treat melasma : 10 Conclusion

Hiperpigmentasi skin is a problem that many patients found the therapy to look for cosmetic reasons. Hiperpigmentasi interference that often complaint patients hiperpigmentasi is melasma and post-inflamasi. Melasma is hipermelanosis which usually occurs in areas affected by the sun.
The cause of melasma is ultraviolet rays, hormonal, drug, genetic, race, cosmetics, pregnancy and idiopathic. Pathogenesis melasma associated with many different fields of science, such as biology, biochemistry, pathology, and patofisiologi process pigmentasi skin, both at the cellular level, biomolekular, skin and tissue. In addition, knowledge of the pathogenesis is very important to establish the diagnosis and treatment
Melasma diagnosed only with clinical examination. To determine the type of melasma, Wood-ray examination is done. While the examination histopatologik only done in some cases.
Hiperpigmentasi treatment in general and in particular melasma, usually because of cosmetics, for their own lesi never give subjective complaints.
In addition to the curtain and use the sun to prevent melasma, the use of cream containing tretinoin, kojik acid and acid azeleat has showed improvement of melasma. Sometimes recommended for chemical peels or use a steroid cream topical. In the case of a heavy, laser treatment can be used to eliminate hiperpigmentasi.

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treat melasma : 9 handling

Handling
Melasma is an aberration in a difficult therapy. Pigment in melasma increased gradually, and it also requires a long time. Cases and chronicles recurrent and may often occur in people who are often exposed to sunlight exposure. All light waves from the sun, including visible spectrum can cause the occurrence of melasma.
Hiperpigmentasi treatment in general and in particular melasma, usually because of cosmetics, for never giving lesi subjective complaints.
Some of the actions of prevention are:

a. Avoid the sun. This is usually done with conventional ways, such as wearing a hat with a wide or paying or using screen sun (sunscreen)

b. Stop the use of contraceptives.
In addition to the curtain and use the sun to prevent melasma, the use of cream containing tretinoin, kojik acid and acid azeleat has showed improvement of melasma. Sometimes recommended for chemical peels or use a steroid cream topical. In the case of a heavy, laser treatment can be used to eliminate hiperpigmentasi.
Pandhi research conducted to evaluate the comparative treatment topikal in melasma treatment. Melasma from 50 patients taken at random, divided into 5 group (10 people per group). Evaluation of drug treatment of clobetasol propionate 0.05%, 0.025% tretinoin, hydroquinone 2%, benzoil peroxide 5% and glycolic acid 10% show the effectiveness of each drug. Effectiveness of drugs is highest clobetasol (80%).
Research other states that have the alpha hydroxyl acid is the right choice in the treatment of melasma suitable for Asian and Latin skin. Research that is conducted Satiti success kojik acid cream 2% can be used as alternative therapy melasma. Melasma can be difficult cured, melasma pigment form slowly and it is slowly.
Topikal range of treatment for melasma, including:

a. Hidroquinon
Hidroquinon is a chemical that impedes hydroxyphenolic so tyrosinase conversion decreased DOPA into melanin. Hidroquinon can be applied in the form of a cream or mixed with a solvent solution. Concentration allowed in the United States is 2%, without a prescription that is used for concentration of 4% or higher again. Hidroquinon related to the effectiveness of the degree of concentration but the side effects that occur along the increased concentration increased.
Other mechanisms that may be the way destructs, melanosit, melanosom degradation, and prevent DNA and RNA synthesis.
Hidroquinon used in the form of a cream-colored with a concentration of 2-50%. Cream is used at night, with the curtain in the afternoon sun. Generally appear to improvements in 6-8 weeks and followed up to 6 months.
Concentration that causes excessive skin irritation, reaction phototoksik with hiperpigmentasi post inflamasi and okronosis eksogen irreversible. Monobenzil ether causes vitiligo-like leukoderma a good lokalisata and general.Selain that, in hipopigmentasi can occur around the treated area. After the termination of the use hidroquinon, often relapse.

