Melasma - Naturopathic MedicineNaturopathic Medicine Summary

Naturopathic Medicine

Naturopathic Summary

The exact cause of melasma has not been established and there are likely many factors that contribute to the development of this pigmentary skin change. Naturopathic doctors focus on helping patients understand and avoid those triggers, and may also add herbs, lifestyle modifications, and dietary supplements to the treatment plan.

Treatment Philosophy

Naturopathic medicine seeks to manage melasma in multiple ways, one of them being education of each patient so that they can fully understand the condition and avoid any aggravating factors. Following education, a naturopath will look at every aspect of each individual patient in order to develop a comprehensive treatment plan that will treat the patient using effective, minimally-invasive treatment modalities such as botanical medicines, lifestyle modifications, and dietary supplements.

Symptoms

Melasma is a condition characterized by the presence of brown discolored patches that appear on the sun-exposed areas, most typically on the face and chest, and can sometimes appear on the arms.[1] Although melasma classically does not cause pain or itching, it can be cosmetically distressing to those affected.[1] All ethnicities are affected, although it appears to be more prevalent in people who have darker skin, and who live in areas that experience strong sunlight or ultraviolet exposure.[1,2] Women are more likely to get melasma as it appears commonly during pregnancy, often called the mask of pregnancy.[1,3]

Causes

The exact cause of melasma is still unknown, but it is likely due to multiple factors that trigger increased pigment production by pigment producing cells.[4] There is likely also increased pigment transfer from pigment producing cells (known as melanocytes) to regular skin cells (known as keratinocytes).[4]

Risk Factors

Medications

  • Oral Contraceptive Pills: A study of 45 women with melasma found that 17.8% reported oral contraceptive pills as a contributing factor.[5]
  • Medications that increase the skin’s sensitivity to light: Medications that increase the skin’s sensitivity to light such as some antibiotics, nonsteroidal anti-inflammatory medications, and retinoids are known triggers in melasma.[1]

Your body

  • Hormonal influence: Women have a higher rate of developing melasma, and it is believed that this may be due to the role of estrogen and progesterone.[1,3] A clinical study showed that skin affected with melasma had more estrogen and progesterone responsive proteins than skin on the same face that was not affected with melasma.[6] Interestingly, men who have been treated with estrogen have developed melasma as a side effect, and this further supports the role of hormones.[7]
  • Pregnancy: Over 25% of women with melasma reported pregnancy as a trigger.[5]
  • Genetics: Family history appears to be associated with melasma, with studies showing 17%, 40%, or 60% of participants reporting relatives affected with the condition.[1,5,8]
  • Thyroid conditions: There appears to be an association between thyroid dysfunction and melasma though more research is necessary to fully understand the correlation between the two.[5,9]

Mental/emotional health

  • Stress: Stress has been reported as a triggering factor for melasma in several studies.[10,11] These studies were based on self-report and more controlled studies are needed to understand how stress may or may not stimulate pigmentation.

Environment

  • Sunlight: Sunlight is a trigger for melasma, and both ultraviolet (UV) light type A and B can cause the appearance of melasma.[1,3,12] Light from the visible light spectrum also triggers pigmentation,[13,14] and may induce more sustained pigment changes in the skin in comparison to ultraviolet light.[14]
  • Toxic exposure: The ingestion of arsenic through contaminated food, water or medication has been associated with the development of dark spots on the skin.[15-17]

Naturopathic Therapies

Mindfulness-based stress reduction

  • No formal studies have examined stress reduction for the management of melasma. The results of self-reporting studies have demonstrated stress can be an aggravating factor[10,11] and it stands to reason that mindfulness-based stress reduction techniques could be a possible method of intervention for the management of melasma.

Botanicals and Herbs

Multiple botanicals have been evaluated in melasma[18] and a few are listed below.

  • Licorice: Chinese Licorice (Glycyrrhiza uralensis) contains multiple chemicals that inhibit skin cells from producing pigment.[19] Common Licorice (Glycyrrhiza glabra) is also used.[20] A study in humans with topical application of multiple botanical extracts, including licorice, found that it was as effective as 2% hydroquinone in reducing melasma.[21] Other studies have evaluated liquiritin, a chemical found in licorice, and found that it improved melasma.[22,23]
  • Mulberry: In a study, topically applied mulberry (Morus alba) extract improved melasma compared against a control treatment.[24]
  • Silymarin: Silymarin, a molecule found in Milk Thistle (Silybum marianum) acts as an antioxidant with stronger activity than Vitamin E,[25] and it reduces the activity of the enzyme that produces the skin’s pigment.[26] Topical silymarin was tested in two doses at 7 mg/mL and 14 mg/mL and both doses reduced melasma in comparison to control treatment.[27] All of the people that received silymarin in the study had complete resolution of their melasma after 4 weeks of treatment.[27]

