Why melasma keeps coming back

The story of Melasma almost same for every patient. The spots usually fade nicely on a cream or serum. Once they stop applying it, the pigmentation was back even worse and darker than before. You will think this is the failure of cream but in reality, this is exactly how Melasma behaves. Once you understand it, you'll be able to control the pigmentation better.

The short version

• In Melasma, the pigment producing cell (Melanocytes) becomes hyperactive and produces more pigmentation (Melanin).
• Creams, lasers and serums clear pigment that is already made. They do not calm the hyperactive pigment producing cell.
• Hence pigmentation returns once treatment is stopped. This is reason why we should control triggers as well.

What switches the pigment machinery on?

• Sunlight and visible light. Including light through windows, tubelight and screens.
• Heat. Commonly kitchen stove heat and outdoor hot climate.
• Hormones. Pregnancy, thyroid issues, irregular cycles, hormonal pills.
• Inflammation and damage to skin. Using harsh scrubs can make it worse.

This is why Melasma is stubborn in Ahmedabad. We get six to eight months of strong sun and heat where most of us commute is in it.

What can I do to calm it?

• Sunscreen is essential. Use it 20 minutes before stepping out. Reapply if you are out past midday.
• Heat cover. Wear a scarf or thick cotton (or better, UPF rated clothing) while outside. Stand back from the kitchen stove or grill.
• Gentle procedures. Dermatologist approved peels or low-fluence laser toning suited for your skin. Aggressive settings used by unqualified laser operators rebound the pigmentation.
• A check for other causes. Thyroid issues, hormonal fluctuations, vitamin deficiency should be done in stubborn widespread pigmentation.

What to expect?

• First visible change noticed after 1 - 2 months.
• Real difference in 3 - 4 months.

Two things that ruin results

• Stopping sun protection once the skin looks clear.
• Switching creams every few weeks because something stronger was promised online.

The four-product routine that beats a twelve-step one

It is common nowadays to see impressive shelves of dozens of products on one's mirror countertop. Ten bottles and four actives, where three of them do the same job.

The skin gets irritated and breaks out. Almost always, the fix is to minimize the long routine into a simple yet effective one.

The short version

• Skin needs four jobs done: Clean | Hydrate | Protect | Treat
• One product per job is enough.

The four products

• A gentle cleanser
  Twice a day with lukewarm water. If your face feels tight afterwards, the cleanser is too harsh.
• A moisturiser
  Gel-cream for oily skin. A richer cream for dry skin.
• Sunscreen
  Every morning. Prevents tanning, pigmentation, early lines and collagen loss. Reapply if you are out through the day.
• One active for your main concern
  Retinoid for acne, texture and ageing, Vitamin C or niacinamide for dullness, Salicylic acid for comedone and congestion. Pick one, manage one condtition effectively before starting another active.

The order

• Morning: Cleanse → Moisturise → Sunscreen
• Night: Cleanse → Moisturize → Active

How to start an active

• Built up tolerance slowly. Use it twice a week at first. Then increasing frequency as prescribed over 1 - 2 months.
• Give any change eight to twelve weeks before you judge it.

What to leave out

• Daily scrubs and alcohol toners.
• DIY homemade masks.
• Fairness creams that contain steroids. These cause facial damage that is hard and rarely irreversible to treat.

Newer psoriasis treatments: biologics and JAK inhibitors

Psoriasis has been managed the same way for years. Older treatment involves steroid ointments, methotrexate and coal tar, with patients assuming this is as good as it gets.

However newer therapies have made psoriasis treatment more safer, faster and manageable long term.

The short version

• Psoriasis is an immune system dysregulation that keeps sending an inflammatory signal to the skin.
• Older medicines suppress the whole immune system. This is why they had more side effects and needed regular blood test monitoring.
• Biologics and JAK inhibitors block only the specific signals that are increased in psoriasis. This means better, faster, safer treatment having fewer side effects.

What are biologics?

• Biologics block one messenger that is elevated in Psoriasis. Switching off the exact pathway that causes psoriasis plaques.
• They are given under the skin as in Injection, once every few weeks to a few months depending on the drug. 
• Results are high. Most patients on IL-17 or IL-23 agents reach 90% clearance or better. Many see completely clear skin. If you have Psoriatic Arthritis. The right biologic treats both skin and joint disease.

What are JAK inhibitors?

• JAKi are targeted medication that block specific inflammation messages. They have rapid action. Plaques starts to settle within first few weeks.
• Given as oral tablets. Molecules like Tofacitinib and Upadacitinib are JAK inhibitors. They are good option for patients who do not want injections.
• However they do need blood test monitoring.

Are they safe?

• Compared with years of steroids or methotrexate, the safety profile of modern biologics is generally better.
• Usually both need a workup first before starting as to be deemed safe before starting on the therapy.

Who should consider them?

• Moderate to severe psoriasis. With large area of involvement.
• Failure to manage only with topical or conventional medications.
• Joint pain or stiffness along with the skin disease.
• Disease on cosmetically visible sites like face, scalp, hands, feet, or nails.

What to expect

• The plaques show improvement in the first 2 - 4 weeks. Most of the clearance is seen by 3 - 4 months.
• Treatment continues with decreased frequency and dosage to keep the disease under remission.

These are prescription medicines that need proper assessment and follow up. They are not for everyone, and cost is a real consideration. A proper consultation can clear your doubts as to assess and predict benefit in your case.

PRP and GFC for pattern hair loss

Patterned baldness is the most common reason for hair thinning in both men and women. In men it shows as a receding hairline and a thinning crown. In women it is usually a widening parting with the hairline preserved.

Over and above the topical and oral medications, PRP and GFC are the injectable treatment option used for it.

The short version

• In pattern hair loss, follicles shrink with each cycle. Hair becomes thinner and shorter until it stops growing.
• PRP and GFC deliver growth factors from your own blood into the scalp to push shrinking follicles back into an active phase.
• They work best on thinning hair. They cannot regrow hair on a scalp that is already bald and shiny.

PRP and GFC: what it is?

• Platelet Rich Plasma. Your blood is drawn and spun so the platelets concentrate. It contains platelets and cells. The growth factors are released gradually as the platelets break down when injected.
• Growth Factor Concentrate. Also from your own blood, but there is higher and more consistent concentration in GFC
• Session time is about 45 minutes. Numbing cream is applied first. Then PRP/GFC is injected uniformly over the affected areas in specific depth.
  

The schedule

• Starting phase. 4 to 6 sessions, one every 3 to 4 weeks.
• Maintenance. One session every 3 to 6 months. Hair loss is ongoing hence repeated sessions matters most.
• Neither of them is a standalone treatment. It works far better alongside topical, oral medication. Correction of iron, vitamin D and thyroid levels is also essential.

Men and women: what differs?

• In men, the crown and mid scalp respond best. A hairline that has receded for many years responds poorly and may be better suited to a transplant.
• In women, diffuse thinning over the top of the scalp responds well. Density and parting width improve.

What to expect

• Hair fall reduces first, usually by end of first month.
• New hair growth starts around 2 - 3 months.
• Visible improvement in density is seen at 4 - 6 months.
• Photographs at every visit are the only reliable way to judge progress.

What ruins results

• Stopping after few sessions because nothing has changed yet.
• Skipping the oral, topical medications, and supplements.
• Dropping maintenance sessions once the hair looks better.