b. Retinoat acid (retinoic acid / tretinoin)
Acid retinoat 0.1% mainly used as additional therapy or a combination. Cream is also used at night, because during the day can occur fotodegradasi. Now retinoat acid is used as monoterapi and obtained a clinical improvement, although it take a while.
Retinoid trusted to work by increasing the turnover limit keratinosit and delivery melanosom to keratinosit. Major side effects of tretinoin is skin irritation, deskuamasi, photosensitive temporary and hiperpigmentasi paradoksikal. Combination with or without tretinoin corticosteroid topical has been promoted.
0,05-0,1% tretinoin pigmentasi with the transcript tirosinase hamper the functioning sintesis melanin. Tretinoin melasma can be effective in reducing the duration of 24 weeks. Tretinoin have any side effects, namely hiperpigmentasi secondary, and eritema irritation. Retinoid that can be used, among other adaphalen, tazarotene and isotretinoin topikal.

c. Azeleat acid (azeleic acid)
Azeleat acid is a drug that is safe to use. Azeleat acid treatment with 20% for 6 months to give good results. Side effects that can happen is feeling hot and itchy. There are no reports fototoksik reaction and fotoalergik on the use of acid azeleat.
Azeleat acid mechanism of action is not fully understood. Reduction DNA synthesis and cellular energy production mitokondria is the resistor in melanosit. Unlike hidroquinon, acid azeleat only work on melanosit the hiperaktif skin and does not affect the normal function melanositnya.
In a research report azeleat acid is as effective as with the hidroquinon 4% and without side effects. Acid azeleat combination with tretinoin or 0:05% 15-20% glikolat acid can accelerate the skin bleaching. Side effects that can happen is pruritus, eritema lightweight, and taste burnt.

d. Acid kojik
Kojik acid produced by fungus Aspergillus oryzae, and can prevent tirosinase. In the research found that a combination of acid kojik 2% with hidroquinon 2% more effective than the acid glikolat combined with hidroquinon 2%. Other research comparing glikolat acid 5% with 4% or hidroquinon acid kojik 4% for 3 months. -Combination before the combination is effective to reduce the hiperpigmentasi in 51% patients. Acid kojik can help patients hiperpigmentasi that does not fit with the other therapy.

e. Agent depigmentasi other
Depigmentasi other agents that have been examined in the treatment melasma is a 4-N-butylresorcinol, phenolic-thioeter, 4-isopropylcatechol and acid askorbat.

f. Combination therapy
Combination therapy is more effective than the use of one type of product. The cause of melasma is not fully known, so that combination therapy can be more effective for different degrees of therapy hiperpigmentasi one kind of product that is only effective on one hiperpigmentasi degrees.
The addition of tretinoin can increase the pigmentasi and keratinosit proliferation by preventing the oxidation of hidroquinon and improve epidermal penetration. Furthermore, the addition kortikosteroid topikal can reduce irritation and prevent melanin synthesis because cell metabolism will decrease. Combination hidroquinon 5%, tretinoin 0.1% and 0.1% had dexamethason known since 1975, with the name and formula Kligman. This formula is often used as combination therapy for melasma in the world.
Of a multicenter study, using random and double blind control trial showed that a combination of new hidroquinon 4%, tertinoin 0.05% and fluosinolon asetonid 0.01% (Tri-Luma, Galderma) that the result is better than other combinations with 2 or more products / agencies where 77% patients showed total recovery. The clinical, indicated a significant increase in the minimum and maximum of 4 weeks for 8 weeks. Side effects that is common is a mild local irritation, eritem.

g. Specific therapy in pregnancy
Melasma therapy in pregnant women should be done after the birth. This is because, melasma to be more resistant to treatment because of factors such as spark hormones during pregnancy is still high. Then, therapy is also beneficial because it does not become predileksi occurrence melasma also increased after birth and the most important therapy for melasma is kontraindikasi pregnancy.

