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Cosmetic Dermatology
Digital Lecture Series : Chapter 26
Dr. Shehnaz Arsiwala
MD, DDV
Consultant Dermatologist Prince Aly Khan Hospital,
Saifee Hospital, Mumbai India
Email Id : [email protected]
CONTENTS
 Introduction
 Procedures
 Cosmetics
•
Chemical Peels
 Topical therapies
•
Microdermabrasion
•
Fillers
•
Botulinum toxin
•
Platelet rich plasma
•
Lasers
•
Moisturizers
•
Sunscreens
•
Antiaging cosmeceuticals
•
Cosmetic camouflage
•
Adverse reactions
 MCQs
 Photo Quiz
Introduction
 Cosmetic dermatology is a rapidly developing field of medicine.
 Various therapies and procedures are used to enhance one’s
aesthetic looks and appearance.
 Common cosmetic problems include acne, pigmentation, agerelated, hair and nail problems.
 Various topical therapies and interventional procedures are used to
address these cosmetic problems.
Cosmetics and Cosmeceuticals
 Cosmetic : Any article intended to be rubbed, poured, sprinkled, or
sprayed on, introduced into, or otherwise applied to the human
body for cleansing, beautifying, or altering the appearance.
 Commonly used cosmetics : Soaps, shampoos, moisturizers, antiaging products, eye and lip cosmetics, bleaching and hair products.
 Cosmeceutical agents : Pharmacological agents which have an effect
intermediate between cosmetics and drugs.
 Cosmeceutical botanicals, retinoids, skin lightening agents,
sunscreens.
 Adverse reactions to cosmetics and cosmeceuticals can occur.
Moisturizers
 Moisturizers are agents which hydrate the stratum corneum by
either providing water or helping to draw water from the deeper
layers of the skin.
 Oil-in water or water in oil preparations.
 Sunscreens, anti-ageing products like retinols, alpha or beta hydroxy
acids and skin-lightening agents may be added to moisturizers.
Moisturizers - types
Oil-in-water :
 More cosmetically acceptable by patients
 Not very effective for very dry skin conditions
 Cream or lotion formulations
Water-in-oil :
 Create an occlusive film on the skin surface; reduce water loss and
traps moisture in the skin
 Stickier, less cosmetically acceptable
 More effective for dry skin and ichthyotic conditions
Moisturizers – cosmeceutical agents
Contents of moisturizers :
 Stearic, linoleic, linolenic, oleic, and lauric acid, fish oil, petrolatum,
shea butter, and sunflower seed oil Petroleum jelly, lanolin, mineral
oil, and silicones.
 Glycerol, pyrrolidine carboxylic acid , Urea, lactic acid, glycolic acid.
 Sesame oil, wheat germ oil and Vit E.
 Bisabolol, squalane.
Sun and Ultraviolet index
Ultraviolet index :
 Informs about amount of harmful effects of UVL on earth on a
particular day.
 0-2 - minimal-sunburn occurs over an hour
 3-4 - low-sunburn in 30-60 mins
 5-6 - moderate-sunburn in 20-30 mins
 7-9 - high-sunburn in 10-20 mins
 10-15 - v high-sunburn in<10 mins
Sunscreens
 Organic agents that block the penetration of UV agents by acting as
filters and by absorbing and reflecting UVL.
 Sunscreens protect from UVA and UVB rays and reflects, absorbs or
scatters harmful rays.
 Sun protection factor (SPF) : ability of a sunscreen to delay suninduced skin erythema.
 Most sunscreens have a SPF label.
Types of sunscreens
 Physical : Form an opaque layer which totally blocks out the sunrays
e.g zinc oxide, titanium dioxide and calamine.
 Chemical : Absorb the rays and convert the energy to heat which is
diffused. These may selectively protect against UVA or UVB.
UVA blockers : Benzophenones, dibenzoylmethanes, Mexoryl.
UVB blockers : P-aminobenzoic acid (PABA) derivatives, salicylates,
cinnamates.
FDA Protocol
 For effectiveness sunscreen should be layer of 0.5mm thickness.
 Reapplication every 20-90 mins depending on activity and lifestyle.
 AAD recommendation is sunscreen with atleast SPF 15 to be worn
round the year.
 Water resistant means sunscreen mantained after 2-20 mins
immersions in water.
