Hormonal Pigmentation / Melasma

The short answer is that melanin-its amount, quality, and distribution- creates human skin colour. The slightly longer answer is that melanin is produced within melanosomes, organelles located in the cytoplasm of melanocytes (skin cells in the basal layer of your epidermis). The number of melanocytes in human skin is the same in people of all races; in darker-skinned individuals, though, the melanosomes are larger and contain more melanin. Once melanin is produced, melanosomes migrate to the melanocytes' dendrite tips, where they come into contact with keratinocytes, skin cells closer to the surface of the epidermis. The final stage of the pigmentation process, however, wherein melanin is transferred from the melanocytes to keratinocytes, is still poorly understood.

Melasma, also known as hormonal pigmentation, is a considerable problem for South African women. It is a chronic skin condition that occurs on the face in the form of brown patches and is a dynamic (active) condition that needs lifelong management. Its incidence is much higher in Asian and darker-skinned individuals than in fair-skinned people.

• In many cases, a direct relationship with female hormonal activity appears to be present because it occurs with pregnancy and with the use of oral contraceptive pills and HRT/ hormone replacement therapy. However, unopposed oestrogen may also be an underlying factor and thus it is essential that the cause of this unopposed oestrogen is identified. If these underlying conditions are not addressed, any pigmentation treatments are doomed for failure and the pigmentation will return. At the Renewal Institute, all consultations are holistic and get to the root cause of the problem be it acne, Rosacea, or hormonal pigmentation. Even our anti-aging consultations are treated holistically.
• The pathophysiology of melasma is uncertain. In many cases, a direct relationship with female hormonal activity appears to be present because it occurs with pregnancy and with the use of oral contraceptive pills and HRT/ hormone replacement therapy.
• After pregnancy Melasma (chloasma) or pigmentation usually clears within a few months of delivery but may persist indefinitely.
• Any change in hormonal status with higher levels of estrogen is thought to trigger and aggravate the condition (i.e. birth control pills and pregnancy). Discontinuing the use of contraceptives rarely clears the pigmentation and it may last for many years after discontinuation.
• However many women without these risk factors also develop.
• Other factors that may be implicated are progesterone (the Mirena),
• photosensitizing medications such as tetracyclines or anti-psychotic medication or medical conditions such as mild ovarian or thyroid dysfunction and dysbiosis, thus it is important to consult with a Renewal Institute doctor to diagnose the cause of Hormonal pigmentation/ Melasma.
• Other possible causes could probably include genetic predisposition and exposure to ultraviolet light, visible light which emits infrared A (sunlight, TVs, computer screens, fluorescent lights, hairdryers, clay ovens), and excessive heat which causes inflammation ( such as saunas and steam baths).
• Stress may also produce certain hormones that worsen melasma.
• UVA rays are a stimulant for melanin (brown pigmentation) to develop on the skin and unfortunately can even penetrate through car window glass.
• Any activities that cause intense heat to the face ( from steam showers, hot closed environments, sitting on the beach even under cover and with full sun protection, etc) causes inflammation which is a powerful stimulator of melanin.
• Melasma is more prevalent in darker-complexioned individuals though persons of any race can be affected due to the intense sun exposure in South Africa.

Pigmentation disorders such as melasma or chloasma (during pregnancy) arise from increased melanin in the lower layers of the skin and increased free melanin in the skin. Hormonal pigmentation is usually brown with a non-distinct border and is usually found symmetrically on the face or jawline. Melasma can appear on the central facial areas such as the cheeks, mustache, and forehead areas. Melasma affects both men and women, though it is more frequent in women (up to 30% may be affected) and usually starts to appear from the age of 28 years onwards.

• Centro Facial (forehead),
• Malar (cheekbones) and
• Mandibular (jawline)

• Epidermal melasma is the most common form and is easily treated with a combination of superficial chemical peels, Candela V-Beam, Limelight, or Photo Genesis procedures.
• Dermal melasma: If the melanin has leached into the dermis, this is known as dermal melasma. The deeper the pigment is, the more difficult it is to treat. Dermal melasma is not treated with superficial peels and is best treated with mid-dermal peels such as MesoBrite™ or MesoBrite Lite™ or injected mesotherapy with Tranexamic acid to penetrate into the dermis to reach the pigment.
• Mixed Epidermal-Dermal melasma is a combination of the above and is treated the same way as dermal melasma.

