Ep 145 – The Rogue Pharmacist: Melasma is More than Skin Deep

Woman with Melasma

Melasma is a common but often misunderstood skin problem. Traditionally associated with hormones, it’s also referred to as “pregnancy mask,” although a simple Google search pulls up varying definitions, causes, and treatments. In this episode of The Rogue Pharmacist with Benjamin Knight Fuchs, we discuss melasma’s cause and prevention, melanin formation, and external factors affecting its treatment.

Associated Skin Care Professionals (ASCP) presents The Rogue Pharmacist with Benjamin Knight Fuchs, R.Ph. This podcast takes an enlightening approach to supporting licensed estheticians in their pursuit to achieve results-driven skin care treatments for their clients. You can always count on us to share professional skin care education, innovative techniques, and the latest in skin science.

Benjamin Knight Fuchs is a registered pharmacist, nutritionist, and skin care chemist with 35 years of experience developing pharmacy-potent skin health products for estheticians, dermatologists, and plastic surgeons. Ben’s expert advice gives licensed estheticians the education and skin science to better support the skin care services performed in the treatment room while sharing insights to enhance clients’ at-home skin care routines.

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0:00:55.6 Maggie Staszcuk: Hello, and welcome to ASCP and The Rogue Pharmacist with Benjamin Knight Fuchs. In each episode, we'll explore how internal and external factors can impact the skin. I'm Maggie Staszcuk ASCP's cosmetology manager. And joining me is of course, Ben Fuchs. Hey Ben. 


0:01:10.6 Benjamin Knight Fuchs: What's up, Maggie. Good to see you. 


0:01:11.6 MS: Good to see you. In today's episode, we're discussing melasma. Now, this condition goes by a couple of different names, and it's always been my understanding that it's brought on by hormones, but is that really true?  


0:01:24.4 BF: Well, you're ahead of the game not surprisingly. Not a lot of people know that it is brought on by hormones. People still blame the sun for melasma, which is unfortunate because while the sun can trigger melasma, when you were a little kid out playing in the sun, did you ever get melasma?  


0:01:38.8 MS: Never got melasma. No. 


0:01:39.6 BF: Right? Did you ever seen any little kids with melasma? I mean, occasionally it'll happen, but it doesn't happen very frequently. When you're young, you go out in the sun, what happens? You tan. Melasma represents a tanning dysfunction. It's a dysfunction of the pigmentation process and it's a... It's when the pigmentation doesn't occur evenly, it occurs in blotches and you hit the nail on the head, it's associated with hormones. But that's kind of... Everything is associated with hormones. Hormones regulate everything in the body. So there's nothing that happens without hormones, but hormone imbalances or hormone dysfunction is really where you run into the melasma problem. Before you even talk about melasma, I think it's important to recognize that there's a distinction between two types of pigment that we don't often distinguish. And this creates a lot of frustration when we try to treat melasma if we try to treat this other kind of pigment, which is known as aging pigment. I think we've talked about this before, it's known as lipofuscin. Right?  


0:02:31.4 MS: I've heard you say that before. Yeah. 


0:02:32.8 BF: Lipofuscin is not melanin. Melasma is a melanin pigmentation. Lipofuscin is said to be aging pigment, and what it really is, it's the residue of dead cells and the parts of dead cells that aren't getting cleared out appropriately. Ordinarily, dead cells and components of dead cells will get cleared out by the lymph system, when the lymphatic system is stagnating or clogging or as we get older and our bodies... Our cells are breaking down faster if we're not healthy, this lipofuscin or brown pigment can accumulate particularly in the hands and in the feet, our hands and the legs, and you'll see... You can see it on older folks hands sometimes. It's like a... Doesn't look like pigment, it's kind of brownish, a very light brownish color, and sometimes people will try to use depigmentizing agents and they'll get very frustrated 'cause nothing's helping. It's also located deeper in the skin than ordinary melanin is, which is where melasma happens. So I think that's important to recognize for professionals who are trying to treat pigmentation issues that they make sure they're not treating lipofuscin with a de-pigment... De-pigmenting agent because it won't work. You have to really work on the lymphatic system in order to do that in general health. But as far as melasma goes, melanin goes, Yes, you hit the nail right on the head. There's a major hormonal involvement. Did you know that melanin is part of the body stress system?  


