Product Puzzles

Mariel Chow asks doctors what really works, and what is just marketing.

February 19, 12:00 PM

 In the last issue four experts – Dato’ Dr. Lim Huat Bee, Prof Dr. Lim Shueh Wei, Dr. Melinda Tong and Dr. Joyce Lim – discussed two common skin conditions - wrinkles and acne - particularly their indications, and how best to manage symptoms through appropriate skincare. Besides revealing which ingredients work best, our experts also shared durations of applicability including how topical agents improve conditions. 
In this issue we continue our quest for healthy, appropriate, and effective skincare choices, by rounding up the same panel of experts who divulged the best skincare solutions for melasma and post-inflammatory hyperpigmentation. Aside from revealing how conditions come to be, our experts also uncover which products work best – and how – and disclose why when skin conditions are concerned, consultation with dermatologists is one’s best bet. 
 
MELASMA
What is Melasma?
Dato’ Dr. Lim Huat Bee and Prof Dr. Lim Shueh Wei: Melasma – which often leads to embarrassment and loss of self-confidence – is a skin disorder that results in blotchy, brown or bluish facial pigmentation. The cause of this common skin condition is complex, and due to overproduction of pigment (melanin) by pigment cells (melanocytes), which are then taken up by skin cells (keratinocytes). It is also triggered by pregnancy, hormonal treatments, and sometimes, certain medications like cancer treatments or illnesses including hypothyroidism. In addition to intrinsic factors, extrinsic factors like sun exposure and contact with scented or deodorant soaps, toiletries and cosmetics may also cause phototoxic reactions which trigger long-term melasma. 
 
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Dr. Melinda Tong: Melasma is a condition that results in blotchy pigmentation of the skin. It is a source of much frustration because of its chronic relapsing nature. The incidence is higher in women and darker skin types. Known triggers for melasma are sun exposure, pregnancy and hormonal treatments such as oral contraceptive pills and hormone replacement therapy. The most important avoidable risk factor is sun exposure. It should also be noted that heat and visible light, in addition to UV radiation (UVR) can also trigger melasma. 
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What skincare do you recommend?
Dr. Joyce Lim: Skincare which reduces pigments are those which can lighten splotches. Examples of these brightening solutions are non-hydroquinone ingredients which are often plant-based or fruit based. The skincare should similarly exclude ingredients which might irritate skin or could trigger pigmentation. Regimens should also eliminate irritating products like toners, masks etc. At the end of the day, the most appropriate skincare programmes for pigmentation are usually not affected by environmental factors like sun exposure. Besides constant and consistent applications of sunscreen, skincare varies according to their base depending on skin type, age and environments. This is precisely the reason why doctors recommend richer creams for those living in drier climates, or for those who have dehydrated or aged skin. The chosen skincare should reduce formation of new pigments and likewise aid in removing existing pigments. Long-term use should not cause irritation as there are solutions which calm skin. Positive outcomes should be visible after a month. 
 
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Dato’ Dr. Lim Huat Bee and Prof Dr. Lim Shueh Wei: We find that melasma treatment has to be tailored so it doesn’t cause irritant or contact dermatitis among patients with sensitive skin. Harsh agents or ingredients may cause post-inflammatory hyperpigmentation (PIH) which can worsen cosmetic outcomes. Patients should discontinue hormonal treatments if possible and also have very good sun protection through application of high sun protection factor (SPF) sunscreens. My advice is to wear sunscreens which contain products to block out visible light as well as UV radiation (UVR). Other physical measures such as hats and masks can be used too.
 
