If you have melasma, it’s important to understand fully what it is, where it stems from and what the pros and cons of Melasma management are before you undergo any treatments. The reason is that some commonly used treatments may backfire and worsen the melasma / hyperpigmentation. A dermatologist and/or your doctor should always be consulted before taking any action against Melasma.
What is Melasma?
Melasma (sometimes called chloasma) is a chronic skin disorder in which areas of the skin become darker than the surrounding skin. This darkening is called hyperpigmentation. It typically occurs on the face, particularly the forehead, cheeks and above the upper lip. The dark patches often appear symmetrically on both sides of the face in a nearly identical pattern. The darker-colored patches of skin can be any shade, from tan to deep brown. Although not as common as on the face, these dark patches may appear on any other sun-exposed areas of the body.
Who gets Melasma?
Anyone can get it, but melasma is more common in women than in men. It generally occurs in normal/healthy adults between the age of 20 and 40 years, but it can begin from childhood or puberty, or even develop only around Menopause.
Melasma is more common in people that tan well or have naturally brown skin (Fitzpatrick skin types 3 and 4) compared with those who have fair skin (skin types 1 and 2) or black skin (skin types 5 or 6).
What causes Melasma?
The cause of melasma is complex, but essentially, it is when facial melanocytes (pigment cells) have a hypersensitivity to hormones such as estrogen, other sex hormones, thyroid hormones, adrenal hormones, MSH, etc. The body’s response to this sensitivity is an overproduction of melanin by the melanocytes, which is taken up by the keratinocytes (epidermal melanosis) and/or deposited in the dermis (dermal melanosis, melanophages).
There is also a genetic predisposition to melasma, with at least one-third of patients reporting other family members to be affected.
The most significant factor in the development of melasma is exposure to sunlight. More specifically, exposure to ultraviolet radiation (UVR) deepens the pigmentation because it activates the melanocytes to produce more melanin.
Using medications that make you sensitive to the sun (photosensitising) can increase your risk of developing melasma. These can include some cosmetics and medicines used to treat ovarian or thyroid problems. Protection from the sun is a necessary part of both the treatment and prevention of melasma.
How is Melasma different from regular pigmentation caused by the sun?
Most solar lentigos, also known as a sun-induced freckles (brown spots), will appear on almost every person at some point in their lives and is caused by exposure to both natural and artificial UV light. Whether they form as single or multiple spots, they generally reside on the upper most layer of the skin (Epidermis) and can be easily removed by laser or pulsed light therapy.
Melasma is sometimes separated into 3 types:
1. Epidermal (close to the skin’s surface)
- Well-defined border
- Dark brown colour
- Appears more obvious under black light
- Responds well to treatment
2. Dermal (deeper inside the skin’s dermal layer)
- Ill-defined border
- Light brown or bluish in colour
- Unchanged under black light
- Responds poorly to treatment
3. Mixed types.
- The most common type
- Combination of bluish, light and dark brown patches
- Mixed pattern seen under black light
- Partial improvement with treatment
How does one treat Melasma?
In mild cases of melasma, eg. women who develop melasma as a result of pregnancy, patients will often see the patches fade months after the baby is born. Women who take oral contraceptives or hormone replacement therapy (HRT) often see the patches fade once they stop taking the medications. i.e. as hormones stabilize in the body, the dark patches of melasma usually fade.
However, with sun exposure, dark spots may be way more intense with no signs of disappearing even with a change in hormones. In this case, one has a few options to help fade or treat dark patches:
The first and fastest option is Intense Pulsed Light therapy. It works by utilising a targeted wave length of light to lightly burn and remove pigmented areas of skin. However, it’s very important to note: Pulsed Light Treatment is only recommended for Epidermal Melasma as these are surficial and easy to treat. Sun exposure needs to be eradicated and post-inflammatory hyperpigmentation may also complicate recovery.
Pros of Pulsed Light Treatment for Melasma:
IPL and lasers are often the first choice for both patients and physicians as results are fast and impressive. When the scab falls off several days after the light based treatments, there is temporary improvement because the top layer of the skin containing pigment has been burned off. It would take months if not years to achieve this same state with topical ointments.
Cons of Pulsed Light Treatment for Melasma:
While IPL and lasers are able to speedily burn the melasma pigment on the very top layer of skin, they cannot stop the production of new pigment by the pigment producing melanocytes. It treats the symptom, but not the cause of Melasma. One would need to tackle the hormones which are causing the hypersensitivity and also relook at their daily sun exposure.
IPL and lasers can also worsen the melasma hyperpigmentation by making it blacker. This process is called post-inflammatory hyperpigmentation. The reason is that in addition to hypersensitivity to hormones, melasma patients’ melanocyte cells are also hypersensitive to light. When the intense light from IPL or lasers hit these cells, they are hyper stimulated to produce much more pigments at a higher rate.
The result from the hypersensitivity to hormones and hypersensitivity to light is that the melasma hyperpigmentation comes back even darker weeks to months after the IPL or laser treatments.
For those with deeper rooted melasma, dermal or mixed varietals, your prognosis is sadly not great, but the following topical treatments are recommended to slowly lighten
- Hydroquinone – a cream that takes pigment out of the skin. It blocks the natural chemical process that leads to the creation of melanin, the substance that makes skin dark.
- Tretinoin – a type of vitamin A that helps to increase the rate at which dead skin cells fall off and new ones appear. This makes the melasma patch fade more quickly as the pigmented cells are shed.
- Azelaic acid cream – works by slowing down or stopping the production of pigment, the substance that makes the skin darker.
- Chemical peels are liquid solutions applied to the skin to provide a mild chemical burn, similar to sunburn. Over time, the burned layers peel off, leaving fresh, new skin. Chemical peels should only be used if melasma does not respond to other treatments as they can be very strong and may cause scarring to the skin.
While NO ORAL TREATMENT exists for melasma, yet, one can remove oral medication from their day to day routines in order to stop If you are not sure what kind of Melasma you have (or if it is in fact Melasma at all), The LightBarr offers FREE test patches in discreet areas of the body (face), which will assist you in deciding a course of action most suited to your kind of pigmentation. Make an appointment here: http://thelightbarr.co.za/contact/make-an-appointment/
Results take time and the above measures are rarely completely successful.
Unfortunately, even in those that get a good result from treatment, pigmentation may reappear on exposure to summer sun and/or because of hormonal factors. New topical and oral agents are being studied and offer hope for effective treatments in the future.