Dr Manav Bawa
Many patients present with facial skin pigmentation in clinics. The impact of pigmentation and melasma can be extremely significant, causing distress and low self-esteem. There are numerous ways to treat skin conditions, including pigmentation and melasma, and one of the first and most important parts of the patient journey is to perform a thorough consultation. This is a way to obtain all relevant information about the patient, the impact that their concerns has on them (including the psychological implications) and the physical signs that are present.
Spending time discussing the patient's concerns and setting realistic expectations is encouraged, as it is important for them to understand the pathology and pathophysiology of their concern. Once understood, most patients will be able to gauge the reasons why certain treatments will be more beneficial than others.
In this article, the author will discuss hyperpigmentation, treatments and the Obagi Nu Derm Transformation System (ONDS), with results from two patients.
Melasma
Melasma is a common acquired symmetrical hypermelanotic condition (Bandyopadhyay, 2009) that affects millions of people worldwide (Rodrigues and Pandya, 2015). In the author's experience, the most common areas where patients describe melasma are the cheeks, forehead, upper lip and chin. However, other areas that are exposed to the sun can also be affected (Bandyopadhyay, 2009).
Melasma is the most common skin pigment concern within the Indian community (Pasricha et al, 2007) and the third most common among patients with black skin (Halder et al, 1983). Its incidence is higher in women in their reproductive years (Bandyopadhyay, 2009), those who are pregnant (Sodhi and Sausker, 1988) (can be called chloasma), those using oral contraceptives (Resnik, 1967) and following ultraviolet (UV) light exposure (Vazquez et al, 1988). Additionally, studies show that there is a strong genetic predisposition to melasma (Ortonne et al, 2009).
The condition is thought to be induced by melanocytes, which produce melanin, which is then stored in melanosomes (Sheth and Pandya, 2011). The colour of skin is determined by the amount of melanin within these cells, as well as the location and number of cells (Nordlund et al, 1998). Melasma presents when the production of the pigment malfunctions (Gupta et al, 2006), and it develops slowly and symmetrically, with worsening states in the summer (Urabe et al, 1998).
Scoring systems
Using an index is an effective way to assess and document the severity of the melasma and then measure the outcome. This can be helpful to present to patients, as well as to document and improve assessment measures; however, it must be remembered that all of these are subjective measurements.
Using an index is an effective way to assess and document the severity of melasma
Melasma Area and Severity Index
The Melasma Area and Severity Index (MASI) was developed by Kimbrough-Green et al (1994) to quantify the severity of melasma and the outcome following treatment. The score takes into account the subjective assessment of the area, darkness and homogeneity with the forehead, bilateral malar regions and chin (Pandya et al, 2011). The MASI score is then calculated using a set formula and ranges from 0 to 48, with a higher score indicating higher severity.
Melasma Severity Index
The Melasma Severity Index (MSI) is a second scoring system for melasma and uses a similar formula-based calculation to assess the severity of melasma and measure the treatment outcome (Majid et al, 2016). It is considered to be simpler and easier to calculate than the MASI.
Management
Photoprotection
Visible and UV light can induce hyperpigmentation (Pathak et al, 1962), and so, the first step in treatment is to advise patients to avoid the sun, especially between 10am and 3pm (Marks, 1999). They should also wear clothing and hats that protect them from the sun and apply a broad-spectrum sun protection factor (SPF) of at least 30 (Rodrigues and Pandya, 2015).
Obagi Nu Derm System
ONDS, which is produced by Obagi Medical, is a combined skin system for patients, containing hydroquinone (HQ) and tretinoin components. Due to the medicated products, the system is a prescription-only medication.
The system contains a cleanser, a toner, HQ, Exfoderm® (chemical exfoliant), a second HQ (to be mixed with tretinoin), a hydrator and an SPF 50 cream. The cleanser, toner and exfoliant improve epidermal permeability to allow improved delivery of HQ and tretinoin (Pannucci et al, 2011). The system also aims to improve dermal density (Herndon et al, 2006).
ONDS can significantly reduce hyperpigmentation at the 24-week stage of continuous use, as well as fine lines and skin laxity, while improving texture and tone (Herndon et al, 2006).
Hydroquinone
HQ is a medicated cream that can significantly reduce hyperpigmentation in patients by preventing the synthesis of melanin (Palumbo et al, 1991; Amer, 1998).
Tretinoin
Tretinoin—a member of the retinoid family—can be used to increase the penetration of HQ into the skin (Gupta et al, 2006). It can also reduce hyperpigmentation as a standalone medication (Halder and Nordlund, 1998) by inhibiting melanogenesis and accelerating epidermal turnover, leading to a reduction in the pigment (Kligman and Willis, 1975; Nordlund et al, 1998). Tretinoin can also be used for acne vulgaris and photoageing (American Society of Health-System Pharmacists Inc, 2004), and can be used in combination with HQ for hyperpigmentation. Furthermore, it is licensed for use with HQ and steroids (for example, Tri-Luma, Galderma) (Murray, 2003).
Case studies
Patient A (Figures 1 and 2) presented in clinic saying that she had experienced facial pigmentation for many years and had tried a number of products in the past without success. She was also concerned about a dullness to the skin and uneven texture and tone, and was looking to optimise her skin health. Following use of the combined HQ and tretinoin system, there was a marked reduction in general pigmentation across the entire face (Figures 3 and 4). There is also a marked clarity and even texture as well as tone to the skin. Figures 3 and 4 were taken at 3 months following continuous use of the combination treatment.
Figures 1 and 2. Patient A before treatment 
Figures 3 and 4. Patient A after treatment
Patient B (Figures 5 and 6) presented in clinic having had melasma on the cheeks for many years, and she, too, had tried numerous over-the-counter skin systems and products, with no reduction in melasma.
Figures 5 and 6. Patient B before treatment
Using the combined HQ and tretinoin system, there was a marked reduction in the melasma; however, it took 6 months to see a significant difference (Figures 6 and 7). The patient also saw a general improvement the clarity and colour of her skin.
Figures 7 and 8. Patient B after treatment
Conclusion
The combined use of HQ and tretinoin has been shown to significantly reduce hyperpigmentation and melasma. Tretinoin can also be used for photoageing and acne vulgaris (American Society of Health-System Pharmacists Inc, 2004). Therefore, it is an effective product that can be implemented in a patient's treatment plan, should they require it.
Key points
- The initial consultation is extremely important, and it should include education regarding the presenting skin condition, as well as setting realistic expectations to the patient
- Risks and downtime should be considered and explained to the patient, as some occupations require no downtime, so potential treatments and starting home care may need to work around a patient's schedule
- Combination treatments and a holistic treatment plan usually provide superior results. Combinations should include home care and regular peels every 6 weeks.
CPD reflective questions
- What is the aetiology and pathogenesis of melasma?
- What is included in the 2 melasma severity scoring assessments?
- What are the main risks of treatment with hydroquinone and tretinoin?