185: Holistic Approach For Dealing With Melasma w/ Dr. Kiran Sethi

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Melasma is a form of hyperpigmentation. It can be tricky to treat, because it has a huge hormonal component that's still not completely understood. My guest today is here to shed some light on this complex skin condition.


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My guest today, Dr. Kiran Sethi, is a Columbia University educated skin and wellness doctor, with further specializations in cosmetic formulations, lasers and aesthetics.

She has been named Elle magazine’s best skin expert, and is best known for her integrative approach to beauty from the inside out.

Join us as we talk about the holistic approach to dealing with melasma.

How are you managing your melasma? Let me know in the comments!

In this episode:

  • What is melasma? Who can it affect?
  • What are the standard treatment options for melasma?
  • How to address the hormonal component
  • How does stress and mindset play into melasma?
  • Melasma triggers
  • Factors to consider when thinking about using hydroquinone or other skin-bleaching agents


“Melasma is a bit trickier than any other typical pigmentation disorder, because the typical pigmentation disorder, we can just treat it, remove it, but melasma depends on sort of the dynamic interconnection of a host of different hormones.” [1:16]

“There's different types of melasma, depending on where it shows up. There's also more surface melasma, there's more deep melasma, there's mixed melasma, there's more like a vascular type of melasma. There's all different types of melasma and we treat them a little bit differently.” [1:49] 


Find Dr. Sethi online here

Follow Dr. Sethi on Instagram | Instagram

185: Holistic Approach For Dealing With Melasma w/ Dr. Kiran Sethi FULL TRANSCRIPT

Jennifer: Welcome Dr. Kiran to the show. I'm so, so excited that number one, we can make this work out, given our time zone difference, and just to have you on the show. You're so well-respected, and I'm really excited to because this is the first time we're ever going to talk about melasma.

Dr. Sethi: Yeah. I'm so happy to be here.

Jennifer: Why don't you tell us, especially for listeners who've never heard of melasma before, what is melasma and can it just impact anyone or are there certain people that seem more prone to it over other individuals?

Dr. Sethi: Melasma, it can actually affect anybody. What melasma really is, is it is a condition that is a combination of a hormonal sensitivity to the sun. Mostly women will get it, men get it much less and you'll see a lot of women they'll be like, “Oh, I got pregnant and I got it.” Or, “I took oral contraceptives and I got it.” Or, “I went through menopause and I got it, or it became less after menopause.” They'll often say, by the way, “Oh, it gets worse around certain times of my cycle. It gets better on other times in my cycle.” It has an enormous hormonal component to it. That's why melasma is a bit trickier than any other typical pigmentation disorder, because the typical pigmentation disorder, we can just treat it, remove it, but melasma depends on sort of the dynamic interconnection of a host of different hormones. It becomes a bit more complex.

Jennifer: Does it just impact the face or are there other areas that you can also have it on?

Dr. Sethi: Sorry. Yeah. It's typically the face. There's the cheeks, the nose upper lip, the forehead, the mandible area. There's different types of melasma, depending on where it shows up. There's also more surface melasma, there's more deep melasma, there's mixed melasma, there's more like a vascular type of melasma. There's all different types of melasma and we treat them a little bit differently.

Jennifer: Wow. My goodness. I thought there was just melasma. Apparently not. This is definitely more complicated. For someone who gets this or who thinks they have it, what would be like, I guess we should start off by just saying briefly, what would be a standard treatment option, that you go to a regular dermatologist, what are they likely going to tell you, here's your options?

Dr. Sethi: In the states, or even in India where I practice, most skin specialists or skin doctors will typically say, “You know what, go on a standard Kligman's formula, which is a hydroquinone a tretinoin and a topical steroid mix. You'll have to do this every day or every other day. Then once the melasma is better, you have to maintain the result, at least twice a week, in order for it to be maintained.” Otherwise, you can't just stop it and then it's over. You actually have to maintain the result. If you don't maintain the result, it will rebound. Yeah.

Jennifer: Interesting. This is an ongoing problem. It's not like once it's gone, it's gone.

Dr. Sethi: Yeah, exactly. That's kind of an interesting part about it, but I actually find that you can actually do a lot without using Kligman's. I do pretty good results in melasma without it, but I'll use alternatives to hydroquinone because hydroquinone, which is considered a bleaching agent. It can be irritating. It can cause redness. There's a very, very, very tiny risk of something called ochronosis where the skin actually gets black and that's hard to treat, but it's very tiny risk. Usually, it's very safe. It makes it the skin thinner, a bit more sensitive, more rosacea. I don't like that. Topical retinoids are fine obviously, but what topical retinoids are vitamin A derivatives, but I try and avoid the other two if I can. If I do have a case of really bad melasma, it's not that I won't use it, but I will use it as judiciously and as minimally as possible.

