Melasma

Melasma is a skin condition presenting as brown patches on the face of adults. Both sides of the face are usually affected. The most common sites of involvement are the cheeks, bridge of nose, forehead, and upper lip.

Who gets melasma?

             Melasma predominantly occurs in women. Only 10% of those affected are men. Brown-skinned races tend to have melasma more than others, particularly Hispanics, Orientals, Asian Indians, and those from the Middle East and Northern Africa.

What causes melasma?

             The precise cause of melasma is unknown. People with a family history of melasma are more likely to develop melasma themselves. Melasma often begins with a change in hormonal status. The most common association is pregnancy. Indeed, melasma is often referred to as the “mask of pregnancy”. It also may occur after starting birth control pills. Hormone replacement therapy used after menopause has not been shown to cause melasma.  

             Sun exposure is often the reason behind a sudden appearance of melasma. It has been shown that ultraviolet light from the sun and even visible light from light bulbs can stimulate pigment-producing cells in the skin to produce more pigment. These pigment-producing cells are called melanocytes. People with brown or black skin have more active melanocytes than those with light skin. These melanocytes produce a large amount of pigment under normal conditions, but this production increases even further when stimulated by light exposure or an increase in hormone levels. Unintentional exposure to the sun is the main reason why those with melasma keep getting the condition over and over again.

             Any irritation of the skin may cause an increase in pigmentation in brown-skinned races. This irritation may also worsen melasma.  Melasma is not associated with any internal diseases or organ malfunction.

How is melasma diagnosed?

             Because melasma is common, and has a characteristic appearance on the face, most patients can be diagnosed simply by a skin examination. Occasionally a skin biopsy is necessary to differentiate melasma from other conditions.

How is it treated?

             While there is no single cure for melasma, many treatments have been developed. Although melasma may disappear after pregnancy, some patients have it for many years, or even a lifetime.

             Sunscreens are critical in the treatment of melasma. They should be broad spectrum, protecting against both UVA and UVB rays from the sun. In addition, physical sunblock lotions and creams, such as zinc oxide and titanium oxide, may be used to block further ultraviolet radiation and visible light. Sunscreens should be worn daily, whether or not it is sunny outside, even if you are not going to be engaging in outdoor activities. We all receive a significant amount of ultraviolet rays simply walking down the street, driving in our cars, and sitting next to windows.

             If melasma develops after starting birth control pills, it may improve after discontinuing this medication. Alternatively, the melasma can be treated with bleaching creams while continuing to stay on birth control pills. Any creams or makeup which irritate the skin should be stopped, as this may worsen the melasma. Gentle soaps and cleansers should be used daily.

             A variety of bleaching creams are available for the treatment of melasma. These creams do not “bleach” the skin by destroying the melanocytes, but rather, decrease the activity of these pigment-producing cells. Over-the-counter creams contain low concentrations of hydroquinone, the most commonly-used depigmenting agent. This is often effective for mild forms of melasma when used twice daily. A dermatologist may prescribe creams with higher concentrations of hydroquinone. Normally, it takes about 3 months to substantially improve melasma. Creams containing tretinoin, steroids, and glycolic acid are available in combination with hydroquinone, to enhance its depigmenting effect. Other medications which have been found to help melasma are azelaic acid and kogic acid. It is important to follow the directions of your dermatologist carefully in order to get the maximum benefit from your treatment regimen and to avoid irritation and other side effects.

             Chemical peels, microdermabrasion, and laser surgery may help melasma, but results have not been consistent. These procedures have the potential of causing irritation, which can sometimes worsen melasma. Generally, they are only used in those who have not responded to sunscreens and bleaching creams, and must be performed with great care.

             Management of melasma requires a comprehensive approach. Avoidance of sun and irritants, use of sunscreens, application of depigmenting agents, and close supervision by your dermatologist can lead to a successful outcome.