In addition to the treatment used topikal, the systemic treatment can also be done include:

a. Askorbat acid (vitamin C)
Vitamin C has the effect of oxidation of melanin into the form of a reduction of melanin color is bright and prevent the formation of melanin to alter DOPA into DOPA quinon.

b. Glutation
Glutation form of reduction is sulfhidril compound (SH) that can potentially prevent the formation of melanin to the road to joining Cuprum (Cu) from tirosinase.

Special measures for melasma therapy can also be used as therapy options, among others:

a. Peel chemical
Peel chemical treatment can help hiperpigmentasi aberration. peel chemical smear done with acid glikolat 50-70% for 4-6 minutes should be done every 3 weeks for 6 times. Before the chemical peel, first given sour cream glikolat 10% for 14 days.

b. Surgical laser
Surgery using the laser Q-switched Ruby laser and Argon. relaps can occur. Hiper-treatment techniques pigmentasi with laser Qight amplification by stilulated emition of radiation) is a development of the current. Laser work monokromik emit high intensity, coherent source of energy that diabsorpsi by water, hemoglobin and melanin in the skin, to the kromophor. Absorpsi energy kromophor damage. Wavelength laser and set the lead in penetration and target kromophor.
Based on the spectrum absorpsi melanin, laser Q-switched ruby (694 nm) laser is an appropriate treatment for lesi hiperpigmentasi. Side effects of laser treatment including not feeling comfortable, redness, swelling, and hiperpigmentasi post-inflamasi. Patients should always be a spot test before treatment is done in full.

c. Intense Pulse Light (IPL)
Derivat of treat laser is Intense Pulsed Light (IPL), in pulsasi berintensitas with high wavelength (515 -1200 nm), which emanated by the light energy delivered to the skin. IPL energy is released to the dermis and diabsorpsi by kromophor. IPL has shown that work well for medical treatment for lentigines but melasma is not yet appropriate expectations. IPL treatment side effects are pain, local irritation and hiperpigmentasi post-inflamasi.

Prognosis
Melasma often disappear after a few months termination contraceptives, hormonal replacement therapy or after the birth. Melasma may relapse again if pregnant or use drugs that can spur melasma.
Melasma type dermis may take longer than the type of repair for epidermis because there is no effective treatment for the pigment in the dermis. Source of pigment from the epidermis is the dermis. Therefore, if the melanogenesis epidermis can blocked for some time, not pigment dermis and fill will slowly peter out. resisten cases and relapse often occurs and has been the prevention of contact with the clear sunlight to total no more needed.

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treat melasma : 8 diagnosis

Melasma Diagnosis
Melasma diagnosed only with clinical examination. To determine the type of melasma, Wood-ray examination is done. While the examination histopatologik only done in some cases.

Melasma Diagnosis Letter
a. Addison Disease
Addison disease is a disease caused insufiensi adrenal, where the increase occurred between kortikotropin and MSH, which is marked by symptoms that are often not typical, such as stiff-stiff, weak, anoreksia, Nausea, stomach aches, Gastroenteritis, diarrhea and emotions that are not stable. Insufiensi adrenal is triggered by infection or destructs autoimmune nonspecific on the adrenal gland. Diseases that often cause infection of Addison disease is tuberculosis. There is destructs cortex adrenal cause feedback inhibition hypothalamus gland and anterior pituitary lost, the consequences kortikotropin sekresi ongoing. Kortikotropin MSH and progenitor of both components is the same hormone. When kortikotropin parsed from prohormon, together with the MSH released. Consequences arising hiperpigmentasi crimson / bronze (Bronze hyperpigmentation) that way.
b. Drug induced photosensitivity is kutaneus disease as a result of the combination of chemical reaction and light, where the actual exposure of one of them does not cause disease. This disease is usually because of drugs or chemicals or systemic topical.
c. Discoid lupus eritematous (LED) is a disease that attacks the system connective and vascular caused autoimmune process and the interaction between genetic factors and immunologic, virus infection and hormonal. LED going on which The speck in the skin eritematosa and atrophy without ulserasi. Deviation localise usually symmetrical in the face, ears or neck.
d. Hiperpigmentasi post-infection occurs after inflammation of the skin. Aberration is very common and tend to settle on the dark skin. The clinical hiperpigmentasi can be found following the pattern and distribution of skin disease.
e. Efelid aberration is a form of skin The speck-The speck of black or brown in areas exposed to sunlight. It was revealed that familial factors are autosomal dominant, and usually occurs in the summer. Localization on the face, neck, shoulder, back and hands.
f. Ookronosis the pigment in the dermis hill that often occur because the stack metabolite hidrokuinon in the dermis.