Jennifer: Is it just topical because you said this is a hormonal issue. Are there some things from other perspectives that you could add in or incorporate into your diet or your lifestyle or supplements that might also be helpful or is there a certain way that we should think about this, given that there is a hormonal component that might be helpful for someone who just thinks it's a skin problem right now? They're like, “Wait, there's a hormonal issue here potentially.” Does that mean also there's a hormonal issue under the surface that you need to pay attention to.

Dr. Sethi: It doesn't mean there's a hormonal issue with the surface. In fact, if you try and pinpoint which hormone, you'll never be able to figure that out. It just means that your hormones make you more sensitive. We still don't know exactly why, but what I tell my patients, I have a very integrative approach to aesthetics as we were talking about earlier. I actually do a whole host of things. One is diet intervention. Anything, any food that has sort of a hormonal component to it, be it dairy. I also say stay very organic. If you have non-vegetarian food because they give them too many antibiotics and hormones as well, which has another hormonal component. We avoid those, stay organic. I also try and avoid too much high-glycemic foods because that spikes insulin. Then you end up in the IDF one pathway, which can trigger more hormonal variation.

Dr. Sethi: We do a lot of diet work. Cortisol, stress is a big trigger of hormonal variation. It's a hormone itself. Stress reduction, talking about things like meditation, exercise, healthier eating patterns, healthier patterns. These are all things that will actually help with melasma and it sounds odd. When you talk to your skin specialist or skin doctor or dermatologist or aesthetic specialist, whatever, and they're talking to you about meditating for your melasma, I'm sure that my patients must be like, “What's happening?” “No, you don't get it. Stress plays a big impact.” Then they're like, “Okay, doc. Fine.” Like, “No.” They're like, “Aww. Come on.” We do that and then we do skincare regiments that have great ingredients actually like Alpha Arbuton, which has really safe, Kojic Acid, licorice extract, Alpha Hydroxy Acids.

Dr. Sethi: We do use our topical retinoids. Vitamin C, Cysteamine is a new ingredient. Tranexamic Acid is a newer ingredient. There's actually Niacinamide. There's so many great ingredients, so we can mix and match them, do some in the morning, do some at night. Those are great. We actually manage good results with that. Then we do also do treatments as well. Great treatments are things like micro-needling done at a very specific depth, of 0.5 to 0.6. mm, which helps actually teach the skin how to behave better. Your skin has like keratinocytes and it has melanocytes and it has fiberglass and they all behave in a specific way. As you get older, or say you have dysregulation, they behave sort of badly. They sort of are like, say you get a pimple, you'll get a mark afterwards.

Dr. Sethi: You have melasma, the signaling is awry, and that's why it just flares. It actually helps improve the signaling. It teaches the skin sort of how to behave a bit better, which I think is really cool. I call it sort of like a time reversal machine and you can infuse great ingredients, like the same ones I was telling you about, Tranexamic Acid, CME, Glutathione, and all of these. That gets deeper into the layers as well, because when you apply a skincare product, only like a few percentage gets absorbed, but when you microneedle it in, it goes much deeper and you can get it to where it needs to go. We do things like that.

Dr. Sethi: Then I'll judiciously add in certain lasers because you have to just watch. You can't be too aggressive with melasma, it gets worse. You can't be too gentle, it just doesn't go. It's like a dance. Every time I might do something different, every time we look at something different, because it's so complex on how it responds, but we actually like, it's really fabulous when it does respond really well because patients who've been through this and it's so prevalent, they are just so happy. That's really great.

Jennifer: May I ask, with these treatments, like the micro needling or the laser treatments, this is again, similar to what you were saying. It's not just a one-time thing. Is there sort of a schedule more or less that someone may have to do these just they have an idea going into this? What would that look like? Yeah.

Dr. Sethi: Yeah. I told to microneedle like once a month. First of all, I tell people, please don't try microneedle at home. If you do it wrong, it's a problem. Also, if you use the wrong ingredients, like you have to use specific ones. There should be no ascorbate. There should be no preserves, because it's so different what you can apply on your face and what you can apply in a deeper layer. You can't just use your skin [inaudible 00:09:15] microneedle on top, you will give yourself a rash. You will. It's a guarantee. Okay. Things like that, but I tell them once a month, because that's enough time for the skin to sort of renew itself, micro needling. Then I also will do the laser again once a month or once in two weeks, depending on sometimes people also have like a, they have a wedding or they have a big event.

