‘Doctor, can you hit my pigments with a stronger laser?’ –  How NOT to treat melasma. 

‘Pico’ or Pico Laser has in the last 2 years became one of the most commonly heard buzzwords in the treatment of pigmentation, so much that it has become very common for patients turning up at aesthetic clinics requesting for ‘picolaser’ for their ‘pigment problems’.

NO ONE SIZE FITS ALL

However, NOT all pigment problems are the same.

In one of my recent clinic sessions, a patient came in for a consultation to address her facial pigmentation. She had gone for a ‘pico’ session in another clinic a few months ago and was told that her pigments will be cleared in one session.

To her dismay, however, the pigment had become darker and she looked worse after the treatment. She waited a few months hoping that it will lighten out, but it did not.

She asked if she can have stronger pico laser to treat her pigments. I had however started her on a pigment lightening cream instead of hitting her harder with the laser.

Why you may ask. Indeed, picosecond lasers of certain wavelengths are useful in treating pigmentary disorders, however, pigments on the face or anywhere on the body can be caused by a myriad of conditions, and a one-size-fits-all approach is certainly not the way to go.

MELASMA

MELASMA

In her situation, the diagnosis of melasma was made. Melasma is a disorder of hyperpigmentation of which aetiology is thought to be an interplay between UV exposure, genetic and hormonal factors.

It typically appears as symmetrical, blotchy brown patches over the cheeks, although the forehead, temples, nasal bridge, upper lips, and jawline are also known to be affected. The condition affects women more than men and commonly appears in the mid-30s.

It can also develop during or after a pregnancy. Other factors increasing the chance of melasma include a history of excessive sun exposure, family history, increased female hormones either by being on hormone replacement therapy or oral contraceptive pills, thyroid disease and low testosterone amongst others.

Also Read: What Harm Can Ultraviolet Radiation Do

Although not a life-threatening condition, it can be very disfiguring for people affected by the condition and has a deleterious impact on the quality of life.

Melasma has NO CURE, but it can be treated.

IS PIGMENT LASER NOT A TREATMENT FOR PIGMENTATION?

Pigment lasers have since the days of Q-switched lasers become one of the most effective tools in the treatment of pigmentary disorders such as sunspots, freckles and have become one of the most invaluable tools in the clinic of an aesthetic physician or dermatologist.

Pigment lasers use the physics theory of chromophores attracting energy from light. Pigments in the skin act as a chromophore and absorb the energy from certain wavelengths of lasers. These pigments are then selectively fragmented due to photoacoustic and photothermal effects from the lasers and are subsequently ingested and cleared by our immune systems.

Now, this works for most pigments, and will even work for other exogenous pigments such as tattoos. However, why is melasma so difficult to treat? It either responds only to return with a vengeance almost immediately after or just does not respond at all?

MELASMA IS A DISEASE OF OVERPRODUCTION OF MELANIN PIGMENTS BY SENSITIZED MELANOCYTES

To understand why we have to first understand how melasma happens. I mentioned earlier that melasma is an interplay between UV exposure, genetic and hormonal factors.

However, melasma is a condition is not the same as skin hyperpigmentation that is induced by UV or inflammation. Through molecular pathway studies, it is now believed that people affected by melasma have increased expression and upregulation of certain receptors involved in the stimulation of melanogenesis and melanosome transfer compared to normal individuals resulting in persistent hyperpigmentation in melasmic lesions.

This essentially means that pigment-producing cells in people with melasma are sensitized and hyper-stimulated, thus when triggered by factors which can stimulate melanin production, will result in even more pigments being produced and deposited into the skin.

LASER OR NO LASER?

For the above reasons, treatment of facial pigments must start with a sound medical approach. The correct diagnosis must be made before embarking on any treatment.

Pigmentary conditions such as freckles, sun spots, post-inflammatory hyperpigmentation can be easily treated with lasers.

Melasma, on the other hand, needs to be treated with a more holistic approach. As the condition is due to upregulation and sensitization of pigment-producing cells, treatment starts with treating the root cause of it, by reducing all risk factors for pigment production as much as possible.

This will include treating hormonal factors such as reviewing a patient’s medications for any medications that can alter hormonal levels such as oral contraceptive pills or hormone replacement therapy; sun protection with broad-spectrum sunscreens.

