What is Melasma?
Melasma is a very common and popular skin disorder that causes brown, dark and rough patches to appear on your skin, especially on the face.
Melasma commonly occurs in pregnant women. This is why melasma is called as "mask of pregnancy”. This condition can be seen mostly in women and very few percentages of men experience this type of skin infection. American Dermatology Association ascertains that 90 percent of people who develop melasma are women.
According to an NCBI book titled ‘Melasma’, the most common areas for melasma to appear are the forehead, above the upper lip, chin, nose bridge and cheeks. Women experience it more often than men do.
Melasma frequently develops during pregnancy. It also has an impact on women who use oral contraceptives and hormones.
Types of melasma
Epidermal
Dark brown patches with a distinct border make up the epidermal type of melasma. Epidermal melasma is more easily visible under black light and typically responds well to treatment.
Dermal
The features of dermal melasma include bluish or light brown patches with an ill-defined border. This type doesn’t respond well to treatment and doesn’t change in appearance when exposed to a black light.
Mixed melasma
Mixed melasma is the most frequently diagnosed form of melasma, and it is distinguished by a mixture of light and dark brown patches and bluish discolouration. This type responds to treatment reasonably well.
Causes of Melasma?
Dermatologists are still uncertain about the exact cause of Melasma. They suggest it may be caused due to improper function of the melanocytes in the skin, which produces extra skin color. People with brown and dark skin tones have a huge chance of getting affected by melasma, as their melanocytes contents are higher compared to lighter skin people.
Using birth control pills & contraceptives
People who take oral contraceptives that contain estrogen and progesterone are likely to develop melasma.
Hormonal imbalance caused by pregnancy
Why pregnant women experience the mask of pregnancy remains a mystery. Researchers speculate that the increased levels of estrogen, progesterone and the hormones that stimulate melanocytes during the third trimester of pregnancy may play a part.
Hormones
Some people may be affected by hormones like estrogen and progesterone. When given progesterone, postmenopausal women are likely to develop melasma. If a person is not pregnant, the melasma lesions most often contain higher than average amounts of estrogen receptors.
Exposure to the sun
UV light causes the body to produce more melanin pigment on exposing the skin to the sun. Melasma is characterised by blotchy patches and spots that resemble freckles. This pigment can sometimes appear unevenly.
Using phototoxic drugs which make the skin sensitive to sunlight results in melasma. Some of these medications include antibiotics, diuretics, Non-Steroidal Anti-inflammatory Drugs (NSAIDs), hypoglycemics, retinoids, anti-psychotics, targeted therapies and a few other medicines.
Reaction to skincare & cosmetic products
One type of cosmetic reaction is known as a phototoxic reaction. A skincare product generally irritates the skin and is more likely to aggravate melasma.
Stress & thyroid disease
The body produces more cortisol when under stress. Elevating cortisol levels could lead to melasma.
Hormonal changes associated with thyroid diseases can cause melasma in some people.
A study presents evidence supporting the link between autoimmune thyroid disorders and melasma as well as the contribution of thyroid disorders to the development of melasma.
Risk factor of melasma
Darker-skinned individuals
Melasma is more likely to develop in people with dark skin tones than those with lighter skin tones.
Sun exposure
Sun is the most common trigger for melasma. The sun’s UV rays stimulate the release of specific pro-inflammatory chemicals, which in turn causes the skin’s melanocytes to produce excessive amounts of pigment.
The skin may tan due to increased pigment production, but it may also cause the melasma to flare up or become darker.
Being a woman increases the risk of getting melasma
Women aged between 20 and 40 years have a higher risk of developing melasma since hormones in women play a role in causing the condition.
Having a blood relative with melasma may also increase
Patients having one or more blood relatives with melasma have a high chance of getting the condition.
Symptoms of melasma
A common symptom of melasma is skin discolouration in certain areas of the body. The patches may appear darker than the normal color of the skin. Melasma is commonly seen on both sides of the face with dark and shallow marks.
Melasma appears in certain parts of the face like:
- Forehead
- Cheeks
- Upper lip
- Lower lip
Melasma also appears in areas that are vastly exposed to sunlight. These areas include:
- Forearms
- Neck
- Shoulders
Dark skin patches
Sun exposure, hormonal changes, and the use of skin care products containing irritants can potentially cause symptoms of melasma. The skin’s pigment-producing melanocytes malfunction and causes dark patches to form.
The patches may be light brown or dark brown. It can occasionally appear as bluish patches or freckle-like spots on the skin.
Melasma locations on the skin
Brachial
Melasma is seen on the upper arms and shoulders.
Centrofacial
Melasma emerges on the upper lips, nose, cheeks and forehead.
Lateral cheek pattern
Going by the name, melasma is visible on both cheeks.
Malar
Melasma spots on the cheeks and nose.
Mandibular
Melasma surfacing on the jawline.
Neck
Melasma developing on the neck.
Diagnosis of melasma
Most cases of melasma can be easily diagnosed during a visual examination with your dermatologist. However, to accurately confirm melasma, your dermatologist may take a small biopsy (a method of removing a tiny portion of the skin for examination in a laboratory) while examining your skin to avoid confusion with other skin disorders.
A visual exam
A dermatologist can frequently diagnose melasma just by closely examining the face and neck of an individual.
Wood’s lamp examination
The doctor might use a dermatoscope or Wood’s lamp, among other specialised tools, to get a close look. The procedure involves using a black light to notice changes in the skin colour.