Diet and Lifestyle

Supplements

  • Red orange extract: Red orange extract (100 mg/day) over 15 days was shown to reduce melanin pigment in the skin.[28]
  • Polypodium leucotomos extract: Polypodium leucotomos extract was initially shown to have promise for the treatment of melasma,[29] but a subsequent study did not find this extract to be helpful beyond the use of sunscreens.[30] Further evaluation is needed to determine its efficacy in treating melasma.

Lifestyle

  • Sunscreen: Sun protection through the usage of sunscreens is important in the treatment of melasma.[31] Blockage of ultraviolet light is critical.[31] It has been shown that sunscreens with zinc oxide and iron oxide block visible light along with ultraviolet light and have a greater effect on improving melasma.[31]

Skin care

  • Vitamin C serum: Topical vitamin C (L-ascorbic acid) has been found to be helpful in melasma.[32,33] One study evaluated L-ascorbic acid vs water and found that the L-ascorbic acid treated side had a 40% improvement in skin brightness while the water treated side had a 13% increase in brightness.[33] A second study found that 5% L-ascorbic acid was as effective as 4% hydroquinone.[32]
  1. Handel AC, Miot LD, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014; 89(5):771-782; PMID: 25184917 Link to research.
  2. Taylor SC. Epidemiology of skin diseases in ethnic populations. Dermatol Clin. 2003; 21(4):601-607; PMID: 14717401 Link to research.
  3. Cestari T, Arellano I, Hexsel D, et al. Melasma in Latin America: options for therapy and treatment algorithm. J Eur Acad Dermatol Venereol. 2009; 23(7):760-772; PMID: 19646135 Link to research.
  4. Ogbechie-Godec OA, Elbuluk N. Melasma: an Up-to-Date Comprehensive Review. Dermatol Ther (Heidelb). 2017; 7(3):305-318; PMID: 28726212 Link to research.
  5. Cakmak SK, Ozcan N, Kilic A, et al. Etiopathogenetic factors, thyroid functions and thyroid autoimmunity in melasma patients. Postepy Dermatol Alergol. 2015; 32(5):327-330; PMID: 26759539 Link to research.
  6. Tamega Ade A, Miot HA, Moco NP, et al. Gene and protein expression of oestrogen-beta and progesterone receptors in facial melasma and adjacent healthy skin in women. Int J Cosmet Sci. 2015; 37(2):222-228; PMID: 25439299 Link to research.
  7. Ogita A, Funasaka Y, Ansai S, et al. Melasma in a Male Patient due to Estrogen Therapy for Prostate Cancer. Ann Dermatol. 2015; 27(6):763-764; PMID: 26719650 Link to research.
  8. Handel AC, Lima PB, Tonolli VM, et al. Risk factors for facial melasma in women: a case-control study. Br J Dermatol. 2014; 171(3):588-594; PMID: 24749693 Link to research.
  9. Rostami Mogaddam M, Iranparvar Alamdari M, Maleki N, et al. Evaluation of autoimmune thyroid disease in melasma. J Cosmet Dermatol. 2015; 14(2):167-171; PMID: 25810215 Link to research.
  10. Tamega Ade A, Miot LD, Bonfietti C, et al. Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women. J Eur Acad Dermatol Venereol. 2013; 27(2):151-156; PMID: 22212073 Link to research.
  11. Freitag FM, Cestari TF, Leopoldo LR, et al. Effect of melasma on quality of life in a sample of women living in southern Brazil. J Eur Acad Dermatol Venereol. 2008; 22(6):655-662; PMID: 18410339 Link to research.
  12. Wu IB, Lambert C, Lotti TM, et al. Melasma. G Ital Dermatol Venereol. 2012; 147(4):413-418; PMID: 23007216 Link to research.
  13. Randhawa M, Seo I, Liebel F, et al. Visible Light Induces Melanogenesis in Human Skin through a Photoadaptive Response. PLoS One. 2015; 10(6):e0130949; PMID: 26121474 Link to research.
  14. Mahmoud BH, Ruvolo E, Hexsel CL, et al. Impact of long-wavelength UVA and visible light on melanocompetent skin. J Invest Dermatol. 2010; 130(8):2092-2097; PMID: 20410914 Link to research.