0:03:45.7 MS: No, I didn't know that. 


0:03:46.6 BF: Yes. It's the whole adrenal cortisol biochemical pathway involves melanin, and in fact, there's a relationship between adrenaline and melanin in terms of biochemical synthesis, and there's a relationship between a cortisol and melanin. And both of them utilize the same kind of precursors dopamine and tyrosine. And so when we're under a lot of stress, we will end up producing a lot of melanin, and that is hormonally mediated, and that's the number one consideration that we want to... Number one approach that we wanna take advantage of when it comes to depigmentizing or taking care of melanization or melasma is lowering cortisol, lowering the stress hormone system, reducing melanin or adrenaline, just relaxing the body. But it's not just psychological relaxing, there's biochemical stresses that are also involved, and that's really how we wanna look at hyper-pigmentation is a sign that the body is under stress. Now, there are hormones that are associated with it, and in our culture, we actually take those hormones orally, and particularly I'm talking about estrogen, and estrogen is a well-known melasma-inducing agent. 


0:04:54.9 BF: In fact, almost up to 50% of pregnant women will get the mask of pregnancy, which is a classic example of melanization, obviously, when you're pregnant... When a woman's pregnant, she'll make more estrogen as well as toxic estrogen. And I think we've talked about this in the past, how estrogen is broken down and detoxified by the liver, but if we're not breaking down our estrogen effectively enough, toxic estrogen can build up. And this is especially problematic for people who have intestinal problems, people who have liver problems and people who have thyroid problems. And so we find that melasma is higher in women who are having digestive issues or thyroid issues, or in general estrogen issues as in menopause... If they're menopausal or perimenopausal, if they're estrogen dominant or if they're high estrogen producers, or if they're pregnant. If on top of that, they're using hormone replacement therapy... So they're using birth control pill, which is not exactly hormone replacement therapy, but it's hormonal ingestion of exogenous hormones or HRT, like if they're a perimenopausal or menopausal or they've had a hysterectomy. So... 


0:06:04.8 BF: Physicians will put women on estrogen. Aside from the fact that estrogen is a really, really powerful, powerful hormone, it can definitely be associated with melasma and hyperpigmentation. If that is the case there's lots of things you could do. You can help the body purify estrogen, work on the liver. Definitely we should be working on the intestine if there's any estrogenic health issues, because estrogen is partially cleared out by bacteria in the intestine. Have you heard of this thing called the estrobolome?  


0:06:31.5 MS: No. 


0:06:31.7 BF: The estrobolome, E-S-T-R-O-B-O-L-O-M-E is the universe of bacteria that live in the intestine that regulate and process estrogen. And when the estrobolome is messed up, such as when you have intestinal health problems or you're eating the wrong foods or you have a small intestinal bacterial overgrowth that can wreak havoc on estrogen metabolism. And that can be associated with melasma, among other estrogenic health challenges. So and this is always something we've learned about in the last 20 years or so, that there's a major, major relationship between how estrogen is processed and gut bacteria via this universe of bacteria called the estrobolome. And you'll probably hear a lot more about the estrobolome in the coming years. It's something that we first noticed about 20 years ago but it's becoming a hot subject for research here on the last five or 10 years. 


0:07:18.3 MS: And this could be men too, not just women?  


0:07:21.9 BF: Absolutely, absolutely but because women are much higher estrogen producers than men it's mostly a female issue. Most melasma occurs in women which is another indicator that you're dealing with an estrogen health issue. When you have a health issue that affects mostly women, you wanna think about estrogen. And there are a lot of health issues that affect mostly women. Most autoimmune disease patients are women. Most hypothyroid patients are women most melasma patients are women. So these kinds of health challenges that affect mostly women it's usually a red flag that you're dealing with estrogen, which is the main distinguishing hormone between men and women. Not that men don't have estrogen and not that men don't get these health challenges too but they're predominantly... These health challenges are predominantly women because estrogen is predominantly... Is found in higher amounts in women. And in fact that might be the distinguishing hormonal feature between men and women. 


