Melasma is a common skin pigmentation disorder. Here we are sharing the latest information from 2020 about it.
What is Melasma?
Melasma manifests as irregular brown/ tan or blue-gray patches in a symmetrical pattern on sun-exposed areas of the face. It typically appears on the upper cheeks, top lip, forehead and chin of women aged 20-50 years. Rarely, it can affect other body areas like the arms. It is uncommon in men.
It is more common in people with olive or dark skin (i.e. Latina/Asian/Hispanic and Middle Eastern descent) but affects people with fair skin, as well.
If it presents during pregnancy it is better known as chloasma or “the mask of pregnancy”. Chloasma tends to resolve within 6 months of delivery.
Melanin is a pigment produced by skin cells called melanocytes. If these cells mutate and become cancerous they form a melanoma. Melanin protects our skin’s DNA from ultraviolet radiation (sun damage). Fair skinned people have less melanin, therefore they burn easier than dark skinned people.
What causes it?
The exact cause is not known, but we do know that several factors play a role. These include:
- UV radiation (sun exposure)
- Dark skin type (as mentioned previously)
- Hormonal factors (both estrogen and progesterone)
- Genetic predisposition
- Thyroid dysfunction
- Telangiectatic melasma (underlying hypervascularity)
- Heat (like hot yoga)
It is important to exclude other causes of abnormal pigmentation, which can include:
- Certain medications i.e. Amiodarone/anti-epileptic medication
- Post inflammatory hyperpigmentation
- Allergic contact dermatitis (often from cosmetics)
- Poikiloderma of the Civatte (commonly found on side of neck)
- Nevus of Ota (bluish or brownish pigmentation in whites of the eye and surrounding eye area)
- Actinic Lichen Planus
- Exogenous ochronosis (rare side-effect of high dose and prolonged use of Hydroquinone, this is why we only recommend a 3 month course)
How can we treat/control it?
Melanin in the superficial layer (epidermis) of the skin is relatively easy to treat and responds well to topical agents such cosmeceuticals /chemical peels and laser therapy. However melasma often affects both the superficial and deeper (dermis) layers. This mixed type is more challenging to treat and it could take weeks to months to see an improvement.
In order to treat melasma, combination or specially formulated creams may be prescribed. The ingredients in these creams have the ability to slow down the production rate of melanin by the melanocytes.
- Hydroquinone 4 % or higher (remains the gold standard)
- Vitamin A 0.1 % / Tazoratene 0.5 -1 %
- Adapalene 0.1 – 0.3 %
- Azelaic acid 20% (safe to use in pregnancy)
- Vitamin C
- Kojic acid
- Lactic acid lotions
- Glycolic acid creams
- Liquorice root
I usually recommend the following regime:
- Compounded formula of Hydroquinone 4%/Retinoic Acid 1% (Vitamin A)/Dexamethasone 1% (corticosteroid) to be applied at night ONLY for 3 months
- Results are then maintained by prescription strength Vitamin A at night
- Results can be enhanced by using Vitamin C in the morning
- Avoid combining Vitamin C with Vitamin A, to ensure full efficacy of both ingredients. Always use Vitamin A in the evening and Vitamin C in the morning.
Sunscreen use and sun avoidance (whenever possible) is not negotiable in melasma sufferers. The use of broadspectrum sunscreen (UVA + UVB) with physical blockers like titanium dioxide and zinc dioxide is preferred over chemical sunscreens.
Melasma is a bothersome condition and cannot be cured but is very possible to control.
Very gentle chemical peeling (glycolic or lactic) can be performed, but in the wrong hands it can make your melasma worse.
Laser therapy is not the primary choice to treat melasma, however there are specific lasers that are more specific to melasma. Patients often require a series of these to achieve the desired results and it is advisable to prepare the skin with hydroquinone for at least 4 weeks prior to a treatment. Best laser for melasma is Qswitch laser combined with Laser genesis.
In cases of telangiectatic melasma it is important to address the underlying vascular cause, in these cases Laser Genesis or Excel V can be used.
New Treatment options?
Oral tranexamic acid has recently been proven in multiple studies to improve melasma. A single tablet is taken daily with results from 8 weeks onwards. Currently a 3 month course is being advocated.
This treatment is not suitable in people with clotting disorders or previous stroke/ DVT/ pulmonary embolism.
People of all races have the same amount of melanocytes, the difference lies in the type of melanin and the amount of melanin being produced.
There are 3 types of melanin in the human body:
- Eumelanin: which has 2 variations – black and brown.
- Pheomelanin (red): which is responsible for all our pink bits (think lips/nipples/genitalia) and red hair.
- Neuromelanin: which is found in the brain and has to do with dopamine production. Loss of this melanin can cause neurological disorders.