Dr. Sethi: They want it to look good before then. I might pre pone certain things, but usually I don't like to overdo it. I think that when we get too aggressive, that's a problem in itself. I don't know if I mentioned this earlier, so I'll finish that. I do a course of six, usually of micro needling sessions and I do the laser and I get to a result of anywhere from 60 to 90% reduction. If I want more than we can keep going. Some people obviously are treatment failures in which case, then we switch, but then we can always find some sort of solution. There's always a solution because there's so many different ways to deal with it. If you want more results than we can go forward. Then I usually will increase the gap because I think that the skin might sometimes need a bit more time to renew itself. Sometimes I will just call it. I'll say, “You know what? I think the skin is good for now. I don't want to touch it.” It's really like the intuitive experience often. Then sometimes I will [crosstalk 00:10:32].

Jennifer: Having your clinical experience too, of just having worked with, I think that's the other point that I really appreciate you made about like, don't do this at home. This is not a DIY project, is that you as a doctor, you have so much experience in looking at different cases that you can see, “Wait, I think we're pushing too hard.” Like you said, “I think we need to, we can do this.” You have that, you're not in it. A lot of times when you're in your own skin, you're like, “I just want it gone. I'll do anything.” You end up doing way too many things trying to get to an end result that you may make it worse.

Dr. Sethi: Yeah, exactly. I tell my patients, I think I spend more time talking about anxiety reduction than about skin sometimes, because I'm like, “All you're doing is, your thoughts are telling you that this will never go away and so you're trying to do stuff yourself to make that feeling of it never going away, go away. Then all you do is make it worse. It's like, your fear is realizing itself. Just take your worry, throw it on me. I will bear it and I will take care of it.” It's like, it's my problem. It's not your problem.

Jennifer: Yes, yes, yes. As sort of an aside, because I was just thinking about this. Is skin or excuse me, is his sun exposure the main problem that will bring this on. Does someone have to avoid being in the sun or wear a lot of sunscreen or wear a hat or are there… I know you said the hormones are a facet of this, but are there any other potential triggers out there that really seem you got to watch?

Dr. Sethi: Yeah. Yeah. The sun is huge. Like I said, the hormones make you way more sensitive to the sun. The sun is enormous. There's a few things that I always tell my patients. No hormonal pills, no oral contraceptives, please. No, no, no. That's forever a no-no. Even the drug eluding IUDs, even those, even the Mirena, the rings, even those, none of those can happen, because it's just going to make everything worse, problematic so no hormone pills. The second thing is the sun is your enemy, unfortunately in melasma, and people never wear the right amount of sunblock, but actually the right amount of sunblock for your face and neck is about two tablespoons. You got to like, yeah. Yeah. It's a lot. It's a lot. Especially in a melasma patient. I tell people two tablespoons is really like one and a half one, one, but I tell them two, so then they at least do the one, one and a half. [crosstalk 00:00:13:00].

Jennifer: Wow. That's a lot. I don't think I've ever put that much on my body.

Dr. Sethi: Yeah. It's a lot. For the spray, I'll tell them to take like six sprays and I'll put it on my face. I tell my patients to get used to it, but if you actually do it right, even that in itself is such a big intervention. Then there's like really great antioxidants you can eat. there's one called Polypodium Leucotomos, which actually gives you like a natural SPF factor of four to eight. If you take the tablets, that's just like a fern extract. That then more antioxidants in your diet, vitamin C, even Glutathione. These are simple things that everyone has to do. We have found that there's a tablet called Tranexamic Acid, which actually was used in gynecology for excess bleeding. We have found that if you take that pill in melasma, it reduces your risk, sorry, it increases your results of the melasma treatment by three times. We would get a multiple of three improvement in your results. We do that a lot as well.

Jennifer: Wow. Oh my goodness. Yeah. I want to ask you, you mentioned about the hydroquinone?

Dr. Sethi: Hydroquinone.

Jennifer: Hydroquinone, Excuse me. You mentioned about that and I wanted to touch on the bleaching, because I think sometimes, I mean, I've seen an awful lot, especially over the past few months, being at home, looking at videos online, there's this, and I guess it's not a new trend, of people wanting to kind of like bleach their skin and areas where they feel like it's too dark or discolored or whatever. That's a really big deal. There's also cultural implications for some of that. What are your feelings and your experiences of working with patients, especially have you seen people where that sort of lightening process has gone really awry or maybe they did it at home or they did it with the wrong person?