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treat melasma : 7 Laboratory examination

Melanin can be seen in the epidermis or dermis using Wood rays (wavelength 340-400 nm). Epidermal pigment will changed when examined with Wood rays are not in the dermal pigment. In the dermal, will melanin appear black blue. On someone with dark brown skin-black, with checks ray lesi Wood does not appear on the patient so that this referred to as type intermediet.
Usually there is no specific laboratory examination for melasma. Tiroid inspection functions can be done if there are indications. Examination with the Wood-ray can help in determining the location of pigment in the epidermis or dermis. In the case of some pigment found in both locations.

According Supardiman (2007) support the examination can be done on people with melasma are: 6
1. Histopatologik examination. With histopatologik examination, can be 2 types hipermelanosis, namely:
a. Epidermal Type: increase the amount of melanin found mainly in the suprabasal layer of basalt and, sometimes in the stratum spinosum to stratum korneum. Cells that contain melanin is concentrated melanosit, cell-cell layer and suprabasal basalt, keratinosit cells and stratum korneum. In most cases, a number of melanosit not increased. Nevertheless, melanosit appear larger, more dendritic and more active.
b. Dermal type: there is makrofag bermelanin around the blood vessel in the dermis and the top down. At the top of the dermis there is a focus infiltrat.
2. Electron microscope examination. Electron microscope examination provides a description ultrastruktur melanosit in the basalt layer increases.
3. Examination with the Wood-ray (wavelength 340-400 nm). Examination with the Wood-ray can be divided into 4 types, namely:
a. Epidermal type: lesi see more color contrast
b. Dermal type: lesi color contrast does not increase
c. Type mix: lesi have increased the contrast, there is not
d. Type not clear: the Wood-ray, lesi not become clear, whereas with the usual ray clearly visible. Usually occurs in people with dark brown skin color, where the Wood lamp examination does not localise pigment.

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treat melasma : 6 Clinical symptoms

Melasma does not cause symptoms in addition to changes in skin color but the big problem may be cosmetic.
Melasma usually attack the women, only 1 out of 20 suffered by men. Melasma generally occur between ages 30 to 40 years. Melasma occurs in many people with darker skin.
Lesi melasma be a young makula brown or dark brown, with a boundary edge is not strictly regular. Lesi on dermal type melasma colored grayish or bluish. Predileksi often on the cheek and nose, called the fact pattern. Pattern found in the mandibular chin. While the pattern sentrofasial about the temple, forehead, eyebrow and top lip. A pattern that is rarely found on the border with arms which looks down on women who use progesterone and native American Indian.