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We also recommend using a mild cleanser, and if the skin is dry, a light moisturiser. Cosmetics may be applied to disguise pigment. Over-the-counter (OTC) products like fruit acids can be used as repeated superficial peels. There are many active ingredients used in topical products for melasma, so this can be confusing and may require dermatologist guidance. In general, patients often need combinations of a wide selection of ingredients such as azelaic acid, kojic acid, kojic acid dipalmitate, cysteamine cream, ascorbic acid, arbutin, hydroquinone, deoxyarbutin, retinoids and salicylic acid. While such agents are suggested, some of these recommendations will require prescriptions from a dermatologist, with careful follow-up care. As such, it’s useful to have a dermatologist monitor each patient’s skin product use to minimise irritation and long-term side effects. As warned by the Ministry of Health, there are many illegal substances featured in many OTC products, including mercury. These problematic ingredients cause permanent side effects, so ensure you’re consulting with dermatologists before deciding on skincare regimens. If more rapid and positive outcomes are desired, laser and device therapies may be judiciously used for melasma treatment. 
 
Dr. Melinda Tong: To avoid pigmentary disorders like melasma, I recommend wearing broad-spectrum sunscreens with high SPF (50+) plus frequent reapplication when outdoors. Wear a broad-brimmed hat or carry an umbrella, and try staying indoors during the hottest times of the day. Lastly, keep cool by avoiding saunas and steam rooms. Sunscreen containing zinc oxide and titanium oxide offer protection from UVR and visible light, but leaves a whitish residue. Sunscreen with iron oxide is another UVR/ visible light filter, but is only available as a tinted cream. There is also an oral antioxidant pill (polypodium leucotomos, a plant extract) which can reduce damage caused by sunburn. However, it should be noted that it is not a substitute for sunscreen and works best in combination with the abovementioned sun protection measures. 
Mild skincare is advised because aggressive washing and scrubbing can damage skin, resulting in PIH.  PIH can worsen the appearance of melasma. While cosmetic camouflage (makeup) can be used to conceal pigment, it can cause other problems like allergic reactions and acne cosmetica. 
If simple measures don’t help, then targeted therapy should be sought in consultation with a dermatologist. Be reminded that not all pigmentation is due to melasma. Other types of blotches can exist concurrently with melasma and require proper diagnosis and appropriate treatment. Melasma itself has subtypes, and in order for optimal therapy, the skin type, presence/absence of other skin problems, medical history, degree of sun/heat exposure, and type of weather all need to be factored in. 
The mainstay of topical therapy is to block the formation of new pigment. Here are some popular lightening compounds: hydroquinone, arbutin, vitamin C, kojic acid, azelaic acid, liquorice extract, emblica, rucinol, resveratrol, mulberry, niacinamide, soy and green tea. Others (such as tretinoin and alpha hydroxyacids) cause mild peeling of superficial pigment, but should be used with caution as they may not suit everyone. Targeted topical therapy is complex and needs to be reviewed,  as lightening products can cause irritation, which may result in PIH. It is best to seek professional advice when pregnant, as not all products are safe to use during pregnancy. 
Light and laser devices are utilised to break up melanin deposits. Popular devices are intense pulsed light, Q-switched Nd:YAG and fractional CO2 lasers. Multiple treatments may be necessary, and PIH can be a complication. Resurfacing lasers and mechanical dermabrasion should be used with caution. Finally, a healthy lifestyle with a diet rich in antioxidants and cessation of smoking are important. 
Post-Inflammatory Hyperpigmentation
What is PIH?
Dr. Joyce Lim: Melasma is a genetic condition related to ageing and sun exposure. The current concept is that it is a photoaging condition. Pigments are generally seen on sun exposed areas and where there are abundant oil glands (as we now know that oil glands play a role too). PIH, on the other hand, is commonly seen in darker skin tones usually after injury to the skin or after skin treatments or after skin inflammation; e.g. PIH is seen after acne or eczema . When the skin is irritated or injured , the melanocytes (melaninforming cells) are activated resulting in pigment production, hence the term post inflammatory hyperpigmentation (PIH). New pigments are seen, usually as dark brown patches which correspond to the area of skin irritation or injury. Therefore, the darker the skin type, the more melanocyte activity, and the higher the chance for PIH formation.
Dato’ Dr. Lim Huat Bee and Prof Dr. Lim Shueh Wei: PIH is transient pigmentation that follows injury or inflammation of the skin. This can be from trauma, burns or skin diseases like lupus, dermatitis and infection. Patients who tend to develop this problem are generally darker-skinned individuals with whom discolouration tends to be worse and lasts longer than lighter-skin patients. This type of pigmentation has the propensity of worsening in sun-induced skin conditions caused by allergic reactions to plants, or inflammatory skin conditions with lichen-planus-like inflammation. Sometimes, our patients have worsened PIH due to medications like anti-malarial drugs, certain antibiotics and anti-cancer drugs. 
Dr. Melinda Tong: PIH is caused by skin injury, resulting in localised melanin deposition. The discolouration ranges from light brown to black. While PIH can affect all ages and both sexes, the risk is much higher in those with darker skin tones. Although PIH may resolve on its own, this process may take months to years, depending on underlying injury, skin type and degree of sun exposure. 
 