 Very water resistant means lasts upto 4-20 mins immersions in
water.
Ultraviolet protection factor
 Is the sun protection achieved by wearing fabrics.
 Tighter weaves, darker colors, synthetic and loose fit- greatest
protection.
 Loose woven, light color, tight fit, natural fibres- least protection
 Wet clothes offer increased SPF.
 UPF recommendation is >30.
Method of sunscreen use
 Select a sunscreen SPF 15-30 with UVA and UVB protection.
 Apply 15-30 mins before exposure.
 Reapply generously after swimming or sweating.
 Select water resistant one for beach/outdoor activity associated
with perspiration.
 To avoid eye stinging, avoid sport gel formula and avoid
benzophenones.
 To maximize eye protection appropriate sunglasses, polarizing
lenses.
 Lipsticks sunscreens-useful.
Antiaging cosmeceuticals
 Cosmetics formulations with pharmaceutical actions.
 Cosmetics with drug like advantages and have ingredients that
influence biologic function of skin.
 Products are formulated with ingredients of pharmaceutical
strength.
 Topical antioxidants, cosmeceutical botanicals and retinoids are
important ingredients.
Topical retinoids
 Tretinoin, adapalene, tazarotene, isotretinoin.
 Retinaldehyde and retinol esters.
Used in :
 Acne
 Photoaging
 Pigmentation
Adverse effects :
 Retinoid dermatitis : redness, burning, dryness
 Post inflammatory pigmentation
 Acne flare up
Classification of Antioxidants
Fat Soluble Antioxidants
Polypodium Leucotomos
Vitamin E
Resveratrol
Carotenoids
Grape Seed Extract
CoQ10/Idebenone
Pomegranates
Lycopene
Fat And Water Soluble Antioxidants
Water Soluble Antioxidants
Alpha Lipoic Acid
Glutathione
Miscellaneous
Vit C
Genistein
Green Tea- Polyphenols
Pycnogenol
Silymarin
Dehydroepiandrosterone
Coffeberry Extract
Selenium
Carotenoids
 Vitamin A derivatives
 Exfoliation, keratin regulation, epidermopoesis, collagen remodelling
and angiogenesis , anti-acne actions.
 Improves photodamage, pigmentation, texture, fine lines and
wrinkles.
 Retinoid dermatitis, sun sensitivity and irritation are common
problems.
 Short contact, night use and low strength is recommended while
starting.
 Oral carotenoids are used for photoprotection and anticancer
actions.
Topical Vitamin E and Vitamin C
Vitamin E
 Photoprotection, reduces photoaging.
 Improves skin roughness and reduces wrinkling.
 Anti-inflammatory and immunostimulatory.
 Wound healing, emollient properties.
Vitamin C
 Water-or lipid-soluble forms.
 Photoprotective and anti-inflammatory.
 Reduces photoaging and wrinkles.
 For effective topical application, vitamin C must be non-esterified,
acidic and optimally at 20% concentration.
Green tea-polyphenols
 Green tea belongs to polyphenolic catechin group.
 Green tea is one of the most studied antioxidants.
 GTPs include extracts such as epicatechin, epigallocatechin,
epicatechin-3-gallate, and epigallocatechin 3-gallate (EGCG); the
anticarcinogenic effects of green tea are attributed to these extracts
and particularly to EGCG.
 EGCG is the main and most potent antioxidant compound in green
and white tea.
 The polyphenols in green tea are excellent antioxidants, antiinflammatory and anticarcinogenic agents. They prevent UV-induced
oxidative damage and induction of matrix metalloproteinases.
Idebenone
 A synthetic analogue of coq10.
 Reduces the photodamage and also reduces fine wrinkles,
roughness and dryness in the aged skin.
 Contact dermatitis is the most popular side effect noted.
Alpha lipoic acid (ALA)
 Fat and water soluble Antioxidants.
 Organosulfur compound obtained from octanoic acid.
 It is an important network antioxidant and an essential cofactor in
mitochondrial dehydrogenases.
 Antioxidant effects are due to bioactive form of LA which is strong
anti inflammatory agent.
 Useful for preventing UVB induced erythema, photodamage and
cancer.
 Supplement used primarily as a "weight loss" and "energy"
supplement.
 Cutaneous benefits of ALA Include accelerated chronic wound
healing.