Treatment should also include topical creams for pigments. The pigment cream hydroquinone is still the standard treatment of melasma although, in the recent years, concerns have grown regarding long term use of the medication and alternatives which work to a lesser degree such as creams containing arbutin, azeleic and ascorbic acids, niacinamide kojic acid have also been used.

Now, that does not mean that laser has no role in the treatment of melasma. Judicious use of lasers and acid peels can act as good adjuncts in the treatment of melasma. When used correctly, they can speed up the lightening of pigments; and in recalcitrant melasma which responds poorly to topical creams, lasers and peels still have a strong role to play.

MELASMA CAN BE TREATED SUCCESSFULLY

Melasma is a complex and challenging condition to treat and requires both times, patience and persistence. A sound and holistic medical approach by the doctor, and diligence on the part of the patients applying and using the prescribed treatments while maintaining lifestyle factors such as staying away from the sun, avoiding irritative cosmetics are crucial to achieving visible improvement and maintaining good complexion in the treatment of melasma. It may not be curable, but it certainly can be treated well.

If you are indeed suffering from melasma, speak to your doctor so that it can be addressed early.

Ultraviolet radiation

Ultraviolet rays / Ultraviolet radiation. Why do we need to protect ourselves against it?

We often get asked to put on sunscreen before going out in the sun. Why is it so important? 

What are ultraviolet rays?

Our bodies are exposed to many forms of radiation on the electromagnetic spectrum on a daily basis. These can be radio waves, microwaves, visible light, X-rays, Gamma radiation, infra-red and ultraviolet (UV) rays.

UV falls in the portion of the electromagnetic spectrum between X-rays and visible light: The shorter the wavelength, the higher the energy; ie. UV has higher energy than visible light.

Conversely, when it comes to penetration, the longer the wavelength, the deeper the penetration. 

The most common UV radiation is sunlight, which produces mainly 3 types of UV, namely:   

UV-A

UV-A has the longest wavelength of the three types of UV radiation we get from the sun. It penetrates deep into the deeper layer of our skin (the dermis). 

UV-B

UV-B has a wavelength between UV-A and UV-C. Some of this is absorbed by the Earth’s ozone layer as it passes through the atmosphere. As it has a short wavelength, it reaches only the outer layer of our skin (the epidermis). 

UV-C

UV-C has the shortest wavelength, all of this is absorbed by the Earth’s ozone layer as it passes through the atmosphere. 

We also get UV from other sources like tanning booths, mercury vapour lighting, halogen, fluorescent and incandescent lights and some types of lasers. 

What harm can UV do?

UV exposure has its benefits. UV-B specifically helps the body produce vitamin D and have also been used in the medical setting to treat certain skin conditions. 

However, excessive exposure to UV radiation can result in chronic harmful effects. These include photokeratitis (inflammation of the surface of the eye due to UV exposure), photoaging/ accelerating ageing of the skin, micro-DNA damage and mutations that increase the risk of and cause skin cancers, sunburn.

Does my exposure to UV change depending on where I am or what I am doing?

Many factors determine how much UV exposure you get. These include: 

Geography and Altitude

The equator receives the strongest UV rays as the sun is directly over the equator and UV travels a shorter distance of atmosphere to reach our skin. The ozone layer in the equator is also naturally thinner so less UV is absorbed compared to higher up in the northern and southern hemispheres. 

Having said that, there are certain terrains that can increase UV exposure due to their reflective properties, such as snow, sand, pavement and water. 

Higher land also receives more UV than lower land because there is less atmosphere. 

Timing (Time of the year/ day)

The sun’s angle in relation to Earth varies with the season. During the equinoxes, the sun rests directly above the equator, whilst the solstice is when the Sun reaches its most northerly or southerly excursion relative to the equator. Hence why the northern and southern hemispheres receive more UV during their respective summer months and conversely receive less in their winter months. 

Image from National Environment Agency (Singapore)

Weather

This serves as a reminder that UV rays are present even on a cloudy day and it can still cause long term damage to skin and eyes. Hence, it is important to continue protecting yourself with sunscreen even if it is a cloudy day. 