0:08:22.8 BF: Also there's the whole cortisol issue with hyperpigmentation and that's the stress hormone issue. So balancing out cortisol becomes very important. And cortisol, elevated cortisol is associated obviously with psychological stress. So relaxing is important but elevated cortisol is also associated with physiologic stress particularly with hypoglycemia low blood sugar. When you're eating a lot of sugar your body becomes very sensitive to sugar and so your insulin goes up. Sugar is actually, I don't wanna say it's a toxin but it acts in many ways like a toxin. So the body has to get rid of blood sugar and it does it via the hormone insulin. The more sugar you eat the higher insulin levels will be, insulin has an effect of pulling sugar out of the blood. So you eat sugar insulin goes up pulls the sugar out of the blood. When the sugar goes out of the blood you experience what's called hypoglycemia. And you may have... Have you ever heard of hangry?  


0:09:17.1 MS: Oh, sure yeah. 


0:09:17.8 BF: Right being hangry is a classic symptom of hypoglycemia. You need to have some sugar. Sometimes people who are really insulin sensitive who are like pre-diabetic they will go through hypoglycemic incidences frequently and they'll get shaky. They may get queasy or nauseous. They'll get brain fog, they'll feel like they need to lay down, they'll have fatigue. It can be pretty serious and they'll have to suck on candy or they'll have to get a glass of orange juice. This is the beginnings of diabetes during that intermediary phase where sugar is pulled out of your blood but you haven't had time to go get a glass of orange juice. Your body is in an emergency state and many of the symptoms of hypoglycemia the shakiness, the dizziness, the queasiness are associated with elevated levels of cortisol. And the more frequently this happens, the higher your cortisol is gonna be chronically. So keeping your blood sugar stable is a very important strategy for keeping cortisol at bay and for ultimately reducing melasma. 


0:10:13.6 BF: Psychological stress I mentioned, also muscle relaxation can help when the muscles are contracted. That's associated with elevated cortisol. You can tell you have elevated cortisol if you have problems sleeping, if you wake up in the middle of the night and you can't go back to sleep. The classic example of elevated cortisol and elevated stress hormones in general is what's called postural hypotension. Postural hypotension is when you change posture like you'll stand up out of a seated position or you'll get up out of bed you change your posture somehow and you feel lightheaded. Hypotension means low blood pressure so postural hypotension refers to the changes in blood pressure, the drop in blood pressure that occurs when you change posture. Sometimes this will happen if people drink coffee or something before they work out before they lift weights for example, bend down to pick up a weight and you stand up and you feel dizzy. Bend down and pick up anything and you stand up to feel dizzy. That's a classic sign of stress hormones. In fact that is the classic sign. There's actually a condition now that you may have heard of called POTS. 


0:11:14.4 MS: I haven't heard that. 


0:11:15.0 BF: It's called postural orthostatic tachycardia syndrome which is a fancy way of saying you change your posture and your heart starts to race. And this is becoming more and more common. And this is also a sign of elevated cortisol or elevated stress hormones. So if you notice any of these symptoms and you're hyper pigmenting guaranteed that you've got stress induced hyperpigmentation or stress hormone induced hyperpigmentation. 


0:11:40.2 MS: Interesting. 


0:11:41.1 BF: Now they... And there's a lot of things you could do by the way for this, one of the best supplements you could use to balance cortisol is melatonin. Melatonin and cortisol have a kind of balancing effect. And interestingly as we get older our melatonin levels naturally drop. Melatonin is a really important anti-aging hormone. Most people know of it for sleep obviously take it for sleep but it really has general relaxation properties and it has anti-aging properties as well. And as we get older our melatonin drops. It's a little tricky to supplement with melatonin because it's a hormone. And when you take a hormone exogenously your body has a tendency to decrease its natural production of a hormone. But if you're older and you're not making melatonin anyway that's less of a factor. I think melatonin is one of the most underappreciated of all the nutritional supplements that you can take. By the way, melatonin itself has skin lightening properties. 


