Dr. Mir Shahnawaz (MBBS, MD)
Melasma is an acquired skin condition characterized by development of symmetrical light to dark brown areas on the face and occasionally on the neck and forearms.
The name melasma is derived from the Greek word “melas” meaning black, which refers to its brownish clinical presentation.
The prevalence of melasma is high in individuals of Asian, Latin American, and communities with Hispanic origin. Melasma affect females much more commonly than males and majority of patients are in their third and fourth decades of life.
For a patient, melasma is a cosmetic problem with severity ranging from mild pigmentation to severe disfiguring hyper melanosis which may have a considerable impact on the quality of life. For a dermatologist, the biggest concern is its therapeutic difficulty. Therefore, it is essential to understand the causes of melasma and the way it progresses.
Multiple factors have been incriminated in the causation of melasma which includes genetic factors, solar radiation, hormonal factors, drugs, and others.
Role of Genetics
Many studies have suggested that melasma has a genetic predisposition. Overexpression of some genes can exacerbate melasma while under expression of others may offer protection against this disorder.
(a) Role of sun-exposure: Exposure to sunlight (UV radiation) is undoubtedly the most important factor that can stimulate increased production of melanin. It is pertinent to note that it has now been established that ‘Visible light” can also induce pigmentation on the skin which is more intense and stable compared to UV-A. This underscores the importance of Iron-oxide containing sunscreens that protect against visible light.
(b) Role of Estrogen hormone: The occurrence of melasma has been seen to be higher in ‘high estrogen states’ like:
• Pregnancy
• Women on Oral Contraceptive Pills
• Women on Hormone Replacement Therapy
• Men using estrogen derivatives in the treatment of Prostate Cancer
(c) Role of Drugs: Drugs like Phenytoin, Oral Contraceptive Pills and certain anti-psychotics, anti-depressants have been reported to exacerbate facial hyperpigmentation.
(d) Role of Pollution:The incidence of melasma is high in geographic areas with heavy pollution.
Clinical Patterns of Melasma
i. Centro-facial pattern: It is the most common pattern affecting majority of the cases. It affects the forehead, nose, and upper lip, excluding the philtrum, cheeks, and chin.
ii. Malar pattern: It is restricted to the cheeks on the face.
iii. Mandibular pattern: It involves only the jawline and chin. It is thought to occur in older individuals and may be more related to severe photo damage.
iv. Extra-facial Pattern: It is recently recognized pattern can occur on non-facial body parts, including the neck, sternum, forearms, and upper extremities.
How to manage Melasma?
Treatments for melasma include topical, oral, procedural, and combination treatments, apart from observing photoprotection.
(A) Observe sun protection
• Avoid staying in sun for long hours.
• Use broad-brimmed hats and sun-glasses while outdoors.
• Use a broad-spectrum sunscreen twice /thrice daily (SPF>30).
An ideal sunscreen should have been a combination of physical & chemical sunscreens, besides being photostable, non-irritant, non-comedogenic, water-resistant and cosmetically elegant.
(B) Topical Ointments / Creams
• Various topical formulations containing arbutin, kojic acid, tranexamic acid, glycolic acid, azelaic acid and Silymarin can be used.
• Triple combination creams containing hydroquinone, retinoid and less potent steroid should be restricted only for initial 4-6 weeks. Prolonged application of over-the-counter steroid-based creams must be avoided as it may lead of skin atrophy, facial hair growth and telangiectasias.
• Vitamin C, Niacinamide and retinol serums can be helpful during maintenance therapy of melasma.
(C) Oral medications
Certain oral medications like tranexamic acid, glutathione, astaxanthin help in downregulating melanogenesis and have a beneficial role in managing melasma.
(D) Chemical Peels
• Epidermal melasma responds better to peels than dermal melasma. It should preferably be restricted to lighter coloured skins only, because in dark coloured, there remains a risk of post-Inflammatory hyperpigmentation.
(E) Mesotherapy
In Mesotherapy, a micro needling device is used to create small channels in the skin to deliver small amounts of topical drugs intradermally. The skin punctures induced by micro needling can also stimulate a beneficial wound-healing response with fewer side effects compared to conventional resurfacing procedures. This technique may result in a deeper and more even placement of the medication to the epidermis and dermis and subsequently result in better clearance of pigmentation.
(F) Lasers and light-based therapy
• Lasers should not be the first line therapy because of unpredictable response, frequent relapses despite initial improvement and risk of post-inflammatory hyper and hypopigmentation.
• A combination of pulsed CO 2 laser (to remove superficial pigment) and Q-switched alexandrite laser (to remove deeper pigment) gives better results than either laser used alone.
• Laser Toning or Laser Facial: Nowadays, technique called “laser toning” or “laser facial” has become increasingly popular for the treatment of melasma.
Takeaways
a) Establish a good cleansing regimen to thoroughly remove the pollutant particulate matter
b) Moisturize your skin regularly
c) Combat Skin stress with anti-oxidants like vitamin C and vitamin E
d) A big NO to over-the-counter Fairness creams
e) Prefer medicated sunscreens over cosmetic ones
f) Avoid facewashes /cleansers that are irritant
g) Use minimal make-up and avoid unnecessary bleaching creams
h) Be patient. Even with treatment, it may take months for melasma to clear up. There’s no overnight fix.
Melasma remains a chronic, therapeutically challenging, and universally relapsing condition. This psychologically devastating disorder should be treated with a multimodality approach that incorporates photoprotective agents, antioxidant treatments, skin lighteners, exfoliants, and resurfacing procedures in severe cases. A myriad of new oral, topical, and combination therapies for melasma have been introduced to expand our repertoire of therapies, and warrant additional trials to substantiate their efficacy and safety.
