Melasma: in detail: causes, types, and treatment
What is melasma?
Melasma is the most common skin problem, more frequently seen in women than in men, generally starts between the age of 20 and 40 years, It’s also called chloasma, or the “mask of pregnancy” as it is so common during pregnancy.
Melasma is a chronic skin condition, resulting in symmetrical, blotchy, brownish to blackish facial pigmentation typically involving face areas such as cheeks, bridge of nose, forehead, above the upper lip, and chin. It may appear in other areas of the body exposed to the sun like neck, chest, or arms…
Melasma is harmless, however, these patches can cause distress and embarrassment. There is good news in this new era of science. There are plenty of ways to reduce the appearance of this skin condition. Let us have a look over the causes of melasma and consider the ways you can treat and prevent future discoloration.
What causes melasma?
The cause of melasma is complex. In general, the pigmentation is due to overproduction of melanin by the pigment cells of the skin called melanocytes. Melasma is more common in people who have brown skin because they have more active melanocytes compared to people with lighter skin. There is a genetic predisposition to melasma, with at least 1/3 rd have family members affected.
Known triggering factors include:
Sun exposure and sun damage: Abnormal exposure to sunlight (Ultraviolet & Visible rays) stimulates the melanocytes, which in turn increases melanin production results in increasing pigmentation of melasma (worsening) and recurrence in summers.
Hormonal changes: Externally taken hormones such as birth control or oral contraceptives pills(containing estrogen and progesterone), hormone replacement therapy, intrauterine devices and implants, and physiological hormonal changes, as seen during pregnancy, stress, thyroid disorders are all known to trigger melasma.
Medications: such as anti-epileptic drugs, anti malignant drugs, and few other photosensitive drugs may trigger melasma.
Skincare products: Scented or deodorant soaps, toiletries, cosmetics may cause a phototoxic reaction leading to an increase in melanin production and worsens melasma.
Types of Melasma:
The pigmentation is due to overproduction of melanin by the pigment cells, melanocytes, which is taken up by the keratinocytes in the outer layer of skin called as Epidermal melanosis and deposited in the inner layer of skin, the dermis called as Dermal melanosis and in the mixed type, the pigment is distributed in both the layers of the skin.
Depending upon the depth of pigment involvement we can differentiate by Wood lamp examination (emit UVA1 black color) as:
Dark brown color
Appears more obvious under black light
Responds well to treatment
Light brown or bluish
Unchanged under black light
Responds poorly to treatment
The most common type
Combination of bluish, light and dark brown patches
A mixed pattern is seen under black light
Partial improvement with treatment
The pattern of Melasma: Classified upon the area of involvement
Three main patterns which are common are:
Centrofacial pattern: forehead, cheeks, nose and upper lips
Malar pattern: cheeks and nose
Mandibular pattern: jawline
Other three patterns which are rarely seen are:
Reddened or inflamed forms of melasma on the face called as erythrosis pigmentosa faciei)
Poikiloderma of Civatte: reddened or inflamed form on the neck with photoaging changes seen in older patients above 50yrs of age.
Brachial type of melasma affecting shoulders and upper arms called acquired brachial cutaneous dyschromatosis.
What are the symptoms of melasma?
As such there are no symptoms and these dark flat patches are neither itchy nor painful. Due to melasma they are cosmetically more concerned and may cause self-image issues leading to embarrassment and distress.
How to treat melasma?
Melasma responds very slowly to the medical line of treatment especially if it for a long time or dermal type and if it has vascular predominance. Treatment required for individuals who are cosmetically concerned.
A. General measures: Treatment needs to be regular to avoid recurrence on abnormal exposure to the sunlight.
Physical protection: use a broad-brimmed hat round the year.
Sunscreen with SPF of 50+ applied to the whole face daily, round the year. It should be reapplied every 2 hours if outdoors during the summer months. Sunscreens containing iron oxides are preferred. Habitual use of sunscreen will enhance the effectiveness of other treatments.
Discontinue hormonal contraception
B.Topical therapy: Most of these are tyrosinase inhibitors and are the mainstay of treatment. The aim is to prevent new pigment formation by inhibiting the formation of melanin by the melanocytes.