What skincare do you recommend?
Dato’ Dr. Lim Huat Bee and Prof Dr. Lim Shueh Wei: When it comes to PIH, the most important step is to treat or remove causative factors. If the pigmentation is caused by medical skin disorders, we will treat the medical conditions like dermatitis and lupus first. Otherwise, skincare should start with good broad-spectrum sunscreen, and sun avoidance. Cleansers and moisturisers have to be gentle and non-irritating to not further aggravate the condition. A variety of other treatments are available through dermatologist prescriptions, including topical lightening agents, antioxidants and fruit acids. Nevertheless, we do prefer more conservative forms of treatment to prevent aggravation. The bottom line when tackling PIH is to keep things simple, and not utilise too many irritating agents. 
Dr. Melinda Tong: Treatment of the underlying cause is important. Chemical peels and treatment with laser/light devices can help. However, these methods may also cause PIH and therefore should be used with care. Many of the topicals used in the treatment of melasma can be effective for PIH. Basic skincare principles like avoiding harsh cleansers or scrubs, minimising irritation, and ensuring adequate sun protection should be followed. Retinoids, azelaic acid, vitamin B/C/E, lighteners (hydroquinone, kojic acid, arbutin), and antioxidants have all been reported to reduce PIH. It is nonetheless important to ensure that these agents do not cause irritation, as they may then contribute to worsening PIH. PIH is a challenging condition to treat, so it is best to consult a dermatologist for optimal therapy. 
Why should patients consult dermatologists when seeking ideal skincare solutions?
Dr. Joyce Lim: Patients must be reminded that some skincare aggravates current conditions, causing more acne and pigmentations. Dermatologists are experts in the skin and its diseases. Hence, we’re able to diagnose problems and institute the correct topical solutions. Besides that, dermatologists have abilities of pinpointing a condition’s trigger factors and causes as well. Many disorders tend to look alike to the layman, where wrong diagnosis is often made. As a result, patients are commonly prescribed incorrect treatments, resulting in further problems. For example, acne may not be due to acne alone, but may be the result of other skin disorders like rosacea, medications and so forth. 
Dato’ Dr. Lim Huat Bee and Prof Dr. Lim Shueh Wei: Wrong skincare often aggravates and exacerbates skin conditions through irritation, discomfort, disfigurement and pain, resulting in poorer skin quality. Unfortunately, the consequences can sometimes be permanent. The word ‘common’ implies a benign nature but this is often not the case with some ‘common’ skin conditions like acne. If incorrectly and inadequately treated, acne can result in permanent scarring which affects a patient’s self-confidence at work, life, and love for years to come. This is precisely why we recommend a dermatologist consultation when dealing with dermal disorders. Dermatologists are specialists in skin, hair and nails, covering all medical, surgical and cosmetic/aesthetic aspects. 
 
All Malaysian specialists, including dermatologists are registered on the National Specialist Register Malaysia (www.nsr.org.my). This is a new and mandatory Malaysian legal requirement since 2018, so check on your doctor’s qualifications, ensuring they are credentialed by the Malaysian Medical Council and Malaysian Ministry of Health