Melasma - Western SummaryWestern Medicine Summary

Western Medicine

Western Summary

Melasma is a common skin condition in which dark patches appear on sun exposed areas of the skin, most commonly the face. Melasma is not dangerous to your health, but everyone can probably agree that walking around with dark patches on the face and cheeks can be embarrassing. The exact cause of melasma has not been established and this may explain why a cure is not available currently. There are many factors that contribute to the development of this pigmentary skin change, creating a complex condition. Excess ultraviolet radiation, changes in hormones, and stress can all worsen melasma.

Treatment Philosophy

Melasma treatment starts with basic photoprotection with avoidance of direct sunlight, sunscreens, and photoprotective clothing. While photoprotection alone will not treat melasma, it will prevent it from worsening while other treatments are employed. Identifying the risk factors causing melisma in each individual will allow targeting of certain exacerbating factors, like changing medications. Topical therapies are prescribed by healthcare professionals and can make significant improvements in most people with melasma. Lasers and chemical peels may also be employed if topical therapies are ineffective or more immediate results are desired.

Symptoms

Melasma is a chronic skin condition with increased pigmentation (hyperpigmentation) that develops on sun-exposed areas of the face, such as the forehead, cheeks, nose, upper lips and chin. It usually appears as symmetrical, irregularly shaped, smooth patches and develops gradually overtime. The color varies from light to dark brown or even grey/blue, depending upon the depth of the pigment that develops within the skin.[1] There are three types of melasma according to depth:[1]

  • Epidermal type: increased pigmentation is limited to the upper layers of the skin called the epidermis. The pigmentation is dark brown in color with well-defined edges and is typically easier to treat.
  • Dermal type: the increased pigmentation is deeper in dermis layer of the skin. The pigmentation is light brown or bluish in color, the edges are ill-defined and more difficult to treat.
  • Mixed type: the increased pigmentation is both in the epidermis and dermis. This is the most common type of melasma with features that combines both epidermal and dermal types.

Melasma usually does not cause any symptoms nor is it harmful to one’s physical health, but the cosmetic discoloration can lead to significant emotional distress, and may negatively affect one’s quality of life.[3]

Causes

The exact cause of melasma is still unknown, but it is likely due to multiple factors that trigger increased melanin (pigment) production by melanocytes (pigment producing cells). Additionally, there is likely to be increased pigment transfer from melanocytes to keratinocytes (skin cells).[1]

Melasma is also known as chloasma faciei or the mask of pregnancy. However, it is not unique to women who are pregnant. Although anyone can get melasma, it is about 4 to 20 times more common in women than men. Melasma is especially common in women who are of reproductive age, such as during pregnancy, or those who take contraceptive or hormone replacement medications. Melasma is reported in up to 70% of pregnant women and in 5 to 34% of women taking birth control pills.[2,6] Melasma is also more common in those with darker skin complexions and those who live in areas that have strong sunlight or ultraviolet exposure.

Risk Factors

Your body 

  • Age: Adults of reproductive age (after puberty and before menopause)
  • Gender: Females are more likely to get melasma than men.
  • Genetics: People with darker skin complexions (Asian, Hispanic and African decent) and people who have other family members with melasma are more likely to get melasma.[1]
  • Inflammation: Any inflammation in the skin can result in darker pigmentation and worsen the appearance of melasma.
  • Autoimmunity: Melasma has been associated with some autoimmune diseases that have hormonal alterations, such as autoimmune thyroid disease.[13]
  • Hormonal disorders: Researchers have found that 70% of women who develop melasma during pregnancy, or while taking oral contraceptive medications also have mild thyroid dysfunction. Furthermore, people with melasma are about four times more likely to have thyroid disorders than those without melasma.[13] After pregnancy, the pigmentation typically fades within a few months following delivery.

Products & medications

  • Soaps and cosmetic products. Harsh soaps and cosmetic products that contain irritating ingredients such as alcohol and fragrance may cause skin inflammation, which can worsen skin pigmentation.
  • Oral contraceptive: birth control pills are the most common class of medication reported to cause melasma. About 25% of new onset melasma can be linked to oral contraceptive use, especially in women who do not have a family history of melasma.
  • Hormone replacement therapy (HRT): has also been reported. However, unlike cases associated with oral contraceptive mediations, these cases do not have a history of pregnancy-related melasma.
  • Phenytoin: an anti-seizure medication, has also been reported to cause melasma, especially in men.[12]
  • Other medications: Any medication that makes the skin more sensitive to sunlight has the potential to trigger and worsen melisma.

Environment

  • UV light exposure. When skin is exposed to UV light or sunlight, melanocytes become more active and start to produce more melanin, which is subsequently transferred to keratinocytes. The end result is increased skin pigmentation. This explains why melasma is most common on sun-exposed areas of the skin.[4,5] Lifelong sun exposure causes melanin to deposit in the dermal skin layer. Dermal type melasma lasts a long time and is difficult to treat.
  • Climate: Living in areas with warm climate, significant sun exposure, and high altitude can increase the risk of melasma in both men and women.[14,15]

Lifestyle

  • Stress: Researchers have found that some cases of melasma could be triggered by stress due to the release of a hormone, melanocyte-stimulating hormone, that stimulates skin pigmentation.[16]
  • Occupation: People who work outdoors tend to get more UV exposure and are more likely to develop melasma than those who work indoors.[14,15]

Treatments

The development and worsening of melasma is best prevented by sun protection and board-spectrum sunscreen use. Some topical and procedural treatments have also been shown to be effective.

Products

  • Moisturizers: While moisturizer use alone has not been shown to help treat melasma, it may sooth skin irritation from other topical and procedural treatments and prevent post-inflammatory hyperpigmentation.

Medications

  • Topical bleaching creams: Topical hydroquinone creams are used worldwide treat pigment imperfections, especially hyperpigmentation. It works by inhibiting an important enzyme that produces skin pigment. Hydroquinone creams have been reported to be up to 80% effective in lightening the appearance of melasma, especially when used together with sunscreen.[17]
  • Topical retinoids: Topical retinoids decrease the transfer of melanin from melanocytes to keratinocytes. They also allow other medications used to treat melasma to better penetrate the skin.[18] However, topical retinoids should not be used during pregnancy or breastfeeding, as it may be harmful to the baby.[19]
  • Topical lightening acid creams: Topical formulations containing azeleic acid, alpha-hydroxy acid, Kojoic acid and glycolic acid may be effective in treating melasma, but can be associated with skin irritation such as stinging, redness, peeling and itching.[20,21]
  • Combination topical medications: Combination formations of topical hydroquinone, retinoids and steroids have been shown to be more effective in lightening melasma than using hydroquinone cream alone.[22,23]

Procedures

  • Chemical peels: Chemical peels using various acidic ingredients such as trichloroacetic acid and glycolic acid may be effective in treating melasma.[24]
  • Lasers and light treatments: Various lasers and intense pulsed light treatments are usually reserved for persistent cases of melasma that do not respond to topical treatments.[24]

Lifestyle

  • Stress reduction: Stress reduction may help reduce the level of pigment stimulating hormones in the body and decrease the risk of melasma.[16]
  1. Jean Bolognia JJ, Julie Schaffer. Third Edition, Volume 2. Elsevier Publishing. Dermatology.
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