Melasma: Diagnosis, Prevention, and Treatment


Melasma is a skin condition presenting as brown patches on the face of adults. The most common sites of involvement are the cheeks, bridge of nose, forehead, and upper lip.

Who Gets Melasma?   
Melasma mostly occurs in women. Only 10% of those affected are men. Dark-skinned races, particularly Hispanics, Asians, Indians, people from the Middle East, and Northern Africa, tend to develop melasma more than others.

What Causes Melasma?
   The precise cause of melasma is unknown. People with a family history of melasma are more likely to develop melasma themselves. A change in hormonal status may trigger melasma. It is commonly associated with pregnancy and called chloasma, or the “mask of pregnancy.” Birth control pills appear to increase the risk of melasma, however, hormone replacement therapy used after menopause has not been shown to cause the condition.

Sun exposure certainly contributes to melasma. Ultraviolet light from the sun can stimulate pigment-producing cells, or melanocytes in the skin. People with skin of color have more active melanocytes than those with light skin. These melanocytes produce a large amount of pigment under normal conditions, but this production increases even further when stimulated by light exposure or an increase in hormone levels. Incidental exposure to the sun is mainly the reason for recurrences of melasma.

Any irritation of the skin may cause an increase in pigmentation in dark-skinned individuals, which may also worsen melasma. Melasma is not associated with any internal diseases or organ malfunction.

How is Melasma Treated?
While there is no cure for melasma, many treatments have been developed. While melasma may disappear after pregnancy or discontinuing an oral contraceptive, it may remain for many years, or a lifetime.

Sunscreens are essential in the treatment of melasma. They should be broad spectrum, protecting against both UVA and UVB rays from the sun. A SPF 30 or higher should be selected, with medical grade quality being preferred. In addition, physical sunblock lotions and creams such as zinc oxide and titanium oxide, may be used to block ultraviolet radiation and visible light. Sunscreens should be worn daily, whether or not it is sunny outside and should be reapplied every 3 hours when out and about. A significant amount of ultraviolet rays is received while walking down the street, driving in cars, and sitting next to windows.

Any facial cleansers, creams, or make-up that irritates the skin should be stopped, as this may worsen the melasma. If melasma develops after starting birth control pills, it may improve after discontinuing them. Melasma can be treated with bleaching creams while continuing birth control pills.

Selecting Obagi Hydroquinone + Vitamin C, Obagi Nu-Derm or the SkinMedica Lytera kit for the treatment of melasma provide quicker and more productive results than bleaching creams sold over the counter. These creams do not “bleach” the skin by destroying the melanocytes, but rather, decrease the activity of these pigment-producing cells. Over-the-counter creams contain low concentrations (2-4%) of hydroquinone, the most commonly-used depigmenting agent. This is often effective for early or very mild forms of melasma when used once or twice daily. A dermatologist may prescribe creams with higher concentrations of hydroquinone. Normally, it takes about three months to substantially improve melasma, although improvement may be seen in as little as 2-4 weeks.
Creams containing tretinoin (Vitamin A acid), steroids, and glycolic acid are available in combination with hydroquinone to enhance the depigmenting effect. Other topical medications that have been found to improve melasma include: vitamin C, azelaic acid and kojic acid. It is important to follow the directions of your dermatologist carefully in order to get the maximum benefit from your treatment regimen and to avoid irritation and other side effects. Remember, a high quality sunscreen with high SPF should be applied and reapplied daily in addition to the bleaching cream. The Obagi system is a particularly effective home treatment for melasma available at medical offices.

Chemical peels, microdermabrasion, and occasionally lasers may help melasma. These procedures have the potential of causing irritation, which can sometimes worsen melasma and so they should only be used by a dermatologist or an experienced medical esthetician in conjunction with a proper regimen of bleaching creams tailored to your skin type. People should be cautioned against non-physicians claiming to treat melasma without supervision because complications can occur.

Management of melasma requires a comprehensive and professional approach by your dermatologist.  The best expert to manage your melasma is a dermatologist, so make sure you're receiving the best care possible. Avoidance of sun and irritants, use of sunscreens, application of depigmenting agents, and close supervision by your dermatologist can lead to a successful outcome.

Article by
Toronto Dermatologic Surgeon