Make an appointment to consult with your Renewal Institute Doctor and he/ she will assist you in determining your risk factors for pigmentation and how best to prevent any problems or conditions that you may be susceptible to.

Pigmentation and dark marks are probably the concern we see the most at our skin clinics and if the pigmentation are superficial, they can be quite simple to treat. But pigmentation does sometimes tend to sit slightly deeper, especially hormonal pigmentation. This deep pigmentation are more difficult to treat. But essentially there are 3 steps to successfully treat/minimize pigmentation/dark marks; 1. Daily use of an SPF 50, unprotected sun exposure will induce more pigment to form and the spot may become darker. We recommend Heliocare 360, this SPF will not only protect your skin from UVA and UVB, but also from visible and infra-red light. 2. We need to speed up your cellular turnover rate, to get the pigment out. This can be done by the use of exfoliating ingredients such as Retinol or AHA’s (Alpha Hydroxy Acids).3. We need to ensure that the pigment cells don’t produce any more excess pigment. This is done by the use of pigment suppressing ingredients such as certain peptides, kojic acid and alpha arbutin. Lamelle Luminesce range are a good option for you as it covers step 2 and 3. The range has a cleanser, day and night cream as well as a very potent serum called Brighter Concentrate that can be used daily. As for the dark circles, here we need to look at what is causing it. It might be pigment forming around the orbital area, then it needs to be treated like above, or it can be due to a lack of drainage. We need to ensure that we have sufficient lymph draining around the orbital area, if not, toxins begin to build up and it shows as dark discolorations. Using an eye cream that contain certain peptides as well as Vit K will help with this. 

With pigmentation, it can be very tricky. In most instances pigmentation around the mouth or lip area is as a result of one of two thing; 1) Hormonal influence, or 2) Trauma from waxing, threading or whatever form of hair removal is done over the lip area. That is generally the norm, however it is not always the case. There can be other factors influencing this. If it is indeed pigmentation then there are a few things that will help you but not necessarily fully solve the problem:

1) You need to be applying a very good facial SPF every single day;

2) You need to be using a pigmentation prevention product

3) Lastly you need to try and minimise the cause of the issue, so for example if it is because of waxing, then you need to try and find other alternatives for hair removal.

Pigmentation and brown spots forming on the face is NOT always just because of sun exposure. In many cases, pigmentation has a hormonal trigger, and unfortunately, going on to birth control pills can be one of those triggers. these hormonal triggers, such as the pill, HRT and pregnancy can result in the formation of pigmentation on the face.

There are a few things that can help you manage this, however, it’s best to properly investigate your specific case and make the best decision for your skin type, pigmentation severity and budget, by having a proper consultation. In the meantime, it’s definitely worthwhile using a good pigmentation inhibiting product on a daily basis. It’s also a very good idea to be using a good SPF on a daily basis come rain or shine as UV radiation affects everyone, even if you are predominantly indoors. 

At the Renewal Institute, we treat all our patients holistically by dealing with all the issues that may be responsible for their initial presentation. One should consult with a Renewal Institute doctor to rule out the possibility of an underlying systemic health disorder that requires medical treatment. There's overwhelming evidence that certain medical conditions are key players in your overall health and are the root cause of your pigmentation problems. Failure to address these conditions may lead to failure of your Hormonal Pigment treatment plan and ALSO lead to chronic disease.

Your Renewal Institute doctor will conduct a physical examination, examining the location, distribution, colour, and appearance of the areas of increased pigmentation. 

Your Renewal Institute doctor will also evaluate whether external factors, such as hormones, medications, chemical exposure, or other environmental influences could have contributed to the increased deposition of pigment in the skin. Furthermore, the practitioner will make note of any prior history of pigmentation disorder and its treatment.

We also include ESSENTIAL supplements into our Hormonal Pigmentation treatment packages for optimal pigmentation treatments and health. Schedule an appointment with one of our experienced Renewal Institute doctors to find out what underlying medical condition/ s could be aggravating your melasma/ hormonal pigmentation.

The initial medical consultation at the Renewal Institute will be approximately 30 minutes. A thorough evaluation will be done by your Renewal Institute doctor, who will identify underlying conditions and lifestyle habits that may be aggravating your condition.

