Articles by
Dr. Prakash Acharya

What is melasma?

Melasma is a chronic hyperpigmentation disorder that produces symmetrical brown to grey-brown patches on sun-exposed areas of the face — most commonly the cheeks, forehead, nose bridge, and upper lip. It affects women far more than men (approximately 90% of cases) and is especially prevalent in South and Southeast Asian populations due to a combination of genetic factors and UV exposure patterns.

In Nepal, melasma is one of the most common dermatological complaints I see — amplified by Kathmandu's high-altitude UV intensity and the cultural reliance on covering up skin concerns with makeup rather than seeking treatment.

The real drivers of melasma

Most patients know that "sun causes melasma" — but the mechanism is more nuanced than simple sunburn. Melasma involves an abnormal increase in melanin production driven by:

• UV radiation — both UVA and UVB stimulate melanocytes (pigment-producing cells). UVA penetrates deeply and can trigger pigmentation even through glass.
• Heat — infrared radiation from sunlight, cooking stoves, or even hot showers can independently stimulate melanin production. This is why melasma can worsen in summer even with good sunscreen use.
• Hormonal influence — oestrogen and progesterone increase the sensitivity of melanocytes. This is why melasma so commonly begins during pregnancy or with oral contraceptive pill use.
• Genetic predisposition — family history is a strong predictor. Skin types III–V (common in South Asia) have more active and reactive melanocytes.
• Inflammation — any inflammatory trigger, including cosmetic irritation or acne, can activate pigment production in susceptible skin.

Why does melasma come back after treatment?

This is the most common question I hear from patients who have completed treatment. The answer lies in the fact that melasma does not erase the underlying predisposition — it treats the visible manifestation. The melanocytes remain in a sensitised state.

Melasma returns when:

• Sun protection is inconsistent or inadequate (SPF alone without broad-spectrum UVA coverage is insufficient)
• Heat exposure is unmanaged (physical sun protection — hats, scarves — matters as much as sunscreen)
• Hormonal triggers persist (continuing the same OCP, pregnancy)
• Maintenance topical therapy is discontinued prematurely

What actually works — Dr. Acharya's approach

Effective melasma management requires a layered, patient, long-term strategy — not aggressive rapid-fire treatments:

• Foundation: strict photoprotection. SPF 50+ with PA++++ rating, applied generously and reapplied every 2 hours. Physical sunscreens (zinc oxide, titanium dioxide) are preferred for South Asian skin.
• Topical therapy: A combination of hydroquinone, tretinoin, and mild corticosteroid (the classic Kligman formula), or newer actives like tranexamic acid, azelaic acid, and vitamin C for maintenance.
• Chemical peels: Glycolic, lactic, or salicylic acid peels to accelerate pigment clearance — done at 2 to 4 week intervals.
• Laser treatment: Low-fluence Q-switched Nd:YAG laser or fractional PICO laser for resistant cases — with careful parameter selection for South Asian skin to avoid rebound hyperpigmentation.
• Oral tranexamic acid: A relatively newer addition that has shown impressive results in reducing melasma from the inside, by interrupting the signalling cascade that activates melanocytes.

The most important thing I tell my patients: melasma management is a marathon, not a sprint. But with the right protocol — and consistent sun protection — long-term remission is absolutely achievable.

The shared goal: waking up dormant follicles

Hair loss (alopecia) most commonly occurs because hair follicles miniaturise and eventually stop producing hair. The goal of regenerative treatments — PRP, GFC, and exosomes — is to deliver biological signals to the scalp that stimulate blood supply, reduce inflammation, extend the growth phase (anagen), and reactivate miniaturised follicles.

These are not "hair transplant" procedures — they don't create new follicles. They optimise and rehabilitate what is already there, making them most effective in early to moderate hair loss (before follicles are completely lost).

PRP (Platelet-Rich Plasma)

PRP involves drawing a small amount of your blood, centrifuging it to separate and concentrate the platelet layer, and injecting this into the scalp. Platelets release growth factors — including PDGF, VEGF, EGF, and IGF — that signal follicles to enter and sustain the growth phase.

• Suitable for: androgenetic alopecia (male and female pattern hair loss), telogen effluvium (diffuse shedding), alopecia areata (adjunctively)
• Sessions needed: 3 to 4 sessions, 4 weeks apart; maintenance every 3 to 6 months
• Onset of results: Visible reduction in shedding within 6 to 8 weeks; density improvement by 3 to 6 months
• Advantage: Autologous (from your own blood) — no risk of allergic reaction

GFC (Growth Factor Concentrate)

GFC is a more refined form of PRP. Rather than using the whole platelet-rich layer, a specialised tube system is used to selectively isolate and concentrate only the growth factors — removing platelets, white blood cells, and other components that may cause unnecessary inflammation.