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treat melasma : 5 Classification

According Supardiman (2007), melasma classified based on the clinical picture, the examination with Wood-ray examination and histopatologis.
1. Based on the clinical picture:
a. Form sentrofasial areas include the forehead, nose, the medial cheek, nose and chin down (63%)
b. Continuous forms of covering the nose and cheek lateral (21%)
c. Mandibular form covering mandibular region (16%).
2. Based on the examination with the Wood-ray
a. Epidermal type. On the type of melasma is more clearly visible with the Wood-ray diffraction compared with normal.
b. Dermal type. Type dermal rays Wood with no visible color contrast compared with the normal ray.
c. Type mixture. On the type of mixture, it appears some locations more clearly, while the other is not clear.
d. Type considered difficult because of dark skin color. This type of radiotherapy Wood, lesi become unclear. Differences in types this is the means of therapy. Dermal type more difficult than treated epidermal type.
3. Based on the examination histopatologis
a. Melasma type epidermal. Type of brown epidermal generally. Melanin mainly found in the basalt layer and supra basal. Sometimes there is melanin in the stratum corneum and stratum spinosum.
b. Melasma type dermal. Dermal type blue brown. In the dermal type macrophage melanin found around blood vessel in the dermis and the top down. In addition, at the top of the dermis there is a focus infiltrate.

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treat melasma : 4 Etiology and Patogenesis

Etiology melasma until now has not been definitely known. According Supardiman (2007), factors that are considered causative role in the occurrence of melasma is patogenesis:

1. Ultraviolet rays.
Spectrum sun damage this cluster sulfhidril in the epidermis which is the enzyme tirosinase resistor with the binding of the enzyme Cu ion is. Ultraviolet rays cause the enzyme tirosinase not dihambat again, so that drive the process of melanogenesis.
Other mechanisms that cause sun exposure can cause melasma is the ultraviolet ray radiation can cause cell membrane lipid peroksidasi so that the generated free radicals stimulate melanosit to release melanin. Curtain especially to block the solar UV-B radiation (290-320 nm) is not satisfactory because there is a wavelength that is longer on the UV-A rays and visible radiation (320-700 nm) have the nature melanosit stimulated to produce melanin.

2. Hormonal
Hormone estrogen, progesteron and MSH can stimulate the formation of melasma.
Hormones have an important role in the human body. On the mask of pregnancy is known in terms obstetrik. Certain mechanisms of melasma because of the pregnancy has not been known. Estrogen level, progesterone, and Melanosit Stimulating hormone (MSH) generally increased in the third trimester. However, in nulipara with melasma, and MSH estrogen level does not increase. Then, the occurrence of melasma because the use of oral contraceptives and diethylstilbestrol used for prostate cancer therapy has also been reported. In the research, women who get menopause will progesteron experiencing melasma, while women who got estrogen not only suffering from melasma, so that it can be proved that progesterone a role in the occurrence of melasma.
One study found that patients with the disease tiroid suffering from melasma. A report of cases also reported that melasma can occur in patients who have experienced emotional stress because of increased MSH produki by hipotalamus.

3. Drugs
For example difenilhidantoin, mesantoin, klorpromasin, sitostatik and minosiklin can cause the occurrence of melasma. Drugs in this collectedthe top of the dermis layer and can stimulate cumulative melanonogenesis.

4. Genetic
Reported cases of family around 20-70%. Genetic factors is a major occurrence of melasma. This occurred mainly in women than men. A person with brown skin and the young sun exposure will increase the excess occurrence of melasma. More than 30% of patients have melasma history of the family who suffered the same aberration. Identical twin trends have also been reported suffering from melasma.

5. Race
Melasma many found in the Hispanic and the dark skin color.

6. Cosmetics
Use of cosmetics that contain perfume, coloring matter or materials that can cause fotosensitivitas which can lead to the emergence hiperpigmentasi in the face if exposed sun.

7. Certain conditions, such as pregnancy and hormone replacement therapy during menopause.

8. Idiopatik.

Pathogenesis melasma is not yet clear, many factors that are considered causative role in pathogenesis melasma.
According Supardiman (2007), pathogenesis the occurrence of melasma involves many factors, such as:

1. Increased production of hormones or because melanosom because ultraviolet rays. Melanosom this increase can also be caused pharmacology materials such as silver and psoralen.