The Renewal Institute doctor will decide on a treatment plan or depending on:

• How long you have had hormonal pigmentation?
• If the Hormonal pigmentation/ melasma has been present for more than 2 years it may be more difficult to improve
• What medications you are taking
• Previous treatment failures or successes
• Whether the dermal pigment is present.
• Your Skin type, deeper/more aggressive skin peels and IPL/Lime Light procedures cannot be done on darker skin types 5 and 6
• Your expectations and budget restraints
• Your occupation/sporting/recreational activities

• A thorough evaluation will be done by your Renewal Institute doctor, who will identify conditions and lifestyle habits that may be aggravating your condition.
• Hormonal pigmentation/Melasma is a dynamic, chronic condition that has to have ongoing management by applying a pigment inhibitor daily. We have numerous Prescription and non-prescription topical Brightening/pigmentation products at the Renewal Institute.
• Without the strict avoidance of sunlight and the continued use of home topicals mentioned above to downregulate the enzymes responsible for making pigment, potentially successful treatments for melasma and pigmentation are doomed to fail.
• To prevent increased Hormonal Pigmentation and PIH (Post-inflammatory Hyperpigmentation) before and after any peel or IPL procedure, pre-treatment for a period of 2 to 4 weeks is recommended to downregulate the enzymes responsible for making pigment
• Our superficial peeling treatment of choice at the Renewal Institute is the Azelaic & Ferulic peel which is a combination of azelaic acid, salicylic acid, ferulic, malic, citric, lactic, and arnica combined with Laser Genesis.
• In addition, THE CONTINUED USE OF RECOMMENDED PIGMENTATION PRODUCTS IS MANDATORY AFTER ANY PEEL / IPL procedure.
• SPF of 50 MUST be applied twice daily
• Any laser procedure such as a fractional laser that causes excessive redness and inflammation should be avoided as there may be aggressive rebounds to hormonal pigmentation a few weeks/ months later especially if NO post-treatment depigmentation products are prescribed
• At the Renewal Institute, we recommend that you avoid hot baths, Bikram Yoga, steam saunas, tanning beds, and dry saunas as they can cause excessive inflammation and may aggravate hormonal pigmentation
• At the Renewal Institute, we also offer Skin Brightening IV infusions for pigmentation.

Many all-natural, topical skin-brightening agents have been found to be quite beneficial in brightening hyperpigmented areas of the skin. These include alpha arbutin, as well as kojic acid, azelaic acid nicotinamide, and Liquorice root (Glycyrrhiza glabra).

Topical applications of natural, fruit-derived alpha-hydroxy acids, including glycolic acid, have been extremely beneficial in combination with the aforementioned bleaching agents. For enhanced results, these products should be used in conjunction with exfoliation treatments such as peels and transdermal pigment brightening Mesotherapy.

The following is a list of skincare ingredients to AVOID due to worsening melasma pigmentation and dark spots.

• oestradiol, oestrogen, genistein, black cohosh, chasteberry, hops, red clever, soy, wild yams.

• If the underlying condition is not identified and managed, then the pigmentation will return and suboptimal treatment can be expected. That is why it is important to visit a skin clinic that treats you holistically.
• Pigmentation present for more than 2 years may be more resistant to treatment as dermal pigment may be present and this may need transdermal therapy with TA (Tranexamic acid) or deeper peels.
• The dermal pigment is caused by the melanocyte distributing pigment/ melanin into the dermis instead of the epidermis.
• This dermal pigment may take longer to resolve than epidermal pigment. The source of the dermal pigment is the epidermis so if the epidermis can be prevented from making melanin for long periods with home topicals and peels/ depigmentation treatments such as a series of superficial peels, Cosmelan and Dermamelan, the dermal pigment will not replenish and will slowly resolve, but this may take months.
• Normal SPF sunblock protects against UVA and UVB but NOT AGAINST infra-red A.
• Without the strict avoidance of sunlight and the continued use of home topicals mentioned above to downregulate the enzymes responsible for making pigment, potentially successful treatments for melasma and pigmentation are doomed to fail.

• infra-red A is a deep dermal ray that causes accelerated aging
• Infra-red A is found in ANY visible light that emits heat such as sunlight, computer screens, fluorescent lights, heaters, and even hair dryers
• Normal SPF 50 sunblock protects against UVA and UVB but does NOT protect AGAINST infra-red A.
• One is only 56 % protected with a good SPF 50 sunblock
• If one applies a topical antioxidant such a Vit C, Vit E, Ferulic, and Phloretin, 96 % sun protection can be achieved
• Only topical antioxidants such as Vit C, Vit E, Ferulic, and Phloretin can protect against infra-red A.

