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Melasma

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Melasma is an acquired hyperpigmentation that is characterized by bilateral irregular brown macules and patches on sun exposed skin
Epidemiology
  • female
  • high fototypes
  • Latin-american and asian countries - pessoas com mais melanina
    • Brasil - preocupação com Lepra e estigma
Pathogenesis
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Melanocyte hyperactivity without melanocyte proliferation
  • Genetic predisposition
  • External factors: UV exposure
  • Hormonal factors: estrogen
 
Melasma pathogenesis
Melasma pathogenesis
  • Involves melanocytes, keratinocytes, mast cells, gene regulation abnormalities, increased vascularization and basement membrane disruption
    • Mast cells and solar elastosis: studies have shown an increased presence of mast cells in areas of the skin affected by melasma, which are involved in the development of solar elastosis. These mast cells promote the production of elastic fibers and contribute to vascular proliferation, influencing melasma’s appearance
    • Basement membrane degradation: Chronic UV exposure can increase the levels of certain enzumes like matrix metalloproteinase 2 (MMP2), which leads to degradation of the basement membrane. This degradation is critical as it facilitates the migration of melanocytes though the dermis, potentially contributing t the persistent hyperpigmentation observed in melasma
    • Vascular chenges: an increase in vascular endithelial growth factor (VEGF) has been noted in melasma-affected areas, promoting increased pigmentation through mechanisms like enhanced melanogenesis induced by endothelin 1 secretion
Melasma types
  • Centrofacial (bigode, fronte)
    • Linea fusca
  • Malar
  • Mandibular
Distribution of pigment by melasma examination with wood light
  • Epidermal
    • The pigment is intensified by light from Wook (increase in brown)
    • La melanin is increased in all layers of the epidermis, few melanophages are observed scattered in the papillary dermis
  • Dermal
    • The pigment does not increase with Wood’s light
    • There are many melanophages throughout the dermis
  • Mixed
    • Presentation becomes more evident in some areas, while in others there is no change at all
  • Indeterminate
    • Wood’s light examination is not useful in people with type VI skin
Escada terapêutica
  1. Dermocosméticos
      • Conceito
        • Vitamina C
        • Protetor Solar
      • Produtos
        • Tinted sunblock
        • Skin Unify SPF 100 (Filorga)
        • Eucerin antipigment serum 4id reversible effect
        • MelaB3 Sérum
        • Photoderma M SPF50 (bioderm) 22€ 40mL
        • Pigmentação pós inflamação de acne: bariederme despigmentante depiderm
  1. Medicamentos tópicos
      2. notion image
      • Hidroquinona (Quinostasa 4%) - inibidor da tirosinase que converte tirosina em melanina
        • 2 semanas id à noite depois passa a 2 id enquanto faz protetor solar 50+, evitar em grávidas e a amamentar (não há estudos)
        • Diariamente a noite durante 4 meses (Joana Calvão)
      • Hidrospot
        • Hidroquinona 4%, ácido glicolico 10%, ácido cítrico 1%, 21,40€ por 30g
        • Aplicar a noite na região hiperpigmentada, gel
      • Klingman triad
        • Composition
            • 💡
            • Hidroquinona 4% + tretinoina + dermocorticoide (prevent irritation)
          • Fórmula caseira: hidroquinona + locoid + ketrel (misturar no dedo e aplicar)
          • Fórmula manipulado: 0.1% tretinoin (ketrel), 0.1% Betametasona/dexamethasone (advantan, dexaval), 5.0% hydroquinone (quinostasa ou hidrospot)
            • Passar como manipulado
            • Tem que se deixar no escuro
            • Mais forte, reservar para casos refratários
          • Internet? Fluocinolone, hydroquinone, and tretinoin triple combination cream (TCC)
          • Pigmanorm - igual à fórmula de klingman, não disponível em portugal mas dá para mandar vir online
          • Espanha (Pedro Jimenez)
            • Klingman light: hidroquinona 3%, ácido kójico 3%, ácido retinoide 0,025%, hidrocortisona 1%, vitamina E 2%, vitamina C 1,5%, emulsion O/W CSP 30g
            • Klingman hard: hidroquinona 5%, ácido kójico 3%, ácido retinoico 0,05%, enoxolona 0,5%, vitamina E 2%, vitamina C 1,5%, emulsion O/W CSP 30g
            • Usar 3x/sem à noite. Nos outros dias dá um serum.
        • Exemplos de alternativas
          • Study: subtitution of hidroquinone with thiamidol 0,1% = same results (alternative to Klingman’s trio)
      • Ácido azelaico 15-20%
      • Chemical peels
        • glicolico 30-50%, salicilico 20-30%, mandelico 10%, e TCA 10-20%
        • Neoretin discrimination control pigment corrector peel
        • Physical procedures such as peels and other abrasive lasers maily act by removing the pigmented superficial layers of the epidermis, with the risk of post-inflammatory hyperpigmentation, which is all the more inevitable when the normal skin is dark
      • Ácido ascorbico 10-15%
      • Kojic acid (1-4%)
      • Retinoides tópicos
  1. Tratamentos orais
      • Ácido tranexamico oral
        • História
          • Descrito na dose 3g/dia para mulheres com metrorragias que tinham anemia. Verificou-se que ficavam sem melasma. Fez-se estudo e verificou-se que dose 6x mais baixa era igualmente eficaz.
        • Mecanismo
          • Anti-plasmin activity → helps reducing melanogenesis and inflammation
          • Inhibits conversion of plasminogen to plasmin, a process that can lead to increased melanin production when unchecked
          • Topical: suppresses cytokine and chemical mediator production. This topical application has shown efficacy in lightening skin affected by melasma and other forms of sun-induced hyperpigmentation.
          • Oral: ++ effective; also noted for its antiangiogenic properties which contribute to its effectiveness in reducing melasma symptoms
        • Dose
          • 125mg/dia pode aumentar para 250mg/dia
          • 250mg 2id
          • Pedro Jimenez: 500mg id
          • Durante 8-12 semanas
        • Considerar risco thromboembolico
          • Screen for protein C and S
          • Não fazer se fumadora, toma contracetivos orais, tem AP ou AF 1º grau trombóticos ou >35 anos(?)
  1. Outros
      • Laser
        • Laser combinado IPL + fraccionado não ablativo q switch nd yag 1064
        • “Physical methods, particularly lasrs, are not effective in dermal melanotic pigmentation” (Saurat)
      • Toxina botulinica tem efeito com pouca evidência ainda
      • Bioestimuladores
      • Metformina
 
  • Exemplo de esquema
    • Hidrospot à noite; Neoretin Discrom Gel-creme Despigmentante SPF50 40ml de manhã
  • Combinação
    • Ácido tranexâmico oral + laser