Interview with Dermatologist Dr. Jeanine Downie, M.D. About Melasma

Dr. Downie Headshot

Recently I was honored with the privilege to interview Dr. Jeanine Downie, M.D., about the treatment and prevention of melasma.  Although Dr. Downie is an expert in many realms of dermatology, she specializes in pigmentary disorders, and is particularly passionate about the topic, having been personally diagnosed with melasma in her early twenties.

Dr. Downie is a practicing board-certified dermatologist of Image Dermatology in Montclair, New Jersey; author of Beautiful Skin Of Color: A Comprehensive Guide for Asian, Olive and Dark Skin; as well as a professional lecturer, wife, and mother. Dr. Downie has been featured in numerous sectors of the public arena as well, including onThe ViewGood Morning AmericaThe Rachael Ray Show, and In Style andO magazines, amongst many others.  Thank you for taking the time to talk toFutureDerm.com, Dr. Downie!

Nicki Zevola:  How common is melasma in your patients?

Dr. Jeanine Downie:   Melasma is very common amongst patients, and I have seen numerous patients with it lately.  One type I have seen a lot of recently is intense heat fluctuation melasma.  [...]It is upsetting, how common melasma is amongst patients.

NZ:  What can be done to prevent or eliminate melasma?

Dr. D:  To prevent or eliminate melasma, don’t necessarily get off of hormonal contraceptives.  Put sunscreen on, reapply every 2 hours, and watch heat.  Patients don’t often consider how much heat aggravates melasma.  Even waxing the upper lip can exacerbate the condition.

NZ:  What can be done to treat melasma?

Dr. D.:   Three major factors:  sunscreen, Tri-Luma, and chemical peels/Fraxel.  

To treat melasma, first use sunscreen.  The prescription Tri-Luma is the only FDA-approved treatment for melasma.  With the Tri-Luma, you may also wish to do chemical peels to help to even the skin out.  Also, laser treatments like Fraxel are useful if the patient has had very deep-seated melasma for many years.  In summary, sunscreen, treatment cream (with Tri-Luma being the best, but a cosmeceutical may be used) and chemical peels or Fraxel.  

NZ:  A lot of attention has been drawn to potential safety issues [i.e., ochronosis] with Tri-Luma, particularly for patients of darker skin tones.  Has this been an issue for you in your practice?

Dr. D:  My practice consists of approximately 60% white patients, 40% black/Latino/Asian, in that order.  Regardless of race, I advise my patients to only putTri-Luma on the dark patches themselves.  I tell them not to put Tri-Luma all over the face, or else patches may evolve that look like a bull’s eye!  Of course, these bull’s eye-like patches may not be a problem, but as a safety precaution, I do not advise puttingTri-Luma all over the face.

Recently, I was giving a lecture at the Cosmetic Boot Camp in Aspen, CO, where approximately 250 dermatologists, plastic surgeons, and facial plastic surgeons attended to learn about cosmetics.  I happen to specialize in pigmentary disorders, especially melasma.  And when a question about Tri-Luma was raised, I explained this:  the tretinoin in Tri-Luma thickens collagen and elastin over time, and the tiny drop of steroid is balanced by the retinoid in the product.  In addition, it has been proven that there is no problem with using Tri-Luma for an extended period of time. The product has been FDA approved for seven years.  

NZ:  Is there a difference between treatments for melasma, dark spots from acne scars, and sunspots?

Dr. D:  Yes.  For dark spots from acne, I advise use of fade creams, the laser treatmentsFraxel or Lyra, and sunscreen.  Sunspots are solar lentigines – I say these are like the ones that appear on Grandma’s hands – are best treated with the laser Gentle-Laze.  Sunspots are an entirely different modality from melasma – don’t use Tri-Luma for sunspots!  In fact, Tri-Luma doesn’t work swimmingly well for sunspots.

NZ:  Melasma often develops during a woman’s pregnancy.  Is there any way to prevent melasma from occurring during pregnancy?

Dr.D:  In terms of being preventative during pregnancy, melasma can occur anywhere – even the arms – particularly if the patient has a family history.  The patient must be very stringent about sun protection, must use sunscreen every 2 hours [for sunscreens that are permissible during pregnancy, please click here].  A patient can also receive peels all through her pregnancy, which can be helpful.  However, I absolutely do not give Tri-Luma to pregnant or nursing women [due to tretinoin/retinol/vitamin A].  

NZ:  In summary, what is the best advice you can give to patients regarding melasma?

Dr. D:  The bottom line is that people need to realize that they should get their irregular spots checked.  Patients need to get melasma diagnosed by a board-certified dermatologist.  Often patients with dark spots cannot tell the difference between melasma, sunspots, dark acne spots, and even skin cancer, so it is vital to have a board-certified dermatologist make the proper diagnosis – it could save your life! In addition, avoid too much sun exposure.  While the sun is not a statistically significant factor in the development of melasma, it makes already-developed melasma patches worse, and can aggravate acne spots and worsen sunspots.  

Have a skin care regime….once you are diagnosed with melasma, sunscreen, Tri-Luma, chemical peels, and/or Fraxel lasers are the best!  Even after [dermatological] surgery, I tell patients they can keep the area covered, use Fraxel, and then use Tri-Luma to help eliminate scarring.  

