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The word pigment means color. Skin pigmentation affects the color of our skin. The skin gets its color from a pigment called melanin. There are special cells in the skin – melanocytes – which are responsible for the production of melanin. When these cells are damaged, this affects the production of melanin, and this can manifest itself in blemishes on the skin, also known as "sun-spots" or "sun blemishes". If the body produces too much melanin (hyper pigmentation) the body color becomes darker, if the body produces too little melanin the skin tone becomes lighter. Vitiligo is a disease caused by a lack of melanin production and is manifested in light spots on the skin.

There are various factors that may cause pigmentation, the most common of which are hormones, and therefore it is often called "hormonal pigmentation" or melasma – in professional language.

What is melasma?

Melasma is a hormonal phenomenon that most often occurs in women of childbearing age. It is likely related to some very special interaction between female hormones and sun exposure, and accordingly we hardly see this pigmentation in men. In less sunny countries, such as England, the frequency of this pigmentation is lower.

Hormonal pigmentation occurs in specific areas: above the upper lip (known as mustache pigmentation), mid-cheek and nose (butterfly pattern) and forehead.

This is a common type of pigmentation that affects women of fertility age. The trigger can be pregnancy, or taking birth control pills (in these cases, it is possible that at the end of the pregnancy or when you stop taking the pills – the pigmentation will pass by itself), but usually the phenomenon will remain present to a certain degree for as long as the woman is in her fertile years.

Not all women develop this pigmentation, and it is known to also has a genetic predisposition. However, once a woman has developed melasma, it is a chronic disease – like blood pressure and diabetes, that will likely accompany her in one way or another, until either her menstrual cycle is over and she enters menopause, or she moves to London. Until then, she is looking into a chronic skin disease, such as psoriasis.

How can pigmentation be avoided?

As Buzz Lorman said in his 1997 song: Wear sunscreen.

Since melasma is the result of an interaction between sun rays and female hormones, the main way to avoid pigmentation is by protecting the facial skin from the sun's radiation. To protect only the facial skin with sunscreen, a teaspoonful of the product needs to be applied. That means that to achieve the level of protection on the product’s label a full 5ML of the cream is needed. A sunscreen that provides SPF 50 protection means that its use extends the sun-exposure time until the skin gets burned by 50 times. 

But! If instead of a a teaspoon, only half a teaspoon is applied, the protection level decreases to a square root of 50 – which is about SPF 7. If only a quarter teaspoon is applied – the protection level goes down to about SPF 1. Most women apply a sunscreen as they apply a moisturizer – a far too little amount in order to achieve the full anticipated protection.

The second problem is that SPF provides protection only from UVB sunlight. UVA and UVB are more relevant sunscreen metrics for protecting the skin from the accelerated division of skin cells that can lead to skin cancer development. When pigmentation is in discussion, the spectrum of sun rays playing a role is much wider.

If so, what sunscreens do protect our skin?

Sunscreens designed for babies contain physical filters that answers to a wide spectrum of sun rays and provides maximum protection. These filters’ protection mechanism is similar to a mirror. The sun's rays hit them gets pushed back. These filters are not aesthetically pleasing because they form a white layer over the skin, hence making them less popular. We use them for infants because they are not chemical, and we are less concerned with the white layer’s appearance. At the same time, for those who are looking for complete protection this would be the right solution. For example, you may find wind or snow surfers whose level of sun exposure is extremely high, who use these filters and even enjoy the "fashion statement" of vibrant color marks on their faces.

When using chemical sunscreens, it is important to remember the following:

  1. Use in bulk, do not skimp.
  2. Do not use last year's sunscreen as it has almost certainly expired, and just like an expired medicine – will not fulfill its expected functions.

How can melasma be treated?

As mentioned, melasma is a chronic skin disease and therefore, the disappointing answer to the question "What can be done to eliminate and remove pigmentation?" is – “Nothing.”

Melasma is pigmentation that must not be agitated. Those who save up and dream of undergoing the most expensive treatment to get rid of it once and for all – are likely to be disappointed. This is similar to thinking that surgery can solve a hypertension condition. It is a chronic disease that requires chronic treatment.

Moreover, highly invasive treatments, such as a laser that removes all the stains at once, can be even more destructive. The results of the laser will be maintained for two weeks, after which the melasma will come back and usually at much stronger intensity.

Treating melasma it is a long-term commitment. There comes a stage in life to make a dichotomous decision – either to be sun-tanned with stains or to be un-tanned without stains. Therefore, the recommendation would usually be to start the treatment in winter. The Israeli winter is sun-abundant, so the recommendation to start in the winter does not stem from the amount of sun exposure, but from the ability to adapt to a lifestyle that will last into the summer as well, which’s essence is to completely avoid sun exposure. It will be harder to start avoiding the sun’s rays during a family summer vacation in Cyprus.

So, what can be done?

Melasma is stubborn, but a deep and long-term commitment to certain topically applied ingredients to the facial skin, which are mostly found in dedicated creams or serums, can help to gradually lighter the skin and also help in breaking the biological process resulting in melanin production. These materials include:

  • Hydroquinone, or its derivative that does not require a doctor's prescription – Arbutin
  • Vitamin C
  • Azelaic Acid and Kojic Acid

In addition, more in-depth medical procedures such as chemical peels, microdermabrasion, processes based on different light technologies and so on.

A word from the doctor

Some of the causes of damage to melanocytes is a damaged epidermal barrier, which also fails to optimally protect the skin against the penetration of sunlight. Therefore, it is important to remember that whether you have chosen medicinal treatment (creams or ointments) or treatment with a device – an essential and restored epidermal barrier must be supported to preserve the treatment results.

And another tip! Surgical masks – much more than anti-corona!

Since we have said that one of the factors that triggers melasma is sun exposure, then it is without a shadow of a doubt that covering-up the face with a "corona mask" removes the main cause of pigmentation from the equation. Over the past summer, my clinic has seen a drastic decrease in the number of cases of pigmentation in the mustache and cheek area, compared to pigmentation in the forehead area – which did not experience a significant decrease.

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