Antioxidants : Clinical perspectives
The clinical use of antioxidants is increasing. The use for these
cosmeceuticals is either as single agent or in combinations
 Correction - fine lines, pigmentation, texture.
 Prevention - Maintenance of correction obtained and true
prevention.
 Added in formulations for photoprotection.
 Antiinflammatory, lightening , immunoprotection and anticancer
actions antimicrobial, and wound healing properties.
 Orally or topically used.
Fine lines, texture and photodamage improvement after 12 weeks of
antioxidant cosmeceuticals
Cosmetic camouflage
 Concealing of unsightly marks on the skin with specially matched
opaque creams and powders.
Contents :
 Calamine, zinc oxide, bentonite
 Colour pigments
 Setting powder
Indications :
 Vitiligo
 Freckles
 Melasma, post inflammatory pigmentation
 Hemangiomas, Nevi
 Scars
Adverse reactions to cosmetics and cosmeceuticals
 Soaps : Repeated use may strip the skin of its protective lipid layer.
 Shampoos : Daily washing with harsh shampoos can dry the shaft
and make it brittle.
 Fragrances : May cause photocontact dermatitis.
 Hair colors : Frequent hair lightening or coloring can cause
irreversible damage to the hair shaft. Cosmetic alopecia may follow.
Adverse reactions to cosmetics and cosmeceuticals
 Moisturizers : Comedogenic ingredients like isopropyl myristate
irritate the pilosebaceous follicles.
 Sunscreens : Vehicle may exacerbate or induce acne; contact
folliculitis may occur.
 Skin lightening agents : Excessive and prolonged use may cause
exogenous ochronosis.
Interventional procedures
 Chemical Peels
 Microdermabrasion
 Microneedling
 Injectables - botulinum, fillers, PRP
 Lasers and other technologies
Chemical Peels
Mechanism
 Epidermal and part of dermal tissue replacement by –
•
Destruction
•
Elimination
•
Regeneration and remodelling
 Controlled stage of inflammation
Classification of Peeling : Depth of Injury
 Superficial Wounding (Light peel)
Stratum granulosum, papillary
dermis
 Medium Depth Wounding
(Medium peel) Upper reticular
dermis
 Deep Depth Wounding (Deep
peel) Mid reticular dermis
Depth of peels
Depth of peel is dependent upon
 Chemical applied
 Concentration of chemical
 Skin type
 Preparation of skin
 Technique of application
Superficial and mild medium depth peels most popular, moderate
medium depth and deep peels are now replaced by laser resurfacing
techniques.
Peel Chemicals
 Alpha hydroxy acids (AHAs) : Glycolic, lactic, mandelic, pyruvic
 Beta hydroxy acids : Salicylic acid
 Trichlorocetic acid, phenol
 Combinations - AHA cocktails - phytic peel
 Newer peels - retinol, arginine peel, azelaic acid peel, acetic acid,
phytic, etc.
Indications
 Pigmentary conditions - Melasma, photodamage, post inflammatory
hyperpigmentation, freckles, lentigenes.
 Early Acne scars with residual active acne, Truncal acne.
 Acne scars without active acne; with/without pigmentary changes.
 Improving fine lines - early wrinkles.
 Improving texture and glow.
Contraindications
 Unrealistic expectations
 Keloid tendency
 Active severe acne
 Active herpes simplex or bacterial infections.
 Isotretinoin recipient in last 6 months.
 Unstable vitilligo and psoriasis.
 Associated photo aggravated skin diseases.
 Salicylic peels during pregnancy, lactation and those sensitivity to
aspirin.
 Phenol peels in cardiac patients.
Chemical peels for acne scars
Pre-treatment
After 35% glycolic acid peels, 4 sessions
Glycolic acid peels along
with topical treatments
in Melasma
Complications
Common
Less common
Erythema
Hyperpigmentation
Irritation
Dryness
Persistent Erythema
Hypopigmentation
Contact Dermatitis
Bacterial Infections
Reactivation Of Herpes
Acneiform Eruptions
Milia
Photosensitivity
Hypertrophy/Keloids
Microdermabrasion
 Causes resurfacing by mechanical micro-abrasion of skin and is a
non- invasive office procedure.
 Aluminium crystals or abraded diamond tips can be used works on
vaccuum suction principle.
