Melasma

Melasma is a chronic disorder of hyperpigmentation that is characterized by bilateral, irregularly shaped brown macules and/or patches on sun exposed areas of the face, neck, or arms. Because of its strong hormonal influence and its first appearance commonly occurring during or after pregnancy, it is often referred to as “the mask of pregnancy.” Melasma is one of the most common causes of hyperpigmentation worldwide, particularly in women with skin of color. It is also triggered / worsened by both ultraviolet light from the sun and visible light from incandescent light bulbs and computer screens. Although many effective topical and procedural therapies have been successfully developed to treat melasma, its association with sun and hormones as triggers makes its long-term clearance challenging. The stubborn and chronic nature of melasma often results in psychological distress and social stigmatization.

Melasma affects more than 5 million people in the United States alone and has a strong predominance amongst women of Latino, African, Native American and Asian descent.  A population study of melasma in Hispanic women in the United States showed that 8.8% currently had melasma and 4% reported having had it in the past. While melasma is most common in women, men, especially those from Central America can also be affected.

The exact cause of melasma is unknown, however we do know that there is a strong association with hormones, light ( both ultraviolet (UV) and visible) and genetics.

Hormonal Influences

Melasma’s association with hormonal changes started when women noticed its first appearance and/ or its worsening during pregnancy, after starting hormone-based contraception or during hormone replacement therapy.  In one published study  based in the US, 29% of women developed melasma after initiating oral contraceptives and in another separate multicounty study, researchers found that 25% of women using hormonal contraception claimed that their melasma appeared for the first time after to use.(2,3) Unfortunately, melasma will persist for years even after pregnancy or discontinuing hormone based contraception.

Ultraviolet radiation and visible light

Sunlight is perhaps one of the most important risk factors and trigger for melasma as it will often get darker/worsen in the summer and fade in the winter.  Additionally, melasma is more common in countries that are closer to the equator.  More recent studies indicate that visible light from television, computers, smartphones, incandescent light bulbs can also trigger/worsen melasma.

Genetics

About half of patients with melasma report having a positive family history.  In a study of 324 melasma patients surveyed globally, 48% reported a family history of melasma, predominately in first-degree relatives. (3)

Melasma presents as light brown, dark brown or sometimes grayish brown small macules or large patches on the sun exposed areas of the body predominantly the cheeks, forehead, upper lip,  jawline, or forearms.

         Although there is no cure for melasma, it can be effectively treated and managed with both topical creams and office procedures. Melasma is a challenge to treat and the first line treatment is always sun protection and sun avoidance.  The reality is, one should not even bother investing time, effort or money into seeking treatment if they are not committed to adequate sun protection.  Once a commitment to sun protection is made, the next step is starting with a topical skin lightening agent that decreases the production of melanin. There are various over-the-counter formulations in addition to prescription agents that are effective in treating melasma.  Given the stubborn nature of this disorder, it is also common for people to combine topical creams with office procedures such as laser therapy or chemical peels.

Sunscreen

Melasma patients should minimize sun exposure by reserving outdoor activities for before 10 AM or after 4 PM when the sun rays are less strong. When outside, use a broad-spectrum sunscreen during the day (and reapplying every three hours), wear wide brimmed hats, sunglasses, umbrellas, and protective clothing. Sunscreen should be at least an SPF 30 and preferably a mineral-based sunblock with titanium dioxide and/or zinc oxide as an active ingredient.

Retinoids

Retinoids even though retinoids are most commonly used to treat acne, they also help improve hyperpigmentation. This is because as the retinoids help the skin cells shed, the excess pigment that is trapped in those skin cells gets shed as well. Topical retinoids are most effective for epidermal melasma because the pigment is in the more superficial layers of the skin. It’s important to remember that retinoids can cause dryness and irritation if used too frequently. Start using just one pea-size amount once a week and slowly advance from there. Examples of over-the-counter retinoids include retinol and adapalene. Prescription strength retinoids include tretinoin, tazarotene, and trifarotene.

Hydroquinone

Hydroquinone is a potent depigmenting agent that inhibits tyrosinase which is an enzyme that controls the rate limiting step of pigment production. Hydroquinone is considered the gold standard in melasma treatment either as a monotherapy or combination therapy. While it is a very effective and safe topical treatment, it’s overuse can lead to a condition called exogenous ochronosis which is a reflexive permanent darkening of the skin. Thus, it’s important to use it for short periods of time (typically three-month intervals) and then give your skin a break for a few months by switching to a non-hydroquinone based lightening agent for maintenance. Hydroquinone is available through prescription.

Cysteamine

Cysteamine is the newest agent on the market for combating hyperpigmentation. Cysteamine is a potent antioxidant that inhibits the tyrosinosis enzyme and other pathways in melanin synthesis. Numerous studies have shown it to be just as effective as hydroquinone however it does not carry the same risks of exogenous ochronosis which makes it ideal for long-term maintenance therapy. Cysteamine is the active ingredient in the topical cream Cyspera. Cyspera is considered a medical grade over the counter product so it’s only available to purchase at a physician’s office or online through their RegimenPro account.

Other topical agents

Other topical agents used for the treatment of melasma include azelaic acid, kojic acid, ascorbic acid, arbutin/deoxyarbutin, licorice extract, and soy. These agents have varying degrees of effectiveness and have not been generally found to be superior to hydroquinone; however, they are useful alternatives when hydroquinone is not available or not tolerated. Fortunately, Skin and Scripts Teledermatology can provide personalized skin care regimens from a board certified dermatologist to help you best manage your Melasma.

-Chemical peels: are beneficial in the treatment of melasma and are considered a second line therapy when used as an urgent treatment. There are many chemical peeling agents and they are often used in different combinations and different strengths. These include glycolic acid, salicylic acid, trichloroacetic acid, mandelic acid, lactic acid. Things such as vitamin C, retinoic acid, resorcinol, and hydroquinone are often added to boost the skin lightening effect of a chemical peel. Depending on the peeling agent and its strength, chemical peels can be either superficial, medium, or deep. Because irritation from chemical peels can result in post inflammatory hyperpigmentation, these peels should be used cautiously, particularly in patients with darker skin types. Chemical peels are office-based procedures and not safe to perform at home. Thus, it is important to discuss chemical peels is an option with your dermatologist to determine which agent is best for your skin and your condition.

-Lasers and microdermabrasion are considered second- or third-line therapies for melasma and are typically considered in more resistant cases. The use of fractional laser therapy has shown promising results and is currently the only FDA approved laser treatment for melasma. Even though this modality is an effective treatment, the chronic nature of melasma and it’s propensity to recur can be very frustrating for patients. The risk of post inflammatory hyperpigmentation is greatest in darker skinned individuals; lasers should be used with extreme caution in these patients and a spot test should be performed to determine an individual’s response to treatment.

(1) [Werlinger KD, Guevara IL, Gonzalez CM, et.al. Prevalence of self-diagnosed melasma among premenopausal Latina women in Dallas and Fort Worth, Tex. Arch Dermatol. 2007;1`43:424-425].
(2) Resnik S. Melasma induced by oral contraceptive drugs. J Am Med Assoc. 1967;199:601-605
(3) Ortonne JP, Arellano I, Berneburg M, et al. Global survey of the role of ultraviolet radiation and hormonal influences in the development of melasma.. J Eur Acad Dermatol Venerol. 2009;23:1254-1262.