NZ:  Thank you very much, Dr. Downie, for taking the time to do this interview!  It was very useful and I feel privileged to have learned so much directly from you.

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Spotlight On: Hydroquinone

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Photo: Tri-Luma, a prescription-strength hydroquinone-steroid-retinoid treatment, is used to treat melasma and dark spots for eight weeks.

Since 1982, hydroquinone has been FDA-approved for the treatment of freckles, melasma, and general brown patching. Today, hydroquinone is the most commonly used bleaching agent in the United States. Over time, hydroquinone has acquired a much-deserved high reputation in the dermatology community, as it is considered to be very effective in reducing the appearance of dark spots on the skin. Hydroquinone works by inhibiting the activity of tyrosinase, the rate-limiting enzyme of melanin production, and by increasing the cytotoxicity of melanocytes (melanin-producing cells). However, hydroquinone has been banned in some countries, including France and South Africa, for concerns about increased cancer risk and ochronosis (darkening of the skin) with its use. Recently, the FDA has raised concerns about the use of hydroquinone and other skin-bleaching agents, as they reported that they wish to “establish that over-the-counter (OTC) skin bleaching drug products are not generally recognized as safe and effective.

Does hydroquinone really cause cancer in humans?

According to Dr. Susan C. Taylor, M.D., a Philadelphia-based dermatologist in this month’s Elle magazine,”The maximum levels of hydroquinone currently allowed (2 percent for over the counter, 4 percent for prescription) aren’t dangerous. At worst, it might cause redness or irritation, but only if your skin is sensitive or allergic to the medication.” And in a 2006 review in the Journal of the American Academy of Dermatology, Dr. Jacob Levitt, M.D. reports that topical applications of hydroquinone in standard product concentrations are not carcinogenic to humans. According to Dr. Levitt, use of hydroquinone in murine (mouse) studies led to an actual decrease in murine hepatocellular carcinomas (cancerous liver tumors) but an increase in hepatic adenomas (benign liver tumors), suggesting protective effects of hydroquinone. Levitt further reports that murine renal (kidney) tumors caused by use of hydroquinone do not appear relevant to humans after decades of widespread use, and murine leukemia has not been reproducible and would not be expected from small topical doses in humans as well. As such, it seems that topically applied treatments with hydroquinone are safe, as Dr. David J. Goldberg, a clinical professor of dermatology at the Mount Sinai School of Medicine reports, “Over 100 scientific articles confirm it is a safe topical for humans; no independent studies prove the opposite.”

What is ochronosis? Is there a defined link?

Ochronosis is a darkening of the skin that is caused by a build-up of phenylalanine or tyrosine. A literature review by Dr. Jacob Levitt of exogenous ochronosis and clinical studies employing hydroquinone (involving over 10,000 exposures under careful clinical supervision) reveal an incidence of just 22 cases in the U.S. in more than 50 years. The reasons for this phenomenon are not clear, but according to Levitt, it could be a result of the use of skin care products containing resorcinol, an agent often used to treat postinflammatory inflammation as well as melasma, acne, and sun-damaged skin and freckles. Resorcinol is often found in combination with hydroquinone in a hydroalcoholic lotion, but it should not be used by individuals with darker skin types. Ochronosis may also be the result of excess sun exposure while using hydroquinone, as hydroquinone tends to thin the skin, making it more photosensitive, but the sun in turn increases melanin production, reducing the effects of hydroquinone. As such, hydroquinone should always be used with a sunscreen.
According to the American Journal of Clinical Dermatology, the majority of patients with ochronosis are Black, but it has been reported to occur in Hispanics and Caucasians as well. Exogenous ochronosis is prevalent among South African Blacks, but is relatively uncommon amongst this population within the U.S. As such, those of African-American descent may wish to take extra precautions in avoiding products with resorcinol and excessive sun exposure when using hydroquinone products.

Does hydroquinone appear to be worth the risk?

The risks of hydroquinone (see above) appear to be minimal. In contrast, Tri-Luma, a prescription strength retinoid (0.5% tretinoin) steroid (0.01% fluocinolone acetonide) and hydroquinone (4%) has been shown to be effective in treating melasma and general darkening of the skin over the course of eight weeks. According to Dr. Audrey Kunin, M.D., a Kansas-City based dermatologist, Tri-Luma should not be used for longer than eight weeks, as the steroid component may cause the skin to become thinner (and hence more photosensitive and prone to sun-induced signs of aging, etc.) Some other prescription hydroquinone treatments available in the U.S. are Lustra (4% hydroquinone, 4% glycolic acid), Lustra-AF (4% hydroquinone, 4% glycolic acid, SPF 15), and Alustra (4% hydroquinone and retinol).

Overall, is hydroquinone safe and effective?

Based on the scientific literature, hydroquinone seems to be both safe and effective at this time. Talk to your dermatologist if you are interested in a prescription-strength hydroquinone treatment. Over-the-counter hydroquinone treatments are available in formulations such as MD Skincare Hydra Pure Radiance Renewal Serum ($95.00, Skinstore.com) and Murad Post-Acne Spot Lightening Gel ($58.00, Drugstore.com). If you are using any type of products with hydroquinone, use a sunscreen daily, and try to avoid the sun for best results, and if you are using Tri-Luma, follow doctor’s orders and do not use for longer than eight weeks.

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