Indications :
 Improves mild acne scars
 Improves skin texture, fine lines
 Minimizes superficial pigmentation
 Improves fine lines
 Striae
 Can improve open pore appearance
Microneedling
 Non invasive procedure with an instrument dermaroller.
 Creates micro injuries to the epidermis resulting in skin regeneration
and collagen induction.
 The micro needled tissue repairs by collagen stimulation and hence
it is also called as collagen induction therapy.
Indications :
 Acne scars, post surgical or traumatic scars
 Wrinkle correction
 Trans-epidermal drug delivery
 Stretch marks
Microneedling
 The procedure involves a series of sessions performed after applying
an anesthetic cream.
 The dermaroller is rolled into the skin over a few minutes. The post
treatment skin appears slightly red and has minimal downtime as
patient can get back to work on same day.
 Absolute sun protection before the procedure and in the interim
phase is recommended.
 The results are visible depending on the type of problem that is to
be corrected textural improvement is seen after first sitting and scar
improvement is visible after a series of sessions.
Microneedling
Pre Treatment
Post Treatment
Injectables
 Fillers
 Botulinum toxin
 Platelet rich plasma therapy
Various therapeutic modalities in cosmetic dermatology, especially the
injectables, laser and technology based devices are used to improve the
appearance of ageing in the skin which may be due to chronological or
extrinsic effects.
Ageing
 Intrinsic or Chronological
•
Genetic makeup
 Extrinsic factors
•
Solar effects
•
Smoking, Alcohol
•
Malnutrition
•
Gravitational effect
•
Sleep lines
•
Muscular action
Mechanisms of skin ageing
 With chronological ageing, skin begins to lose firmness and lift causes the skin to look older.
 At molecular level, the connective tissue in the skin becomes
weaker, the body produces less collagen and elastin, the key
components of healthy, youthful looking skin. In women the
breakdown of collagen and elastin is enhanced by exposure to
external factors.
 Sagging in the aging face occurs due to gravity and changes in the
fat compartments.
 The loss of fat pads in the upper and mid face and around the
mouth, tightening of the central ligaments and loosening of the
lateral ligaments- results in the “arc of aging” of the older faces.
Age related skin changes
Epidermis
 Thinner, Flattening of DE junction
 Slow multiplication of cells and delayed healing time
Dermis
 Loss of dermal thickness
 Disorganized collagen bundles, abnormal elastin
 Changes in glycosaminoglycans – less water holding power
Changes in appearance
 Dryness, Skin peeling
 Roughness, Pallor
 Loss of protective power, delay in recovery from surface damage
Delaying skin ageing - Tips
 Avoid Sun Exposure - Exposure to UV light will increase the potential
for fine line and wrinkle formation.
 Stop Smoking - Smoking depletes the skin of critical moisture and
predisposes you to wrinkle formation.
 Get Plenty of Rest - Sleep provides a way for your body to relax and
rejuvenate.
 Maintain hydration of skin.
 Use a Humidifier - Humidifiers provide moisture to the air
preventing the skin from dehydrating.
 Night use of retinol or hyaluronic acid or oligopeptide creams.
 Antioxidants will also help to protect the skin throughout the day
when applied in the morning.'
Fillers
 Using dermal fillers is a treatment of wrinkles, folds or loss of facial
volume through a minimally invasive technique.
 Fillers are most popular and easy to perform.
 Best option for deep folds and grooves in antiaging concepts so far.
 Important to choose a right technique for different face areas.
 Always fills 90 - 100% of deep wrinkles.
Dermal fillers
Types of fillers :
 Temporary : gets absorbed in 3 to 6 months
 Semi-permanent : absorbed within 2 years
 Permanent : lasts longer than 2 years
Sources :
 Heterograft/Xenograft : Bovine collagen, porcine collagen,
hyaluronic acid
 Allografts : Human-derived collagen
 Autografts : Autologous fat, collagen,fibroblasts
 Synthetic : Silicone, polytetrafluoroethylene
Classification of Dermal Fillers
Replacement Fillers :
 Restore soft tissue volume lost in deep dermis or subcutaneous
space.
 Collagen.
 Hyaluronic acids (HAs).
Stimulatory Fillers :
 Restore volume by stimulating fibroblast activity, collagen synthesis
and soft tissue growth.