2. Retardation in Malphigian cell turnover. This condition can occur because drugs sitostatika.
Pathogenesis melasma associated with many different fields of science, such as biology, biochemistry, pathology, and patofisiologi process pigmentasi skin, both at the cellular level, biomolekular, skin and tissue. In addition, knowledge of the pathogenesis is very important to establish the diagnosis and treatment.

Read More - treat melasma : 4 Etiology and Patogenesis

treat melasma : 3 Epidemiology

In the case of melasma comparison between women and men is 24: 1, especially visible in the fertile with age women Exposure history directly affected the sun. Highest incidence at age 30-44 years, whereas according to Montemaro in 2001, 90% of cases occurred in melasma women, if any clinical symptoms in men and histologisnya same.
Research conducted by Goh and Dlova 1999 in Singapore, the ratio of melasma among women and men of 21: 1.
Melasma is a big problem for the East Asia, with skin type III or IV that is equal to 90%. Although the exact number of incidents in some countries is not known, but in East Asia is reported that the patient came to the clinic every year by the skin of 0.25 -40%.

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treat melasma : 2 Definition

Melasma is hipermelanosis which usually occurs in areas affected by the sun. Melasma derived from the Greek, which means the weld while cloasma black comes from the word cloazin, which means to be green, so that melasma more appropriate terminology is used to hiperpigmentasi in the face.
Melasma or khloasma is often called a hiperpigmentasi The speck that is often found in the region face the second cheeks, forehead, chin, mouth up, and can be extended up to the neck. Color can vary from brown to black youth and does not regularly shaped. Size also varies. Lesi usually symmetric, especially when the cheek, while spreading like a mask.
Synonyms of melasma is chloasma which sometimes used to describe the occurrence of melasma during pregnancy. On pigmentasi pregnancy can also occur in general, and often arise in the linea alba becomes a linea nigra, the areola mammae, and on the genitalia area eksterna. Hiperpigmentasi this is happening because of the increased level in the blood so that MSH stimulation occurred melanosit activity, is also estimated to increase estrogen and progesteron role in this interference pigmentasi.

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treat melasma : 1

Human skin color is a combination of several kromofor, the melanin that gives color brown, which gives oksihemoglobin red, which gives deoksihemoglobin blue carotene and the color orange-yellow. Melanin is the component that contributes most dominant color in the skin, so that interference is caused mainly by pigmentasi not have melanin pigment.
Melanin produced by cells melanosit located in the stratum basalis epidermis. Production of melanin occurs in the melanosit and then distributed to keratinosit around melanosit it. Main function of melanin is to absorb ultraviolet radiation. Differences in skin color of different races is not determined by the number of melanosit but depend on the metabolic activity melanosit, the size and shape melanosomnya the organela forming melanin.
Hiperpigmentasi skin is a problem that many patients found the therapy to look for cosmetic reasons. Hiperpigmentasi this is the result of deposisi melanin in the skin caused by increased synthesis or increased the number of melanosit. The many changes color depending on the location of melanin in deposisi. Hiperpigmentasi interference that often complain from patients hiperpigmentasi is melasma and post-inflamasi. These conditions have a major impact because the changes will affect the color of the face someone in the psychological, social life, and confidence.
Hiperpigmentasi determine the cause is very important in the approach to therapy. Based on history and clinical findings of patients, causes hiperpigmentasi likely due to post-inflamasi factors, drugs,
photosensitive agents, ultraviolet rays or systemic disease (eg, Addison disease, liver disease, pregnancy, tumor pituitari). So that the treatment interruption pigmentasi this can succeed, the agent must be determined and it is managed well.
Beauty is not only seen from the outside, but beauty is in support of the creation of a person to appear beautiful. Beauty also need to be outside, because of the line with the age, beauty could be someone outside the pale. One difference that can change the skin of someone's appearance is melasma.
To date, the melasma is still a problem in both the cosmetics and the skin disease in the clinic, this is because handling a difficult and requires a long time.

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