0:12:31.7 MS: Really?  


0:12:32.1 BF: Yeah mela for melanin, tonin meaning regulating it regulates pigment. And in the animal kingdom, melatonin is associated with a pigmentation that's linked to fertility. And it turns out that there's a relationship between melatonin and fertility or between melanin I should say and pigmentation and fertility. In the animal kingdom there's a lot of animals who will change color as a signal to mate... 


0:12:57.6 MS: To attract the mate. 


0:12:58.5 BF: To attract the mate exactly. So there's a relationship between melanin and actually melatonin and estrogen as well so this whole complex of pigmentation and fertility and stress are all located in the same kind of biochemical milieu in the body. So melatonin is a great supplement for helping balance out cortisol vitamin A and vitamin E can help balance out cortisol keeping your blood sugar stable. As I said relaxation strategies, sleep is an important... Getting enough sleep is a great way to help balance out cortisol. So you can see that when we think about pigmentation you started this off nicely when you said it's associated with hormones which it is. Most people will say, Oh what kind of I gotta get my hydroquinone or I gotta get my I need to exfoliate it or stay out of the sun. These are all the things that we think of when we think of pigmentation because in our culture and you and I in our... The skin business we're somewhat responsible for this we always say if you have a skin problem you have a skin problem. In other words if you have a skin problem treat the skin. 


0:13:58.0 BF: If you have a skin problem it's not always not necessarily a skin problem. It's an internal problem. In fact most of the time if you have a skin problem it's an internal problem. And while melasma obviously shows up on the skin and we wanna get rid of it, the best way to do it is to get rid of it from a biochemical perspective via the mechanisms that are causing the melasma in the first place. That being said, there are topical strategies you can do to get rid of melasma. And of course if you're have access to medical ingredients you have a medical director or you're working with a dermatologist hydroquinone is considered to be the gold standard in depigmentizing, but in addition to being the gold standard it's also pretty darn toxic. It's really, really powerful stuff. 


0:14:41.7 BF: And if you're using hydroquinone the doctor the dermatologist or the pharmacist will tell you, "Make sure you use it for three months and then stop using it." Because it can permanently debilitate melanocytes and then you end up with a blank spot you'll end up with a white spot instead of... You have no pigment at all. You don't want that to happen. Hydroquinone is also has... The chemical structure of hydroquinone is also associated with carcinogenesis with cancer so it's really not a nice molecule, nonetheless it's effective. It's the gold standard in skin pigmentation and skin depigmentation. The prescription strength of hydroquinone is 4% but compounding pharmacists like myself know that doctors will prescribe 10%... 


0:15:22.5 MS: Wow. 


0:15:24.3 BF: 8%. I've made a 20% hydroquinone. 


0:15:27.3 MS: Wow. 


0:15:28.1 BF: Yeah and I would wear a mask and do it under the hood 'cause I didn't want to even come close to that stuff in gloves. But it is very effective. My favorite topical way to depigmentize the skin is retinoic acid or retinol. To me it's just as effective as hydroquinone but it's nontoxic. And so you get anti-aging benefits instead of toxicity benefits when you use retinol and retinoic acid. Retinol and retinoic acid work on the surface, they help increase turnovers so skin melanin will flop off. Melanin is on the skin surface and it will flop off in the... In the corneal sites in the desquamation process. But it also works... Retinol and retinoic acid also work at the level of the pigment making cell, the melanocytes. They regulate pigmentation at the melanocyte level. So you don't only get topical benefits you also get biochemical benefits with retinol and retinoic acid and off course, you get all the anti-aging benefits as well. There's a lot of other things that are kind of getting some buzz these days but none of them are really effective. Kojic acid has been used for years and for the life of me I've worked with kojic acid for almost 30 years now I don't see a lot of benefits with kojic acid. I find it very unimpressive skin lightener although it's considered to be one one of the more important topical cosmetic ingredients for skin lightning. There's a new one out called tranexamic acid, have you heard of this one?  