  15. Otles S, Cagindi O. Health importance of arsenic in drinking water and food. Environ Geochem Health. 2010; 32(4):367-371; PMID: 20383791 Link to research.
  16. Maity JP, Nath B, Kar S, et al. Arsenic-induced health crisis in peri-urban Moyna and Ardebok villages, West Bengal, India: an exposure assessment study. Environ Geochem Health. 2012; 34(5):563-574; PMID: 22580621 Link to research.
  17. Rahman MM, Ng JC, Naidu R. Chronic exposure of arsenic via drinking water and its adverse health impacts on humans. Environ Geochem Health. 2009; 31 Suppl 1:189-200; PMID: 19190988 Link to research.
  18. Fisk WA, Agbai O, Lev-Tov HA, et al. The use of botanically derived agents for hyperpigmentation: a systematic review. J Am Acad Dermatol. 2014; 70(2):352-365; PMID: 24280646 Link to research.
  19. Kim HJ, Seo SH, Lee BG, et al. Identification of tyrosinase inhibitors from Glycyrrhiza uralensis. Planta Med. 2005; 71(8):785-787; PMID: 16142649 Link to research.
  20. Bandyopadhyay D. Topical treatment of melasma. Indian J Dermatol. 2009; 54(4):303-309; PMID: 20101327 Link to research.
  21. Costa A, Moises TA, Cordero T, et al. Association of emblica, licorice and belides as an alternative to hydroquinone in the clinical treatment of melasma. An Bras Dermatol. 2010; 85(5):613-620; PMID: 21152784 Link to research.
  22. Amer M, Metwalli M. Topical liquiritin improves melasma. Int J Dermatol. 2000; 39(4):299-301; PMID: 10809983 Link to research.
  23. Zubair S MG. Comparison of efficacy of topical 2% liquiritin, topical 4% liquiritin and topical 4% hydroquinone in the management of melasma. . J Pak Assoc Dermatol. 2009:158–163; PMID:
  24. Alvin G, Catambay N, Vergara A, et al. A comparative study of the safety and efficacy of 75% mulberry (Morus alba) extract oil versus placebo as a topical treatment for melasma: a randomized, single-blind, placebo-controlled trial. J Drugs Dermatol. 2011; 10(9):1025-1031; PMID: 22052272 Link to research.
  25. Valenzuela A, Guerra R, Videla LA. Antioxidant properties of the flavonoids silybin and (+)-cyanidanol-3: comparison with butylated hydroxyanisole and butylated hydroxytoluene. Planta Med. 1986; (6):438-440; PMID: 3562659 Link to research.
  26. Choo SJ, Ryoo IJ, Kim YH, et al. Silymarin inhibits melanin synthesis in melanocyte cells. J Pharm Pharmacol. 2009; 61(5):663-667; PMID: 19406006 Link to research.
  27. Altaei T. The treatment of melasma by silymarin cream. BMC Dermatol. 2012; 12:18; PMID: 23031632 Link to research.
  28. Puglia C, Offerta A, Saija A, et al. Protective effect of red orange extract supplementation against UV-induced skin damages: photoaging and solar lentigines. J Cosmet Dermatol. 2014; 13(2):151-157; PMID: 24910279 Link to research.
  29. artin LK CC, Woolery-Lloyd H, et al. . A randomized double-blind placebo controlled study evaluating the effectiveness and tolerability of oral Polypodium leucotomos in patients with melasma. Journal of the American Academy of Dermatology. 2012; PMID:
  30. Ahmed AM, Lopez I, Perese F, et al. A randomized, double-blinded, placebo-controlled trial of oral Polypodium leucotomos extract as an adjunct to sunscreen in the treatment of melasma. JAMA Dermatol. 2013; 149(8):981-983; PMID: 23740292 Link to research.
  31. Castanedo-Cazares JP, Hernandez-Blanco D, Carlos-Ortega B, et al. Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Photodermatol Photoimmunol Photomed. 2014; 30(1):35-42; PMID: 24313385 Link to research.
  32. Espinal-Perez LE, Moncada B, Castanedo-Cazares JP. A double-blind randomized trial of 5% ascorbic acid vs. 4% hydroquinone in melasma. Int J Dermatol. 2004; 43(8):604-607; PMID: 15304189 Link to research.
  33. Huh CH, Seo KI, Park JY, et al. A randomized, double-blind, placebo-controlled trial of vitamin C iontophoresis in melasma. Dermatology. 2003; 206(4):316-320; PMID: 12771472 Link to research.