Melasma Article – By Lisa Jenks, MD
Melasma is a common and often difficult to treat skin problem. It is a condition in which an over production of melanin causes brown or grey-brown patches on the skin. These patches classically present on the forehead, lateral aspects of the cheeks, above the upper lip and on the chin. However, they can appear on other areas of the face as well as on other parts of the body.
Ninety percent of melasma patients are women of childbearing age and it has been reported that approximately 6 million women in the United States have this condition. Melasma often first presents during periods of hormonal change, such as during pregnancy or with the use of birth control pills. Due to its frequent onset during pregnancy, it has been referred to as the “mask of pregnancy”. People with darker skin, such as those with Asian, Mediterranean, Middle Eastern, African or Latin/Hispanic heritage, are more likely to get melasma. Additionally, people with a close relative who has melasma are at a higher risk of also developing it.
The causes of melasma are not completely understood, but it is due to an overproduction of melanin. The human body’s production of pigment is a very complicated process, which is why the reduction of any pigment usually requires a multi-pronged approach. Melanocytes are cells which live in our dermis and which produce melanin, which is pigment. Melanin is bundled up in melanosomes, which move up to the surface of our skin and disperse, which then appear as our coloring or complexion. The biochemical process of making melanin is complex and involves many proteins, enzymes and hormones. An individual’s amount of melanin depends upon many factors, including genetics, sun exposure, prescription drugs, illnesses and hormones. Darker skinned people are probably more prone to melasma because they have more active melanocytes than do lighter skinned people.
Melanin does have many positive functions, including the absorption of UV light, which diminishes the risk of skin cancer and provides protection against photoaging. While the over-production of melanin as seen in melasma does not pose a medical risk, its emotional damage can be high, including lowered self-esteem, decreased social functioning and decreased work productivity. Therefore, it is a condition that we should all be able to address.
First, it is important to differentiate melasma from more typical hyperpigmentation due to sun exposure. When your patient complains of “dark spots”, take the time to study their distribution on the face and to ask the appropriate questions, such as when it started and what their ethnic background is. In addition, ask what makes the “dark spots” worse. Melasma clients usually will report that even small amounts of sun exposure, heat, and harsh products all exacerbate their condition. If you determine that the “dark spots” are melasma, a frank discussion on expectations is important.
Melasma should be considered controllable, but not treatable. There is no “magic wand” that you or anybody else can wave that will make it go away and stay away. This is different than traditional sun spots, which can be treated successfully with (for example) an IPL, after which, if good sun protection is used, they will stay gone. Although a rare person’s melasma will dissipate on its own, since this type of hyperpigmentation’s underlying causes include genetics and hormones, permanent reduction is usually not possible.
Patients should be made to understand that, after their melasma is reduced with treatments, they need to follow strict protocols and, even then, they will likely need repeat treatments in the future.
If your melasma patient is currently on birth control pills, she may want to consider an alternative form of birth control. The hormonal changes induced by oral contraceptives are often a culprit and reducing those can make a significant difference. If she’s pregnant, reassure her that the hyperpigmentation may improve dramatically in the months following her delivery.
It is important for these clients to understand that any sun exposure can increase their hyperpigmentation. A combination of a chemical and physical block sunscreen is best for them, since that gives maximum protection. They should never use a sunscreen that only offers chemical protection, since those still allow absorption of heat and of the sun’s rays. In addition, they need to wear hats, long sleeves and sunglasses. Remind your clients that UV rays can penetrate car and building windows and are still present during winter months.
Heat usually makes melasma worse because heat does increase the activity of melanocytes. In some patients, this means they even need to avoid working over a hot stove. Athletes who work out (even indoors without any sun exposure) may find that their melasma is difficult to control because they are constantly heating themselves with exercise. Helping these clients to identify ways in which they can reduce heat exposure may include having a fan directed onto their faces while cooking or using a cooling bandana that can be purchased at sporting goods stores while exercising.
Stress may also exacerbate melasma. When we are stressed, several hormones (such as adrenocorticotropic hormone) are increased. Some of the same hormones that are released during times of stress also contribute to pigment production. Melasma clients should be made to understand this so that they can hopefully develop methods of controlling stress in their lives.
The first rule of treating these patients is to not use heat. Heat can make melasma worse, so traditional laser procedures are contra-indicated. Currently, there are FDA trials being conducted using laser energy that enters the melanocytes so quickly that heat is not built up and these are showing promise in improving melasma. However, traditional lasers will likely make your patient’s face even darker. This is especially true in darker skin patients, who already have a risk of hyperpigmentation with laser treatments.
Chemical peels can be an effective treatment for these clients. Peels which use hydroquinone, kojic acid and/or azelaic acid can all produce good results. Jessner’s peels and high strength (60 – 70%) glycolic acid peels have been shown to improve melasma. However, it is important to set appropriate expectations with patients. Many times, the increased pigment in melasma is deep in the dermal layer of the skin. Traditional peels are not going to penetrate into the dermis and, therefore, sometimes have limited effects. In most cases, a series of peels is needed.
Skin lightening agents have shown success in improving melasma. Prescription strength hydroquinone (at least 4%), especially in combination with Retin-A and a steroid (triple therapy cream), has been shown in multiple studies to improve melasma. One large study looked at 1260 people with moderate to severe melasma who used a triple therapy cream and found that over 75% showed “complete or nearly complete” reduction in their melasma. Hydroquinone should not be used for longer than 4 months at a time, after which clients can be switched to non-hydroquinone based products. These often contain ingredients such as kojic acid, azelaic acid, Vitamin C, niacinamide and licorice root extract, all of which inhibit the production of melanin.
Some melasma clients have increased sensitivity to harsh ingredients, so start these people on mild products and work up slowly. The triple therapy creams can cause irritation, so clients using that may need additional products with calming, anti-inflammatory ingredients, such as niacinamide, olive leaf extract, and green tea extract.
In summary, melasma is a complex disorder of pigmentation, which can be controlled, but not usually completely eradicated. A multi-pronged approach that includes topical skin lightening products, chemical peels and the proper skin-care home regiment are all usually needed. In addition, helping these clients learn to minimize sun and heat exposure, as well as stress reduction is important. A variety of peels and topicals can interfere with the production of melanin at several different steps in the biochemical cascade, ultimately resulting in nice improvement. Once improvement is seen, a maintenance regiment will likely yield the best long-term effects.