• Suitable for: Same indications as PRP, but preferred for patients with more significant inflammation or those who haven't responded optimally to PRP
• Sessions needed: Typically 3 sessions; some patients see excellent results in fewer
• Onset of results: Often slightly faster than PRP — many patients notice reduced shedding within the first month
• Advantage: Purer concentrate, less pain than PRP, minimal post-procedure inflammation

Exosomes — the frontier

Exosomes are nano-sized extracellular vesicles derived from stem cells (typically mesenchymal stem cells from umbilical cord or placental tissue). They don't contain cells themselves — instead, they carry thousands of signalling molecules, growth factors, microRNA, and proteins that communicate with your scalp's own cells to drive regeneration.

• Suitable for: All types of hair loss; especially valuable in patients who haven't responded well to PRP, or in inflammatory alopecias
• Sessions needed: Often fewer sessions needed (1 to 2 sessions for a course) compared to PRP
• Onset of results: Faster — many patients notice improvements within 4 to 8 weeks
• Advantage: No blood draw required (sourced externally), higher potency, versatile (also used for facial skin rejuvenation)

So which one should you choose?

There is no universal answer — the best treatment depends on your hair loss pattern, severity, budget, and response to previous treatments. At Reva Skin and Hair Clinic, Dr. Acharya performs a thorough trichoscopy assessment before recommending a protocol. A common approach is to start with GFC for most patients due to its superior purity and comfort, and to consider exosomes for patients with more advanced loss or inflammatory components.

The most important takeaway: all three are most effective in early to moderate hair loss. The sooner you start, the better the outcome.

What is HIFU and how does it work?

HIFU (High-Intensity Focused Ultrasound) uses precisely focused ultrasound energy to create controlled thermal coagulation points at specific depths within the skin — reaching as deep as 4.5mm to target the SMAS (Superficial Muscular Aponeurotic System), the same fibromuscular layer that surgeons target in a traditional facelift.

At each focal point, the temperature briefly reaches 60 to 70°C, causing immediate collagen denaturation — and, critically, triggering the body's wound-healing response to produce new, organised collagen over the following months. The result is a gradual lifting and tightening effect that develops over 2 to 3 months and continues improving for up to 6 months.

Who is HIFU for?

HIFU is best suited for:

• Adults (typically 30s to 60s) with mild to moderate skin laxity who want visible lifting without surgery
• Patients with jowl softening, brow drooping, neck laxity, or general loss of facial definition
• Those who want to delay or supplement surgical procedures
• People who cannot or will not undergo downtime-requiring procedures

HIFU is not ideal for severe skin laxity (where surgery provides clearly superior results), very thin skin with little subcutaneous fat, or patients with active acne or infections in the treatment area.

What to expect during and after HIFU

During the procedure, most patients experience a warm to hot sensation and intermittent brief sharp discomfort as the focused energy is delivered — particularly over areas with less soft tissue (jawline, cheekbones). Topical anaesthetic cream and/or oral analgesia are used to manage this.

Afterwards:

• Mild redness and swelling: resolves within 24 to 72 hours
• Transient tenderness along treated areas: 1 to 5 days
• Occasional temporary numbness or tingling: usually resolves in days to weeks
• No wound, no downtime — most patients return to work the same day

How long do results last?

Peak results are seen at 3 to 6 months. Lifting effects typically last 12 to 18 months, after which a maintenance session is recommended. The natural ageing process continues — HIFU slows it but does not stop it. Skin quality, sun protection habits, and overall health significantly influence longevity of results.

HIFU at Reva Skin and Hair Clinic

We use world-class machine - the ULTRAFORMER 3 at Reva SKin and Hair Clinic.

Dr. Acharya performs a detailed facial analysis before every HIFU treatment — mapping the areas of laxity, assessing the fat pad positions, and customising depth and energy delivery to each patient's anatomy. This personalised approach is what separates a good HIFU outcome from a mediocre one.

Mistake 1: Expecting results too quickly

Most topical acne treatments take 8 to 12 weeks to show meaningful results. Patients often switch products every few weeks based on impatience — preventing any single agent from working. Give treatments adequate time before concluding they've failed.

Mistake 2: Using harsh, drying cleansers

Over-washing and using alcohol-based or heavily foaming cleansers disrupts the skin barrier, triggers compensatory oil production, and worsens acne. Gentle, non-comedogenic cleansers twice daily are optimal. Hydration is not the enemy of acne-prone skin.

Mistake 3: Skipping moisturiser

Acne-prone skin still needs hydration. Skipping moisturiser causes the skin to overproduce sebum. A lightweight, oil-free, non-comedogenic moisturiser is essential — especially when using drying actives like retinoids or benzoyl peroxide.

Mistake 4: Ignoring diet

The evidence linking high-glycaemic diets and dairy to acne is increasingly robust. High-sugar foods and white carbohydrates spike insulin, which in turn stimulates sebum production. Reducing these and monitoring the effect is worth doing in parallel with topical treatment.

Mistake 5: Self-treating hormonal acne

Jawline and chin acne in women is almost always hormonally driven. Over-the-counter products rarely address the root cause. A dermatologist assessment can identify hormonal imbalance (including PCOS) and introduce treatments like spironolactone or appropriate contraceptive options that work on the actual driver — not just the surface.