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melanin is involved the author will use a fractionalised CO2


laser. Mandelic acid has also been shown to be of


benefit in these cases. If the melasma is epidermal then topical depigmenting


agents, such as hydroquinone (HQ) are a good starting point. These creams come in either in OTC (over-the- counter) (2%) or POM prescription (4%) strength. As physicians, we tend to use 4% as standard. Hydroquinone is a chemical, which inhibits tyrosinase, one of the enzymes involved in the production of melanin. The author also uses azelaic acid (20%) as it also


decreases the activity of melanocytes. Hydroquinone topical has been assigned to pregnancy category C by the FDA. Animal studies have not been reported. There are no controlled data in human pregnancy. Hydroquinone topical is only recommended for use during pregnancy when benefit outweighs risk. It is unknown if hydroquinone cream is excreted in breast milk. After pregnancy, the author uses many topical


patients with thyroid disease and stress may result in increased levels of melanocyte stimulating hormone42


. The


pigmentation usually disappears itself four months after the circulating hormone levels return to normal. The author feels it is important that someone with


clinical experience of pigmented lesions should be involved in their removal. There are many reasons for this, melanomas can regress and depigment and lesions such as lentigo malignas can appears in the same locations on the face as melasma. That said, melasma is comparatively easy to diagnose as it tends to occur in large patches rather than isolated lesions. When there is doubt, the author recommends using a Wood’s UV light to determine the depth of melanin pigmentation in the skin: contrast in epidermal pigmentation is increased while contrast in dermal pigmentation is decreased under Wood’s lamp illumination compared to ambient visible light. Under Wood’s lamp, excess melanin in the epidermis can be distinguished from that of the dermis. Dermal melanin is more difficult to remove by


methods that do not reach this level. Of particular benefit is a dermal melanin analysis system but not all clinics have this technology at their disposal. The author finds this is of particular benefit, especially when using a series of IPL laser treatments to help depigmentation. If the pigmentation is dermal then another method of removal will be required as it will only serve to darken the lesions. Whenever dermal


64 ❚ March 2015 | prime-journal.com Melasma is


the formation of irregular pigmented patches and are commonly found on the sun-exposed face in the period surrounding pregnancy.


creams for depigmentation. Tretinoin as 0.025% OTC or 0.05% POM is a retinoic acid that increases skin cell (keratinocyte) turnover. This treatment cannot be used during pregnancy. After pregnancy, facial peels with alpha or beta hydroxy acids or chemical peels with glycolic acid can also be used. The biggest problem with removal of melasma is the possibility that the condition will return. The patient should also be told the lightening effects are gradual because the pigmented cells have to grow out to the stratum corneum and a strict avoidance of sunlight post procedure is mandatory. We should also be aware that ordinary sunscreen in my opinion does not prevent melasma recurring and topical agents with physical blockers, such as titanium dioxide or zinc dioxide should be used. Ordinary light will make melasma recur. Some products such as those containing vitamin C and SPF benefits provide some protection and nourishment to skin. Other products containing retinol, (a less irritating form of vitamin A), can boost cell turnover within the skin’s surface to reduce the appearance of dark spots. Other less wounding treatments such as glucosamine, mulberry root, and yeast extracts can work to accelerate the skin’s natural exfoliation process, in effect buffing away the dark spots. Of course the patient may not want a procedure and may be told that cosmetic cover-ups can also be used to reduce the appearance of melasma.


Varicose veins and spider veins Solution: Lasers, IPL, sclerotherapy, surgery Pregnancy tends to worsen spider veins and smaller varicose veins because circulating hormones associated with pregnancy soften the vein walls and valves. During pregnancy, veins have to carry a greater circulating blood volume. Sometimes the enlarged uterus compresses abdominal veins, causing further back pressure on the leg veins. Changes in body chemistry due to birth control pills and constrictive clothing, such as tight hosiery, can also contribute to spider vein development. Other related factors are heredity, obesity, menopause, ageing, prolonged standing, leg injury, and abdominal straining43


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