 Poly-L-lactic acid (PLLA).
 Polymethylmethacrylate (PMMA) - Permanent.
 Calcium hydroxylapatite (CaHA).
Target zones that are commonly treated
 Nasolabial folds – smile lines
 Lip rhytides – upper lip lines
 Marionette lines – lines around mouth
 Volume enhancement – sunken cheeks
 Lip filling and contouring
 Chin and cheek augmentation
 Tear trough treatment – under eye
 Back of hands
 Neck and chest
How are they placed under the skin : Injection techniques
Hyaluronic acid
 Commonly used filler.
 Naturally occurring linear polysaccharide found in extra cellular
matrix of connective tissue and serves as a ground substance.
 Exhibits no species or tissue specificity.
 It is cross-linked for stability in tissues.
 Are superior to collagen fillers with minimal allergy and
immunogenicity reports.
Fillers : Nasolabial fold correction
After linear threading nasolabial folds
Botulinum toxin (BTX)
 BTX is natural, purified protein relaxes wrinkle-causing muscles
creates a rejuvenated and more youthful appearance.
 Produced by the bacterium clostridium botulinum (Serotype A).
 Inhibits release of acetylcholine at the neuromuscular junction
causing temporary flaccid paralysis of muscle.
 Resultant effects of BTX
•
BTX effect takes 2-3 days, full effect seen 7-15 days post
treatment.
•
The effect lasts
•
4-6 months or longer, patient dependent.
•
May last longer with repeated treatments.
•
Result will wear off progressively (not sudden).
Recommendations for Reconstitution and Handling
Diluent
0.9% non-preserved sterile saline
Concentration
ratio of 100 U/ 2.5cc
Storage
Before reconstitution
After reconstitution
2C to 8C for up to 24 mo
Up to 6 wks at 4C
Handling
Special precautions not required
Cosmetic indications of BTX
 Frown lines BETWEEN THE EYEBROWS
 Crow’s feet on outer part of eyes.
 Forehead lines horizontal lines on forehead seen when eyebrows
are raised.
 Bunny lines or nasal scrunch are seen at sides of nose while
scrunching the nose.
 Marionette lines Where the muscles pulling the corners of the
mouth down are stronger than those pulling it up.
 Popply chin this results from the contraction of the mentalis muscle.
 Platysmal bands are vertical neck bands that appear with age.
 Facial sculpting Square to lean jaw is to relax the hypertrophic
masseters muscles which give most of the asian patients a square
jaw look.
Global correction upper half of face
Platelet rich plasma therapy (PRP)
 A tool of the modern era of regenerative processes.
 Preparation of an autologous platelet concentrate suspended in
plasma, also known as platelet-rich plasma, contains growth factors
and it is administered to wound sites for wound healing, tissue
repair.
 Growth factors released from activated platelets initiate and
modulate wound healing in both soft and hard tissues.
Indications
 Hair growth
 Antiaging
 Rejuvenation
 Scar healing
Technique
 The injections are performed using very small needles after numbing
the skin with a surface anesthetic cream over one hour.
 A recovery period involving transient swelling; and in some cases,
bruising which is mild and transient.
 PRP evokes an inflammatory response which is desired.
 The results are normally seen within 2-3 months and may require 3
to 5 separate sessions.
 In general, usually over a 3 to 4 week interval, patients should be
able to see improvements in: skin texture; complexion; and tone.
 These improvements can continue for up to a year.
LASER
L
- Light
A - Amplification by
S - Stimulated
E - Emission of
R - Radiation.
Principle : Chromophore
 Action of lasers is through the chromophores.
 Chromophores absorb energy and are destroyed.
 Oxyhemoglobin, hemoglobin, melanin and water are the main skin
chromophores.
 Lasers may lead to damage of the collateral structures PHOTOTHERMOLYSIS.
Principle : Selective photothermolysis
 Only wavelengths of light absorbed by the target tissue than the
surrounding tissue are selected.
 Light is delivered in pulses to prevent diffusion and thermal damage
to surrounding tissue.
 Energy is delivered to target in less time than required for heat
diffusion to surrounding tissue.
Thermal Relaxation Time
 Time taken by the chromophore to loose 63% of its heat after being
heated up.
 Different chromophores have different thermal relaxation times
depending upon their size.