0:16:47.9 MS: I have, yeah. 


0:16:48.5 BF: Tranexamic acid is getting some buzz I haven't found it to be super effective nothing like hydroquinone or retinoic acid or retinol certainly. Vitamin C has got some anti-tyrosinase properties. Tyrosinase is the enzyme that is important for... That's critical for the production of pigmentation. Tyrosinase works on tyrosine when you hear ase at the end of a word that tells you it's an enzyme that works on the prefix of the word. So a protease works on protein, amylase works on carbohydrate, lipase works on lipid, tyrosinase works on tyrosine. As I said earlier tyrosine is part of this whole dopamine melanin, adrenaline biochemical pathway and tyrosine inhibiting the enzymatic activity on tyrosine blocks that pigmentation pathway from occurring. So tyrosinase inhibitors are the main way that cosmetic skin lighteners work and tranexamic acid... I'm pretty sure tranexamic acid is but vitamin C definitely is a tyrosinase inhibitor. So that's got anti pigmentation benefits and then there are a lot of botanicals that have tyrosinase inhibition effects. But because pigmentation is a biochemical process and it's something the body wants to do it's really difficult to stop it from happening by putting a topical ingredient on your skin. Shy of just exfoliating and getting rid of the pigment there's really not a lot you can do to try to override something the body wants to do from an internal biochemical perspective with a topical cosmetic ingredient. 


0:18:23.6 BF: Which is why people are so darn frustrated by this by melasma and hyperpigmentation and I can't... It's 10 times a week I get calls about melasma and about how hyperpigmentation about how frustrating it is and I understand why because we're being told that it's a skin problem. We're being sold skincare products to get rid of it. But it's really a hormonal issue and a biochemical issue and it's something that the body wants to do. The pigmentation is part of the biochemical environment of the body and without addressing it at that level it's really not... There's not much you could do from a topical perspective aside from just getting rid of the pigment via exfoliation or desquamation. 


0:19:00.7 MS: And so let's say somebody has melasma and then they take care of the hormone problem or the cortisol problem they now are nice and balanced does that pigment resolve on its own or the pigment is there now to stay?  


0:19:12.1 BF: No the pigmentation process occurs in this really interesting way, pigment is made in melanocytes the melanin producing cells. But it's not oxidized or darkened in the melanocyte. It's darkened in the keratinocytes. So what happens is the melanocyte will actually inject the pigment into the keratinocytes as the keratinocytes is rising. And so the pigmentation that we see that we are so... Find so frustrating, is actually a surface phenomena it's in the corneal sites. It's in the cells that are in the top, the keratinocytes as it's rising to the top of the corneal site at the surface. So that's why exfoliation works to get rid of pigment. However if you haven't adjusted the hormones, you're gonna pigment again you're gonna hyper-pigment again, you're gonna melasma again. However, as you said, if you adjust the hormones if you take care of the estrogen and you take care of the cortisol you address the hypothyroidism and again we didn't mention this... 


0:20:06.2 BF: I don't think we mentioned it but hypothyroidism is one of the... It's also associated with pigment... Hyperpigmentation. If you address those hormonal issues then as the melanin, the old pigment naturally exfoliate it won't get replaced. So yes by adjusting your pigment you can get rid of... Or by adjusting your hormones you can get rid of the pigment permanently. The hyperpigmentation I should say. 


0:20:28.0 MS: That wraps our show for today and we thank you for listening but if you just can't get enough of Ben Fuchs, The Rogue Pharmacist, you can listen to his syndicated radio program @brightsideben.com. For more information on this episode or for ways to connect with Ben Fuchs or to learn more about ASCP check out the show notes. 


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