Hydroquinone 2–4% as cream or lotion, applied accurately to pigmented areas at night for 2–4 months. It may cause contact dermatitis (stinging and redness) in a few patients. It’s better to avoid using in higher concentration and for a prolonged time, may cause a bluish-grey discoloration of the skin, known as hydroquinone-induced ochronosis
Azelaic acid cream, lotion, or gel can be applied twice daily for a long time and is even safe in pregnancy.
Kojic acid or kojic acid dipalmitate is often included in many formulations, as it binds copper, required by L-DOPA (a cofactor of tyrosinase) and in few causes irritant contact dermatitis
Cysteamine hydrochloride (5%) cream thought to involve inhibition of tyrosinase.
Ascorbic acid (vitamin C) also acts through copper to inhibit pigment production. It is well tolerated but highly unstable, so is usually combined with other agents.
Methimazole (antithyroid drug) cream has been reported to reduce melanin synthesis and pigmentation in hydroquinone-resistant melasma.
New agents under investigation include zinc sulfate mequinol, arbutin and deoxyarbutin (from berries), liquorice extract, rucinol, resveratrol, 4-hydroxy-anisole, 2,5-dimethyl-4-hydroxy-3(2H)-furanone and/or N-acetyl glucosamine
Other active compounds used for melasma include:
Tretinoin and Corticosteroids: Tretinoin to enhance the efficacy of hydroquinone, can be bought only by prescription, and are usually given secondary to hydroquinone. A mild topical corticosteroid such as hydrocortisone, work quickly to fade the color. When patients don’t respond to hydroquinone alone, “triple cream”, containing hydroquinone, tretinoin, and a corticosteroid is a good option.
Soybean extract, which is thought to reduce the transfer of pigment from melanocytes to skin cells (keratinocytes) and to inhibit receptors.
Tranexamic acid has been used experimentally for melasma as a cream or injected into the skin (mesotherapy), showing some benefit. It may cause allergy or irritation.
Oral treatment of melasma
Oral medication for melasma are under scientific research
Tranexamic acid inhibits plasmin normally used orally to stop bleeding. It reduces the production of prostaglandins, the precursors of tyrosine. It is used in low doses and reported to be effective and safe in the treatment of melasma.
Glutathione is a systemic skin whitening agent but has potential severe adverse effects.
Interventional treatments: These following treatments are advised if conventional treatment fails
Chemical peels: should be done under the supervision of a dermatologist, will choose the type and strength of the chemical peel (glycolic acid, hydroquinone, salicylic acid) best suited to you. The superficial skin is peeled off, which allows topical tyrosinase inhibitors to penetrate more effectively.
Microdermabrasion: should be used with caution in the treatment of melasma. Mechanical exfoliation by microdermabrasion, vacuum suction, and abrasive material is used to exfoliate the top layers of skin. Multiple sessions will be needed, in combination with sunscreen and other creams to get the optimum results.
Laser or Energy-based devices: The ideal treatment for melasma would destroy the pigment while leaving the cells alone.
Q-Switch Nd: YAG lasers, picoseconds lasers, fractional erbium glass lasers and intense pulse light(IPL) are better options. Pigment lasers such as Q-switch Ruby & Alexandrite to be used with caution. Pico lasers due to its photo-acoustic effect showing more promising results than the photo-thermal effect of nano q-switch laser.
We at Clear Skin Centre are using Fractional microneedle RF, for those not responding further to the above-mentioned lasers, showing promising results especially in the steroid-dependent case, could be by normalizing the epidermal barrier.
Pregnancy and Melasma
Melasma in very few cases clear out spontaneously, without treatment, after delivery of the bay in post-pregnant women, could be due to regularizing of hormonal imbalance. Pregnant and breastfeeding women need to use even topical medicines with caution or under instructions of a dermatologist, as they are proved to be harmful to the fetus and the newborn.
Under an expert dermatologist’s guidelines, many people with melasma have a good outcome. Melasma is usually stubborn and takes a few months of treatment to fade. The expert ensures that you get the most benefit from treatment. Dermatologist advice can help avoid skin irritation and other side effects of treatment.
After your melasma clears, you may need to keep maintenance therapy to prevent melasma from returning.
You can help prevent your melasma from returning by wearing sunscreen and a wide-brimmed hat every day.