These tools help the dermatologist see how far the darker pigment has penetrated the layers of your skin when placed on or close to it. The examination helps diagnose and treat melasma effectively.
Biopsy
Melasma can occasionally resemble other skin conditions. The healthcare provider may conduct a biopsy to distinguish between various skin conditions.
The skin biopsy entails removing a small portion of the skin and examining it. Biopsy is a quick and safe procedure usually done on a routine visit to the doctor’s office.
The results of the biopsy typically show the following if a person has melasma:
- Melanin spotted in the dermis within melanophages.
- Melanin present in the basal and suprabasal keratinocytes
- Solar elastosis and elastic fibre fragmentation.
- Dendritic (branched) melanocytes.
The Melasma Area and Severity Index (MASI) helps determine the severity of the melasma.
Treatment for melasma
Melasma automatically vanishes after some time without any treatment. For women, it occurs only at the time of pregnancy and disappears after the delivery.
Melasma can last for years for people who have very low immunity. If melasma does not disappear over time, a person can opt for treatment for immediate recovery.
Prominent treatment options include:
Hydroquinone medication
Doctors always prefer hydroquinone as the primary mode of treatment for melasma. This medicine is available as a cream, lotion or gel.
Hydroquinone can be directly applied to the patched area of the skin. Hydroquinone tends to lighten the colour of the patched skin.
Combined creams
A dermatologist may prescribe triple creams which is a tri-combination of creams like hydroquinone, tretinoin and corticosteroids.
tretinoin and Corticosteroids
Corticosteroids and tretinoin are creams/gels used for secondary treatment of melasma. Both corticosteroids and tretinoin lighten melasma patches and scars.
According to an NCBI book titled ‘Melasma’, topical retinoids are shown to be effective in treating melasma.
The study further adds that there is a significant reduction in melasma pigmentation on using tretinoin 0.1% cream. The effectiveness of tretinoin 0.1% cream in treating melasma in dark-skinned patients has been supported by another study.
Hydrocortisone is a topical corticosteroid that makes the dark melasma spots fade. Using the cream at night on the melasma patches for two to four months is effective.
Azelaic acid or kojic acid
Apart from normal medicated creams, a dermatologist may prescribe kojic acid or azelaic acid.
Topical Creams
The first-line therapies for melasma are typically topical ones, including photoprotection.
The most frequently used therapeutic substances are those that prevent Melanin from being produced through melanogenesis and melanocyte proliferation.
Monotherapy is preferred to the concurrent use of a variety of topical therapies with various mechanisms of action.
Medical procedures
A dermatologist may recommend following procedures if topical treatment fails to work.
- Laser therapy - Laser therapy for melasma has varying degrees of success. To target specific chromophores in the skin, lasers use thermal energy. Since they tend to cause less inflammation and consequently less post-inflammatory pigment alteration (PIPA), non-ablative lasers are preferred for treating melasma over ablative lasers.
- Intense pulsed light (IPL) - Intense pulsed light (IPL) is proven to be a successful treatment both as a monotherapy and in conjugation with Q switched Ruby Laser (QSRL).
- Chemical peels - Chemical peels are an adjunctive treatment option for melasma because of their capacity to accelerate keratinocyte turnover and increase epidermal remodelling. Chemical peels are frequently combined with other topically applied medicines.
- Microneedling - Mesotherapy, also known as microneedling, is an additional adjunctive treatment that uses tiny skin channels to deliver topical medications intradermally in small doses. The skin punctures caused by microneedling can promote a helpful wound-healing response. This method might enable the medication to be applied to the epidermis and dermis at a deeper and more even level.
- Additional topical medications
The following topical medications are also beneficial treatments for melasma.
- Azelaic acid
- Kojic acid
- Retinoids
- Glycolic acid
- Mequinol
- Arbutin
Sun protection
Avoiding UV and visible light is essential for preventing flare-ups and melasma exacerbation. Broad-spectrum UVA and UVB filters with visible light blockers, such as iron oxide, have been shown to cause fewer melasma relapses in comparison to broad-spectrum UV filters.
Prevention of melasma
Daily sunscreen use
The key to preventing melasma from developing or worsening will be to use broad-spectrum sunscreens, particularly those that shield from light sources other than ultraviolet light.
Additionally, sunscreens with zinc and antioxidants provide us with broader protection.
Physical blockers with tint are the best because they provide protection from visible and infrared light as well as UV light, all of which can contribute to the development of melasma.
Outdoor hats
Wearing a hat with a brim can protect the face and neck. Good sun protection can reduce or prevent sun damage, skin cancers and melasma for those who are susceptible. Hats shield the skin from ultraviolet rays and offer long-lasting sun protection.
Gentle skincare
Fragrance-free, gentle skincare products are suitable for melasma. Skincare products that burn, sting or irritate the skin might make the dark spots darker. Selecting good products to use on the face is vital to prevent melasma.
Waxing
Waxing on body parts that have melasma is not advisable. Skin inflammation brought on by waxing may make melasma worse. Inquiring with a dermatologist about other hair removal methods that might be suitable can help.
Conclusion
Most melasma cases fade over time once hormone levels are balanced. To avoid melasma, wear protective clothing if you are under the sun for a long period of time. Melasma is not a Severe skin infection, but you should not be careless to treat it immediately.
If you are diagnosed with melasma, talk to your healthcare specialist or dermatologist to get rid of this skin disorder.