Dr. Sethi: Yeah. I've definitely seen that. In India, you can get like the Kligman's thing I was telling you about, you can get it over the counter and your pharmacist can also just give you whatever he wants. There's no prescription, technically there's no prescription regulation. A lot of people like their pharmacist or their friend will be like, “Oh, try this and it'll make you white.” They'll start using it. They'll use it for years. They'll come in with just the kind of skin that you'll be shocked as thin. It's red. It's super sensitive. Even if you touch it, you can't like handle it. They're miserable. They're really miserable. I have seen a lot of side effects from it, which is why I really, after seeing all of that, I'm naturally just more wary. I'm so wary of it because I've seen people just use it to such a bad extreme. You will get more, you will definitely, your complexion will change, but then your skin will be so papery thin, then you've also aged your skin by 10 years.

Jennifer: When the skin becomes thin like that, are you stuck? For someone who's listening to this where say, maybe they've even used like topical steroid cream and I know steroid creams can also thin the skin of the face. Are you stuck? Do you feel like someone, that's a hard road or it can your skin rejuvenate [crosstalk 00:16:12]?

Dr. Sethi: Your skin can get better. In fact, we do things like micro needling again, because it does create collagen. You actually get fetal collagen. It's like a good, healthy collagen, and you can keep doing that. We do really good skincare. We have to calm the skin down. I will stop everything on those patients and be like, you are going to suffer for a month. You will feel very uncomfortable, but I have to give you some doxycycline. I usually give them a bit of oral antibiotics to calm down the inflammation. Some calcium neuron inhibitors like [inaudible 00:16:41], very often we use to sort of calm it down. These are all prescription things guys. We'd use that to calm things down, but I won't let them use any topical steroids at all. It's sort of like a complete detox. It's a very tough that first month, two months is very tough because your skin is like addicted to it.

Dr. Sethi: It just only knows how to function with that on it. It doesn't know what to do. That whole process gets very, very uncomfortable for them. Then after that, it actually starts to get better and better and better usually. We find a bunch and there's a few other things that I'll prescribe based on what they need. Then we start certain treatments, like even a laser that we do called Clear Lift has also been shown to be really great in sort of the thinner skin. It sort of just builds up that collagen. These are the things that I've used, but I keep it very gentle, because I think that the more gentle, the better in super thin skin like that, and it can be improved. There's nothing to worry about.

Jennifer: No abrasive scrubs from melasma. Nothing abrasive.

Dr. Sethi: No. If I give a scrub, it might be once a week, it might be once a month. Usually, I'm using pretty good creams to get rid of the pigmentation. You don't really need much. Like I said, melasma is the kind of thing that if you go too hard, you can make it worse. It's like a constant balancing act that I'm doing with them.

Jennifer: Interesting. This has been so fun. Thank you so much for also just sharing so much of your candid wisdom that you've gained over the years, not just from medical school, but being in practice and you really, you're also very worldly. You started, you worked in, were you in New York, I feel like?

Dr. Sethi: Yeah. I was born and raised in New York. I did my undergrad, did my med school. I did residency in New York. I did my masters in dermatology, skills in [inaudible 00:18:33] and masters of science and derm in the UK. I've been in India and I used to do free clinics for the poor for quite a few years. That was wonderful. Then I had a skincare line. I've done everything. I've done everything.

Jennifer: It was such an honor when you were open to being on the show. I really, I was so excited because it's nice to have guests on who were so knowledgeable and it's not just like you're book smart. You're also understand how to pivot and shift and look at things from different perspectives because of so much clinical experience. That's the kind of wisdom that I think people who do AI and computer generated, things would love to put in a program, but it's just, your brain is amazing. It's such, such an honor to have you here sharing this with us and to hear just all the different variations and whatnot. I think people appreciate knowing that they have more options than just the few that there being given.

Dr. Sethi: Yeah. There are. There are a lot of options and I really believe, especially when it comes to melasma, you have to take a very holistic approach to it. I thank you so much for your kind words. I really try to do the best I can to look at all different ways of looking at things. I believe that there's, nothing is ever a no. It's always like, “Well, let's consider it.” I think that sort of helps me a bit, but thank you.

Jennifer: Awesome. People can find you on the internet. What is your website?

Dr. Sethi: My website is www.iscaderm, I-S-Y-A-D-E-R-M.com. I'm on Instagram, on @drKiransays, D-R-K-I-R-A-N-S-A-Y-S, and @isyaderm. I do online consultations as well. I do a lot on Instagram. I give a lot of wisdom, as much as I can in one minute, on Instagram. People can find me there.

Jennifer: Perfect. We'll link to all of your profiles and the ways that people can connect with you over in the show notes. I thank you so much for coming on the show. I really appreciate your time and I hope we can have you back sometime.

Dr. Sethi: Thank you so much. Absolutely. Take care.

“Melasma is a bit trickier than any other typical pigmentation disorder, because the typical pigmentation disorder, we can just treat it, remove it, but melasma depends on sort of the dynamic interconnection of a host of different hormones.”