What is Melasma & How to Treat It

melasma example dark spots on cheek

In addition to wonderful memories, summer can leave behind unwanted darkening of the skin.  Persistent hyper-pigmentation of the face, called Melasma, occurs on the cheeks, bridge of nose, forehead, upper lip and occasionally the forearms.  It is similar in appearance to age spots, but the dark patches cover a larger area.

Melasma occurs in all skin types, but especially in skin of color.  East Asian, Southeast Asian, Hispanic and Blacks populations have the highest rates.  Up to 30 % of middle-aged Asian women exhibit Melasma.  In general, women are affected more frequently; the American Academy of Dermatology estimates that 90 % of Melasma sufferers are women.  Men are not immune; nearly 35 % of men from Central America – particularly Guatemala – develop the condition.

What causes Melasma?

Sunlight is the principal trigger.  The greater the sun exposure, the greater the risk.  Age increases the potential as does a history of vitiligo and the existence of multiple moles or birthmarks.

The second most important cause is female hormones.  Not only is Melasma more common in women, it’s also more severe.  It occurs during pregnancy (the “mask of pregnancy” or Chloasma) and with the use of oral contraceptives and hormone replacement therapy (HRT).  Unfortunately discontinuation of the medication doesn’t necessarily reverse the pigmentation.

Why does Melasma differ by ethnic group?

Skin color is determined by the density and distribution of melanin, or natural pigment, in the skin.  All ethnicities have a similar number of melanin producing cells, or melanocytes, in their skin.  What differs is the level of melanocyte activity and how closely the cells are grouped together.  Skin types with more melanocytic activity, or darker skin types, react to inflammation or UV exposure with more robust melanocytic activity, leading to hyper (increased) and sometimes hypo (decreased) pigmentation.

How is Melasma treated?

Sun protection is the cornerstone of Melasma prevention and treatment.  Daily use of a broad spectrum (at least SPF 30) sunscreen that blocks both UVA and UVB is critical.  These should be applied at least 20 minutes before and 30 minutes after sun exposure.  Products  should contain one or more of the following ingredients in order to protect against the long UVA wavelengths: Zinc Oxide, Titanium Oxide, Ecamsule and/or Avobenzone (Parsol 1789).  Protection can also come from wearing iron oxide-containing makeup.  Hats with a 2-3 inch brim along with sunglasses are helpful in reducing UV light exposure.  It’s important to remember that damaging sun rays penetrate through a car window.

Topical skin bleaching agents such as prescription-strength Hydroquinone, either alone or in combination with topical retinoids and steroids, are very useful in treating Melasma.  Their efficacy is enhanced when combined with a series of peels with either Glycolic Acid, Salicylic Acid or Trichloroacetic Acid.  Peels and topicals should be adjusted according to skin type for best results.

Other agents also have a role in reducing pigmentation including vitamin C and E, Azelaic Acid, licorice, Kojic Acid, Ellagic Acid and Arbutin.  Lasers are often promoted for Melasma treatment but they are not as effective as they are for solitary age spots or blood vessels.

Oral medications, such as Tranexamic Acid, are also helpful as an adjunct treatment for some patients.

Summary:

I find that a multi-modal approach, tailored to a patient’s ethnicity, location of pigment in the skin and underlying health status leads to significant and durable improvement in Melasma.  The good news is that if Melasma bothers you, it’s not something you have to live with!