Medicine Surgery Conference Exhibition, Melasma, Melasma treatment, hyperpigmentation, chronic melasma, topical treatments, combination therapy, photoprotection, skin care,
​​​​Melasma is a chronic hyperpigmentation disorder that often poses significant challenges to dermatologists. The condition can be either congenital or acquired, with localized hyperpigmented lesions.

Dr Inneke Jane Hidajat (pix), Dermatologist and Venereologist at Ciputra Hospital Citra Garden City, Kalideres, West Jakarta, elaborates on these complexities during her presentation at the Aesthetic Medicine & Surgery Conference & Exhibition (AMSC), titled “Challenges in Melasma Management in Tropical Countries.”

“Congenital hyperpigmentation is classified into epidermal types, such as café-au-lait macules and melanocytic nevi, and dermal types, like the nevus of Ota and blue nevus,” explains Dr Inneke. “On the other hand, acquired hyperpigmentation affects both the epidermis and dermis. Epidermal types include freckles, lentigines, and melasma, while dermal types include melasma, post-inflammatory hyperpigmentation, and ashy dermatosis.”

She further emphasizes that hyperpigmented lesions may also be diffused, such as those induced by drug use or associated with systemic diseases. Genetic disorders, such as dermatopathia pigmentosa reticularis and dyskeratosis congenita, can also result in mottled or reticulate pigmentation. Acquired forms of this type of pigmentation include poikiloderma of Civatte, erythema ab igne, and systemic conditions such as graft-versus-host disease and dermatomyositis.

Why is melasma so challenging?
The multifactorial pathogenesis of melasma makes it particularly difficult to manage. “One of the main reasons melasma is so hard to treat is its genetic predisposition,” says Dr Inneke. “Patients with this condition often have melanocytes that are extremely active and respond aggressively to triggers.”

She explains that sun exposure is a key contributing factor, especially in tropical countries where avoiding the sun is nearly impossible. "Less than 10% of people reapply their sunscreen every 24 hours," Dr Inneke adds. Hormonal changes, particularly in women, including those taking contraceptive pills, as well as exposure to blue light from screens, further exacerbate the condition.

Strategies for treatment
When it comes to managing melasma, a tailored, multi-modal approach is essential. The key to treatment is eliminating risk factors, such as sun exposure, and using strong UV protection. The aim is to decrease melanosome transfer and accelerate melanin removal from keratinocytes.

However, finding the right treatment for each patient is not straightforward. Some topical medications can cause irritation, leading to non-compliance, while others, like oral tranexamic acid, are not suitable for all patients. "Excessive laser treatments may worsen pigmentation in some cases," she adds.

Therefore, a balanced approach is needed—one that tailors treatments to the patient's skin while carefully weighing risks and benefits. Tranexamic acid is one example of a medication that can help halt the melanin production cycle by inhibiting the plasminogen activator, but it must be used judiciously.

Topical treatments: Evidence and efficacy
A recent systematic review and meta-analysis by Yu-Feng Chang and colleagues examined the irritation rates of common topical treatments for melasma. The results show that tranexamic acid (0.8%) has the lowest irritation rate, followed by kojic acid (5.3%) and azelaic acid (18.7%). In contrast, hydroquinone (HQ)-containing combinations have a higher irritation rate at 50.9%, making them less tolerable for some patients.

Dr Inneke stresses caution, particularly in patients with a history of urinary thrombosis. Instead, she advocates for conditioning the skin with hyaluronic acid and other hydration-promoting agents. "Improving skin hydration enhances the skin barrier, allowing it to better defend against reactive oxygen species and external environmental stressors," she explains.

This skin conditioning can also improve post-treatment recovery, promoting better skin texture and brightness.

The role of succinic acid and hyaluronic acid
Dr Inneke highlights the benefits of combining hyaluronic acid and succinic acid in treating melasma. “Succinic acid improves microcirculation in the skin and boosts cellular resistance to hypoxia, while hyaluronic acid helps in collagen production and hydration,” she explains.

Succinic acid also inhibits tyrosinase, the enzyme responsible for melanin production, effectively halting melanogenesis. Additionally, hyaluronic acid fragments can activate macrophages through tyrosine kinase receptors (CD44), which in turn help eliminate melanosomes.

In a study published in Dermatology on July 22, 2016, the potential of succinic acid to enhance essential amino acids in the skin was cited. This includes increasing concentrations of cysteine by 45%, arginine by 60%, and lysine by 50%, all of which contribute to healthier skin.

Combination therapy and photoprotection
In conclusion, managing melasma is a complex process that requires a comprehensive approach. Combination therapies, including topical agents, oral medications, and injectables like hyaluronic and succinic acid, offer the most effective outcomes. However, it's important to acknowledge the potential adverse effects and adjust treatment accordingly.

Emerging treatments continue to evolve, providing new avenues for managing this challenging condition. Photoprotection remains the cornerstone of successful melasma management, significantly improving treatment outcomes when used consistently.

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