Melasma


Melasma Causes Hyperpigmentation

There’s a name for the splotchy and hyperpigmented spots women get on their face after they have a baby. This condition is called melasma. Melasma is also known as the pregnancy mask. Want to know something scary? You don’t have to get pregnant to get Melasma! Melasma is an acquired pigmentary condition. This skin condition can happen to anybody. Melasma is most commonly seen in women of reproductive age with darker skin types. It’s also associated with UV exposure, thyroid disease, certain drugs, and hormonal factors. (1)

How common is melasma?

Depending on the population studied, melasma has a prevalence between 1.5-33.3%. (1) I have a special interest in melasma because it’s extremely common among Hispanic women. They’re the population I see most day in and day out in Miami. My mom even has it. Actually, I fully expect to develop melasma as soon as my hormones go awry. Melasma develops during 50-70% of pregnancies. (2)

What does melasma look like?

Here are some examples of melasma. Feel free to browse the internet at your leisure.

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What causes melasma?

We don’t know for certain. A lot of different factors have been implicated such as genetic predisposition, sun exposure, pregnancy, oral contraceptives, thyroid disease, and drugs like phenytoin. (1) One study found that pregnant women were at higher risk of developing melasma if they got more sun exposure during their pregnancy. Hence the term pregnancy mask. (3) All types of light can increase the amount of pigment on the skin.

Molecular Level Explanation

There are several different types of cells in the skin. The keratinocytes make up the regular skin cells. Langerhans cells are a type of cell involved in the immune system.

Finally, there are the melanocytes. They’re the ones that get a bad rap. They can mutate and become melanoma.

Melanocytes are the cells that produce pigment. This gives skin its color.

Melanogenesis is the process of creating pigment.

The pigment is called melanin. It’s housed in special structures called melanosomes within the melanocytes.

Since they are located in the deepest layer of the epidermis, the melanocytes have to pass the ready made melanin to the keratinocytes that lie above.

epidermal skin cells

The cells in your epidermis.

In melasma, there is a double whammy of pigment production that causes the dark spots on the face. There are an increased number of melanocytes and an increased production of melanin.

UV Light Makes Melasma Worse

UV light from the sun increases melanin production. People who suffer from melasma have to avoid the sun in order to stop their skin from making more pigment. The most widely accepted theory is that UV exposure hyperactivates the melanocytes to produce too much pigment.

Anything that causes inflammation of the skin can trigger hyperpigmentation. Be careful when pursuing treatment options!

Estrogen Makes Melasma Worse

Estrogen, which goes up during pregnancy and is an ingredient in many oral contraceptives, induces the release of a chemical called melanocyte-stimulating hormone. I’m sure you can imagine what that hormone does. The melanocytes are stimulated by melanocyte-stimulating hormone to make more melanin. Women get melasma disproportionately more often than men.

Types of Melasma

There are actually 2 classifications of melasma based on how deep the pigment is located. (1)

The epidermal type contains melanin only in the epidermal (outer) layer of the skin.

The dermal type contains melanin deeper down in the dermal layer of your skin. Your dermatologist can check the depth of the pigment using the Wood’s light.

Unfortunately, it’s really hard to treat the dermal type of melasma. It’s located much deeper in the skin, and most treatments can only scratch the surface.

Treatment of Melasma

Prevention

The best treatment for melasma is prevention. I’ve said it before, and I’ll say it again. WEAR YOUR SUNSCREEN! Slather on the broad spectrum SPF 30+. Stay out of the sun when it’s not necessary. Wear a hat! Get your car windows tinted. There are so many skin conditions that are aggravated by the sun, and this is just another example.

Topical Medications

The first line therapy for melasma is a triple-pronged approach. It is a combination of a lightening cream, a corticosteroid, and a retinoid.

Hydroquinone

The lightening cream is always hydroquinone. It is the most widely used and best-studied lightening agent. Hydroquinone inhibits melanogenesis directly. It inhibits one of the enzymes necessary for the production of melanin.

Tri-Luma is the newest cream that combines hydroquinone 4%, fluocinolone acetonide 0.01% (corticosteroid), and tretinoin 0.05% (retinoid) all in one. This cream is new. There are no competitors on the market right now.  Therefore, Tri-Luma is expensive. As always, ask your dermatologist for a coupon card. But, be prepared to pay some kind of copay depending on your insurance. Some dermatologists may be able to have this product compounded at a specialty pharmacy. This should be much cheaper.

Common side effects of using hydroquinone are irritation, contact dermatitis, and rarely ochronosis (a bluish discoloration of the skin). Doctors will recommend that you take a hydroquinone holiday every 3-6 months so that you decrease the risk of developing ochronosis.

Corticosteroid

You can use hydroquinone alone to lighten the skin. However, the best results in clinical trials have come from the triple agent cream. The corticosteroid helps to limit inflammation in the skin. It improves the penetration of the cream into the skin. It also prevents the oxidation of hydroxyquinone before it can do its work.

Retinoid

The retinoid also inhibits one of the enzymes in melanogenesis. It increases the loss of the pigment you already have by increasing cell turnover. It also interferes with the transfer of melanin to the keratinocytes. Tretinoin is one example of a retinoid. You can read more about Tretinoin here.

Other Lightening Creams

If you don’t want to use hydroquinone, then you can try using other compounds that inhibit melanin synthesis. These include azaleic acid, tranexamic acid, kojic acid, mequinal, and resorcinol.

Several cosmeceuticals companies have formulated their own lightening and pigment correcting creams.

Chemical Peels

Chemical peels are probably a bad idea for melasma. Melasma is propagated by inflammation. Chemical peels produce more inflammation. Very strong concentrations of acid are not recommended. Melasma should only be treated with a low strength chemical peel. Some dermatologists specialize in treating melasma and can offer peels indicated specifically for melasma. If your current dermatologist doesn’t offer this service, ask for a good recommendation.

Intense Pulsed Light and Laser:

Intense pulsed light and lasers are a bad idea if they are high intensity and high energy. IPL and lasers are not good for melasma because they’re commonly associated with post-inflammatory pigmentary changes. In people who suffer from melasma, this means it can get worse. If your dermatologist thinks you should try laser treatments, make sure he or she knows what they’re doing in terms of settings on the machine. The Fraxel laser can be used to treat melasma in women with light skin color (Fitzpatrick types 1 and 2).

Will my melasma ever be cured?

Unfortunately, the answer is probably not. Melasma is stealthy and recurrent. It is not an easily treated skin condition. Melasma will likely relapse if you are not always vigilant about sun exposure. Even walking to your car in the sun is enough to trigger melasma once you’ve achieved remission.

The good news is that melasma is completely benign. With the diligent use of a hydroquinone/corticosteroid/retinoid cream and sun avoidance, many people achieve partial or complete remission of their melasma. Don’t give up because you don’t see results overnight. It can easily take 8 weeks to see results. You need constant use of the lightening cream and sun avoidance to achieve remission.

Have more questions about melasma? Ask in the comments below.

References

  1. Sarkar R, Arora P, Garg VK, Sonthalia S, Gokhale N. Melasma update. Indian Dermatol Online J. 2014;5(4):426-35.
  2. Wong RC, Ellis CN. Physiologic skin changes in pregnancy. J Am Acad Dermatol 1984;10:929-40.
  3. Ortonne JP, Arellano I, Berneburg M, Cestari T, Chan H, Grimes P, et al. A global survey of the role of ultraviolet radiation and hormonal influences in the development of melasma. J Eur Acad Dermatol Venereol 2009;23:1254-62.

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