 TRT predicts the PULSE WIDTH to be used for a particular
chromophore.
Target
Size
TRT
Tatoo ink particle
1
10 ns
Melanosome
1
1 us
Erythrocyte
7
20 us
Epidermis
50
1 ms
Blood vessel
50
1 ms
Ectatic bold vessel
100
15 ms
Hair Follicle
200
20-100 ms
Wavelength
Holmium
Nd:YAG
Er:YAG
KTP
UV
400 nm
VISIBLE
10600
2940
2100
1064
694
755
577-630
532
488 - 514
x-rays
cosmic rays
190 - 390
Excimer
INFRARED
700 nm
Microwaves
TV and
radio
waves
Lasers
 Lasers for hair reduction
 Pigmentary lasers
 Resurfacing lasers
 Vascular lasers
Other technology based devices include use of radiofrequency and high
frequency ultrasound- used in skin tightening and body contouring.
Lasers for Hair Removal
Long pulse Ruby laser
694 nm.
Long pulse Alexandrite laser
755 nm.
Long pulse Diode laser
800 nm.
Long pulse Nd : YAG laser
1064 nm.
Intense pulsed light
400 – 1200 nm.
Pre Treatment
Post Treatment
Diode- 28J/cm2,
100ms. 3sessions
Lasers for Pigmented Lesions
Q- switched lasers
Frequency doubled Nd : YAG laser
532 nm.
Ruby laser
694 nm.
Alexandrite laser
755 nm.
Nd : YAG laser
1064 nm.
1064 Q Switched ND YAG Laser for Tattoo Removal
Pre treatment
Immediate Post
treatment
Post treatment
After 2 sessions
Ablative Lasers
 Erbium YAG laser
2940 nm.
 CO 2 laser
10600 nm.
Indications
 Acne scars
 Wrinkles
 Rhinophyma, xanthelesma
 Verrucous epidermal nevi
NON ABLATIVE LASERS and
Radiofrequency
 Infrared lasers
• 1320 nm Nd : YAG laser
• 1450 nm Diode laser
• 1540 nm Erbium Glass laser
 Broad band light
 Intense pulsed light
 Non ablative radio frequency
Indications
 Wrinkles
 Superficial atrophic scars
Laser resurfacing - Grade 2 rolling & superficial boxcar scars
Pre Treatment
Post Treatment
Combination Therapy with Q switched ND YAG laser and
fractional carbon dioxide laser :
Texture, pigmentation and acne scars improvement
Lasers for Vascular Lesions
Flash pumped pulse dye laser
585 nm.
Long pulse Alexandrite laser
755 nm.
Long pulse FD Nd : YAG laser
532 nm.
Intense pulsed light
515 - 590 nm.
Long pulse Nd : yag Laser
1064 nm.
Excimer Laser
Monochromatic light of wavelength 308 nm
Targeted treatment of :
 Vitiligo
 Psoriasis
Complications of Laser
 Persistent erythema
 Vesiculation and crusting
 Hyperpigmentation
 Hypopigmentation
 Scarring
Good expertise → minimal complications
MCQ’s
Q.1)
A.
B.
C.
D.
Ultraviolet index
Informs about amount of harmful UVL on earth on a particular day
Informs about SPF factor
Informs about sunburn factor
Informs about UV damage
Q.2)
A.
B.
C.
D.
Chemical peels destroy
Epidermis
Dermis
Oil glands
Epidermis and part of dermis
MCQ’s
Q.3)
A.
B.
C.
D.
This is not a chromophore for lasers
Water
Gas
Oxyhemoglobin
Melanin
Q.4)
A.
B.
C.
D.
Thermal Relaxation Time predicts
The pulse width to be used for a particular chromophore
The fluence used
The spot size
Thermal damage time
MCQ’s
Q.5)
A.
B.
C.
D.
Wavelength of diode laser for hair removal is
810nm
1064nm
655nm
786nm
Q.6)
A.
B.
C.
D.
Botulinum toxin
Inhibits release of acetylcholine at the neuromuscular junction
destroys nerve axons
causes myelin sheath denervation
causes activation of neuromuscular junction
Photo Quiz
Q. What laser can be used to clear this tattoo?
Photo Quiz
Q. What interventions can be considered for this patient
with acne scars, aging skin and melasma?
Thank You!