Melasma
– The Black Mask
A common pigmentation disorder characterized by symmetrical, irregular brown or gray patches on sun-exposed area, especially on the face. 1 Melasma is more common in women (90%), but it can also affect men. People with darker skin tone, particularly in areas of high sun exposure, are especially susceptible to getting melasma. Asia, Latin- America, Middle East, and Northern Africa are areas with a higher prevalence of melasma.2
Melasma is notoriously difficult to treat and has a high rate of recurrence. Although asymptomatic, melasma is a disfiguring disease that negatively affects the quality of life (QoL) and self-esteem of affected individuals. 3
Signs & Symptoms
Common signs (what you see) of melasma are brown or gray-brown patches on the face. These patches most commonly appear on the:
- Cheeks
- Forehead
- Bridge of the nose
- Above the upper lip
- Chin
Some people get patches on their forearms or neck. This is less common.
Melasma does not cause any symptoms (what people feel). But many people dislike the way melasma makes their skin look. If you dislike these patches, sun protection and treatment can help.9
Causes
Exact cause of melasma is still not clear. But it likely occurs when the pigment-making cells in the skin (melanocytes) produce too much pigments (melanin). People with darker skin are more prone to melasma because they have more active melanocytes than people with fair skin.
An interplay of genetic, hormonal, and UV factors which are unable to completely eliminate and often recalcitrant9
SUN EXPOSURE
Ultraviolet (UV) light from the sun stimulates the melanocytes. In fact, just a small amount of sun exposure can make melasma return after fading which explains why melasma is often worse in summer. It is also the main reason why melasma sufferers get it again and again.
A CHANGE IN HORMONES
Pregnant women often get melasma, also called chloasma or mask of pregnancy. Birth control pills and hormone replacement medicine can also trigger melasma.
GENETICALLY PREDISPOSED
Affected people often have a family history of melasma
Diagnosis & Treatments
Dermatologists find most cases of melasma easy to diagnose during a visual examination. However, skin biopsy may be necessary to differentiate it with other skin conditions.4
An appropriate management approach requires tailoring treatment options, selecting appropriate maintenance therapy or alternative treatments based on the clinical response and tolerance. Daily photoprotection with broad spectrum sunscreens is key in the management of this therapeutically challenging and universally relapsing disorder.8
Treatments
Triple Combination Therapy*
A combination of hydroquinone, tretinoin and corticosteroids which is the preferred mode of treatment for the synergism and reduction of untoward effects. This therapy may cause erythema and peeling, and can only be used for a maximum of 3 months.6
*hydroquinone 4% , tretinoin 0.05%, fluocinolone acetonide 0.01%
Hydroquinone
The most commonly prescribed agent but can cause irritation, erythema and stinging sensation of the skin. Prolonged usage may lead to untoward effects like contact dermatitis, nail discolouration, hypopigmentation (white spots) of the surrounding skin and ochronosis (blue-black pigmentation).5 Hence it is banned in EU and is a prescription-only in US (2-4%).6
Azelaic acid
Initially developed as a topical anti-acne agent but because of its effect on melanin production, it has been used to treat hyperpigmentary disorders like post-inflammatory hyperpigmentation (PIH) and melasma. Free radicals are believed to contribute to hyperpigmentation, and azelaic acid acts by reducing free radical production5
Retinoid
A Vitamin A derivative that basically peels the topmost layer of the skin. It may cause retinoid dermatitis that can increase the chance of sun burn. For sensitive skin, it may cause the skin to be aggravated by exposure to wind, cold, use of soaps and certain cosmetics.5
Kojic acid
A fungus derivative which has a debateable ability to inhibit melanin production and is usually combined with other lightening agents. Common side effects are contact dermatitis and increasing the skin sensitivity.5
Arbutin
A leaf extract from certain plants. Its synthetic forms alpha-arbutin and deoxyarbutin are more effective than the naturally occurring compound.1 It is used as a gentler alternative to hydroquinone which is banned in Europe.5
Niacinamide
A Vitamin B3 derivative which prevents melanin transfer to keratinocytes. This agent is stable and is unaffected by light, moisture, acids or alkalis. It is formulated in combination with other agents.5
Vitamin C
Vitamin C is not only an anti-oxidant but it also disrupts melanin production. It is usually formulated with other agents.5
Licorice
Licorice has both anti-inflammatory properties, inhibits tyrosinase and causes depigmentation by melanin dispersion and removal.5
Soybean extract
Soybean extract inhibits deposition of melanin granules into the keratinocytes, but its effect is reversible. It is also formulated with other agents.5
Chemical Peels
Chemical Peels (i.e. Glycolic Acid) can improve melasma by removing the outermost cells of the skin that contain the pigment. Chemical peels should be undertaken by an experienced practitioner as they can make the pigmentation worse, lighten the skin too much or cause scarring.5
Microneedling
Microneedling is a process where the skin is repeatedly punctured with tiny needles to help creams penetrate deeper into the skin. This may result in pain, swelling, infections and scarring (including keloids).5
Laser & Light-based Therapies
Laser and Light-based Therapies work on the principle of wavelengths that can penetrate certain cells, in case of hyperpigmentation, melanosomes within the melanocytes. They are usually used together with topical treatments. However, they must be performed correctly as it can lead to more damage if the laser/light wavelengths penetrate too deeply.5
Tranexamic Acid (TXA), a moderately potent plasmin-plasminogen inhibitor, used to prevent bleeding. As plasminogen also exists in human melanocytes, TXA inhibits melanin production by interfering with the interaction of melanocytes and keratinocytes through inhibition of the plasminogen-plasmin system.7 TXA is currently used via a spectrum of delivery routes including oral, intradermal and topical.
Oral TXA
Oral TXA’s unofficial use at a dose of 250 mg twice daily has shown efficacy in treating melasma but general concerns linger with regard to safety profile given its propensity to induce systemic side effects. Oral TXA should be prescribed with care and caution.8
Intradermal TXA
Intradermal TXA were reported to be an effective way of treatment for melasma with minimum risk of adverse effects but is considered invasive and may cause discomfort.8
Topical TXA
Topical TXA is a promising treatment for melasma without the side effects of oral TXA but is limited by difficulty in skin penetration.7,8
Prevention
The next step in treating melasma is to prevent the sun from aggravating the condition. This may require extreme diligence.
Tips to make melasma less noticeable9
- Wear sunscreen daily that offers broad-spectrum protection and a Sun Protection Factor (SPF) of 30 or more
- Wear a wide-brimmed hat and sunglasses when you’re outside
- Choose gentle skin care products like TDF® Derma Formula
- Avoid waxing as it may cause skin inflammation which can worsen melasma
