Chemical peels in melasma: Recommendations by Indian pigmentary expert group
M3 India Newsdesk Dec 05, 2018
Treatment of melasma frequently follows a multimodality method, and the second-line of management which is renowned for melasma is chemical peeling. Here are recommendations from a group of experts from Pigmentary Disorders Society (PDS) in collaboration with South Asian Pigmentary Forum (SPF).
Melasma is a commonly-acquired chronic refractory condition caused by hyperpigmentation of the skin that is difficult to treat, and severely impacts the patient’s quality of life. Chemical peeling can be used to improve the epidermal component of the skin. The capacity of the peel to stimulate phagocytosis of stagnant melanin determines the dermal component.
Use of chemical peels
- In skin types IV to VI, deep chemical peeling is not recommended for the dermal component of melasma since it may cause scarring and severe dyschromia.
- In case of moderate to severe melasma, when measured by spectrometry, better efficacy is seen with topical application of a triple combination with sequencing peels.
Before performing therapeutic correction, proper counselling of the patients should be done regarding the chronicity of the disease, the significance of photoprotection and the role of hormones in disease persistence because psychological and social stress are attached to the expected outcomes.
Points to consider
- Controlled epidermal dyscohesion and consequent regeneration are caused by chemical peels.
- Post-inflammatory hyperpigmentation (PIH) should be prevented with care under the cover of vigilant priming and good sun protection, as PIH tends to occur more frequently in people of colour after undergoing medium and deep peels.
- To maintain good outcomes and to prevent post-inflammatory hyperpigmentation (PIH), it is necessary to do proper patient selection, good counselling, priming of skin, and use post peel topical therapies.
- There is better and faster clearance of melasma when chemical peels are combined with topical therapy as is evident in the literature.
Chemical peels are given in cases of melasma with predominant epidermal pigmentation and in focal or pan facial conditions.
Chemical peels are not indicated in cases of strong dermal pigmentation, unrealistic patient expectations, active infections/inflammation, and photosensitivity.
Pre-peel work up
- Explanation regarding realistic expectations
- Detailed discussion about the nature of treatment, time taken, and expected outcome
- Explanation about the possible side effects
- Informed consent
- Melasma evaluation
- Melasma Area and Severity Index score
- Woods lamp examination to determine epidermal or dermal nature of pigmentation
- Skin biopsy when indicated
Basics to consider before peeling
- Melasma duration
- History of skin infections, e.g. herpes virus infection
- History of drug intake (photosensitizing medication, isotretinoin (medium depth peels), oral contraceptives, immunosuppressives)
- History of allergy to any topical or systemic drug
- Occupational history and outdoor hobbies
- Treatment in the past 3 months with medium depth or deep chemical peel
- Previous facial surgeries
- Keloid formation
Sun Protection Factor
Sun protection factor (SPF) is a complete obligatory step in the treatment of melasma. It is essential to have a broad-spectrum sunscreen with an inorganic filter of SPF 30, and this should be initiated after the first consultation itself.
In cases of melasma, it is necessary for priming to occur at least 4 weeks before the commencement of the peeling procedure. If using 4% hydroquinone, priming is done for a minimum period of 4 weeks.
Priming ensures a uniform diffusion of the reagent and decreases the risk of complication. Thus, it is important to choose the right and exact priming agent. Commonly used priming agents include Hydroquinone, retinoids, glycolic acid, and kojic acid.
The gold standard agent used for priming is 2 to 4% hydroquinone (HQ). After 5 to 7 weeks of HQ treatment, its depigmenting effects are seen.
- A maintenance phase of at least for 3 months should be observed after the peel
- After four weeks of HQ, peels can be given, and HQ stopped for one day before giving the peel
- HQ can be restarted a day after the peel in cases of superficial peels
The most common retinoid used for priming is tretinoin and this can be given alone or in combination with kojic acid (KA), arbutin or glycolic acid (GA).
- The most extensively used alpha hydroxy acids (AHA) for priming is glycolic acid (GA) and it should be given at least 2-6 weeks prior to starting peels
- GA should be stopped one week before the peel and then it can be reintroduced two days after the procedure
The combination of kojic acid with other agents, when given two times a day for 1-2 months is proven to be effective. Triple combinations, even when with low strength retinoids can increase the irritation potential of any peeling agent, so it is important to stop retinoids one week before starting the peels.
Optimum post-procedure care is necessary to ensure quick recovery of normal skin and to decrease the risk of complications. This depends on the condition being treated.
- To reduce discomfort, an ice compress is applied immediately after the procedure
- In case of excessive desquamation, emollients are used
- To prevent erythema and PIH, more so in darker skin, it is necessary to use a broad-spectrum sunscreen
- Use of lightening creams and maintenance peels should be continued in the maintenance phase
- Chemical peels are used in the treatment of melasma as they can produce excellent cosmetic enhancement, even though topical therapy is the keystone of melasma treatment as an adjuvant and maintenance therapy.
- In Indian patients, very superficial and superficial depth peels are generally considered to be safe. Surplus information is available over the kind of peel that is being used for the treatment of different forms of melasma.
- A good result can be seen when treating epidermal melasma with peels if the melasma is of less than one-year duration.
- To improve epidermal pigmentation, peels are useful.
- There is no role of the superficial chemical peels on the dermal pigment.
- To prevent the recurrence of melasma, peels should be mandatorily combined with topical agents as therapy and with maintenance treatment.
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