• For continued sun protection and to maintain results, oral supplements such as Heliocare (Polypodium Leucotomas) together with MSM with Vit C can be taken orally to increase one's resistance to the sun.
• In addition, Polypodium Leucotomas are powerful antioxidants that stop the enzyme that breaks down collagen (MMP) and protect against infra-red A, which is present in the light from sun exposure, computer screens, fluorescent lights, etc.

• A thorough evaluation / medical history will be taken at the initial consultation to ensure that all causes of Melasma are addressed.
• After a series of 4 to 6 in-office medical peel treatments combined with home topicals, the topical products need to be applied indefinitely and one of the above-mentioned topicals is recommended. These can be alternated over time.
• If there is no improvement after the 6th treatment then we usually recommend a Health Renewal consult with one of our integrative doctors to exclude medical causes of pigmentation. This may also include a course in Renewal Institute brightening intravenous infusions with Glutathione.
• In addition, if there is no improvement after the 6th treatment of superficial peels and topical products, MesoBrite™ or MesoBrite Lite™or Injected Tranexamic acid mesotherapy treatments are recommended to treat dermal melasma and PIH which has been present for more than 2 years.
• If the melanin has leached into the dermis, this is known as dermal melasma.
• The Laser Genesis procedure can be done in all skin types as it targets dermal pigment by heating up the melanophage ( which contains the melanin) trapped in the skin and aids the "release" of the trapped dermal pigment so it can move up to the epidermis where it can be exfoliated with normal epidermal renewal. Laser genesis also "polishes" the skin and improves fine lines, wrinkles, pores, and texture.
• For all peels, prescription creams such as Retin A or retinol must be stopped stop three days before each treatment and restarted three days after the peeling process.

MSM is a powerful activator of the powerful antioxidant Glutathione. MSM may facilitate the breakup of pigmentation in the skin/ dermis as it is a natural detoxifier of the lipofuscin/lipopolysaccharides/ brown pigment in the skin.

MSM contains sulfur which is necessary for the production of new cells and plays an essential part in the synthesis of collagen and keratin, vital protein substances that are needed to make and maintain hair, nails, and skin. Hair and nails grow faster and stronger with good levels of sulfur. This compound is also responsible for the flexible bonds between cells and helps to block the cross-linking of collagen, an effect responsible for the appearance of wrinkles and aging skin.

Sulfur helps the body to form keratin, the protein that makes up the main part of the outermost layers of your hair and nails. It is a tough, fibrous protein that is very resilient to the effects of damaging chemicals and other harmful agents. Each strand of hair has its own keratin supply, which is stored in the root. Sulfur is also contained in biotin, a B vitamin that is essential for shiny hair and strong nails. You may be interested to know that the natural inclination of hair to be straight or curly is maintained in part by the sulfur amino acids. MSM benefits dry scalp and hair and improves nail growth and benefits your cuticles and nails.

• The most common localized pigmentation disorder affecting the skin are ephelides, more commonly known as freckles. Freckles appear as flat brown pigmentation in sun-exposed areas, usually on the face. They are much more common in fair-skinned individuals, and a propensity to have freckles is an inheritable condition. The degree of pigmentation in the skin changes according to the amount of ultraviolet light exposure so that freckles usually darken in the summer and lighten in the winter.
• Another very common skin disorder is known as Post Inflammatory Hyperpigmentation PIH. The underlying mechanism is unclear but may involve inflammatory mediators such as prostaglandins and leukotrienes. While the causes and clinical presentation of post-inflammatory hyperpigmentation can vary, they are usually secondary to a traumatic incident to the affected area of the skin such as acne, dermatitis, eczema, or any form of inflammation of the skin. Sun exposure can worsen this condition. Topical therapies and treatments in combination with sunblock may help this condition
• Solar lentigos/sun spots appear as brown lesions (about 1 centimeter in diameter), typically on the face and hands. Both acute and chronic UV exposure can cause lentigos. While they rarely appear on patients under fifty, they are not caused by age -- sun-protected skin is not affected, even in elderly patients. Solar lentigos are completely preventable with sun avoidance and daily sunscreen use. Finally, whether solar lentigos are treated or untreated, patients should undergo routine skin exams, as they may be at greater risk for skin cancer.