UV Index

The UV index (UVI) is a rating scale used throughout the world to indicate the amount of skin damaging UV reaching the Earth’s surface. 

On 19 Feb 2018 in Singapore between 1pm to 3pm, UV Index indicated “Extreme”
Source

In Singapore, the National Environment Agency reports the UVI. It is measured at the Changi Meteorological Station and is reported hourly from 7am to 7pm.

Protective measures should be taken if out in the sun, especially during the peak hours of 11am to 3pm

What can I do to protect against UV?

  • Sunscreen 
  • UV protective umbrella and seek shade
  • Sunglasses that block UV-A and UV-B rays 
  • Wear a broad-brimmed hat

Author: Dr Kwan Yuan Dong

Dr Kwan is a medical aesthetic doctor in S Aesthetics Clinic, Singapore. He is passionate in educating the public about medical aesthetic procedures, skin care and anti-ageing treatment.



*DisclaimerInformation provided in this article is for reference and educational purposes only. It does not replace actual medical advice and consultation with your doctor.

Also See: Pico Laser Singapore, Mole Removal Singapore

As social media becomes an increasingly larger part of our social lives, be it group photos taken at events, or selfies that we post onto our own profiles, we are also increasingly pressured to look the way we have portrayed our digital avatars. 

PHOTO EDITING, SELFIES AND BEAUTY APPS

Photo editing used to be available to only the highest echelons of society, mainly in the form of airbrushed pictures and videos seen in the media.

The advent of beauty and social apps such as Meitu, Instagram and Snapchat in recent years have vastly changed this. Now, every social class in society who has access to a smartphone has the ability to use the various facial filters and editing options to edit their photos and make adjustments to facial features to control the image they portray online. This has redefined the perception of beauty and has allowed us to enhance and beautify our facial and body features in a few clicks and swipe. It has allowed us to take control of our public face in the virtual realm. As a result, wide ranges of “selfies” have since populated the vast social media, ranging from minor edits to completely unnatural looking photos such as the infamous “snake man” from China.

FAKE PIC?

However, despite the now-common phenomenon of photo editing, the advent of these tools has also fuelled new insecurities, such as “what if people noticed?”, “oh, that must have been an edited picture”, “he does not look like that in real life” etc. Also, there is often a fear of not putting your best foot forward – for example, not getting a job or not getting the second date for not looking like the photo in your CV or profile. These have as a result fuelled both insecurities as well as aspirations to look more like our digital images or avatars. 

In the last decade or so, the once-taboo topic of having aesthetic procedures done is now increasingly becoming more mainstream and better accepted socially. Indeed, the acceptance of cosmetic and facial plastic surgery has increased and it is an increasingly common sight to see people discussing what they had done at dinner events, or even overhear discussions about trips to foreign countries for aesthetic and plastic surgical procedures. It is also more common for people to turn up in aesthetic and plastic surgery clinics requesting to look like their app-edited selfies. 

JUST VAIN OR “SNAPCHAT DYSMORPHIA” AT PLAY?

The phenomenon, as it becomes more common, is also attracting more discussions and opinions. Singaporean media TODAY published an opinion recently discussing how doctors in aesthetic and plastic surgery clinics are getting an increasing number of patients requesting to look more like their app-edited selfies, and the concern of how much mental health issues such as body dysmorphia disorder and low self-esteem is at play when it comes to wanting to improve one’s looks.

Rightly so, aesthetic treatments will not treat a fundamental psychological problem and patients who truly have body dysmorphia disorder will not attain satisfaction from aesthetic treatments and in fact may go down a slippery slope of repeatedly seeking enhancements without ever getting satisfaction. 

CAN I LOOK LIKE MY SELFIE?

The desire to enhance one’s look is not new. Selfie-editing apps, however, have now brought the idea of editing how one looks to the masses. After seeing enhanced versions of themselves, people want to be able to control how some of their facial features look. Of course, most people will only want minor improvements, such as a smoother complexion, sharper-looking features, removing their eye bags or dark circles, a more lifted face. Realistic requests and expectations are usually achievable although people also have to be prepared to accept some deviation from their desired results occasionally. 

WHAT CAN BE DONE

With aesthetic and plastic surgery procedures receiving more acceptance, the million dollar question is now whether achieving one’s desired look is possible. 

There are a host of treatments to address particular concerns, and when used in combination, they can generally achieve the ‘wants’, albeit minor deviation from the desired results occasionally. 

Patients who want a clearer complexion may undergo treatments to improve skin texture and tone such as light based therapies the likes of Intense Pulsed Light (IPL) treatments and lasers, chemical peels, rejuvenation injections such as Rejuran and skin boosters as well as botox and fillers to lighten the appearance of wrinkles. People with acne scars may consider lasers, peels and injection based treatments such as Rejuran S to lighten and ameliorate the scars over time. 


Read More: Look Refreshed with Restylane Skinbooster

To alter facial features however, a combination of skin tightening treatments, contouring treatments, fillers, thread lifts, botox, or even the more invasive plastic surgery may be used to enhance features such as a higher nose bridge, more defined jaw, slimmer face, higher cheekbones, or even fuller lips; and to reduce the appearance of undesirable features such as a double chin, sagging jowls, deep smile or laugh lines, frown lines, crow’s feet etc. By enhancing the aesthetically pleasing features and reducing the appearance of undesirable features, aesthetic doctors can often rejuvenate and freshen up one’s appearance.

One other common concern is tired eyes. Although most people put this down to having insufficient sleep, the factors causing this is much more complex than that. Tired looking eyes is usually due to a combination of pigmentation in the under eye area, lax skin around the eye, venous congestion as well as herniation of the fat pad under the eye that becomes worse with age. To achieve the ‘eye bag’ function that face editing apps achieve, a combination of treatments including light based therapies such as lasers, fillers and polynucleotide injections, chemical peels, topical skin care as well as addressing age related volume loss in the cheek area, are typically employed to rejuvenate the eyes. 

Read more:
Rejuran i – Everything You Need to Know

As evident from above, there are many options and ways of dealing with particular aesthetic concerns. However, the perception of beauty and facial features varies greatly, not only between cultures, but also between individuals. This is also the reason why customization and tailoring a personalized treatment plan to each individual is so important. 

THE PRICE OF BEAUTY

All these however come at a price. In an ideal world, everyone will want every treatment that can keep them looking like they were in their 20s. However, as with any procedures, there will be a cost to it. The cost of cosmetic procedures have always been perceived to be high and only accessible to the highest echelons of society. 

In Singapore, the growing aesthetic market has attracted the attention of multiple stakeholders. Over the past decade, the number of aesthetic providers have been steadily increasing. With the increased numbers of providers, costs have been on a downward trend over the past decade. Average prices for procedures have fallen over the years and consumers are having an increasing number of choices in terms of providers as well as treatment options. 

Despite this however, misled by the outdated perception that procedures in medical clinics are costly, some people have unwittingly attended unscrupulous beauty parlours that provide aesthetic procedures illegally, sometimes with dire consequences such as infections, blindness, skin necrosis, disfiguring scars etc. 

There are also people who travel abroad to countries like Thailand or South Korea for cosmetic surgical procedures. While people often get satisfactory results, cosmetic surgeons and practitioners in Singapore are often left to manage complications or revisions from botched surgery overseas. 

WHERE DO I START?

Everyone has a different motivation in wanting to improve their appearance. The first and foremost important question to answer is if that motivation is warranted and valid. Beyond that, other things such as invasive vs. non-invasive procedures, expectations, desired results also make important considerations. Although reading up from validated websites is also a good way to start, readers will have to be cautious of the source, quality and truth of the information they obtain, as every individual responds differently to treatments and there is a lot of misleading half-truths on the world wide web. Having friends who have done it first-hand to speak to will also be helpful and the final step will be to speak to one or even two trusted doctor to understand the procedures, the possible outcomes, risks and treatment plan to definitively address the aesthetic concern before embarking onto the journey of looking like your selfie. 

See also: rejuran, rejuran healer

Author: Dr Kwan Yuan Dong

Dr Kwan is a medical aesthetic doctor in S Aesthetics Clinic, Singapore. He is passionate in educating the public about medical aesthetic procedures, skin care and anti-ageing treatment.


*DisclaimerInformation provided in this article is for reference and educational purposes only. It does not replace actual medical advice and consultation with your doctor.