Melasma

Symptoms Of Melasma 

The classical symptom of melasma is the appearance of brown to gray-brown patches primarily on the face. The expression of the patches are predominant in the areas that are exposed to sun. It includes organs such as cheeks, upper lip, chin, and forehead. 

In rare cases, melasma occurs on the jawline, neck, arms, or any other organ. The color of the patches vary depending upon the skin tone of the individual and the severity of the condition. Sometimes, the patches look bluish-gray in darker-skinned individuals. 

There are three patterns in which melasma can be distributed:

• Centrofacial: It is the most common pattern of melasma. The patches are distributed over the cheeks, nose, forehead, upper lip, and chin. 

• Malar: This pattern involves the cheeks and nose.

• Mandibular: It involves the jaw. 

Characteristics of patches 

There are several conditions that can cause patches on the skin. The specific characteristic of melasma include:

• The color of the patches and spots are darker than the natural skin color.

• The patches develop on both sides of the face.

• The size of the patch is large due to the joining of the small unevenly shaped patches.

• The patches are more visible in sunlight.

• The patches are neither itchy nor painful.

Types Of Melasma 

Melasma can be divided into three categories based on the layer of skin involved. 

1. Epidermal melasma

In this, the patches are formed in the uppermost layer of the skin known as the epidermis. The patches are usually of dark brown color with a well-defined border. Epidermal melasma has a good response to the treatment. 

2. Dermal melasma

It is characterized by the presence of light brown to blue-gray patches that extend to the second deeper layer of the skin – the dermis. The border of the patches is usually disoriented. Dermal melasma shows a poor recovery even after the treatment. 

3. Mixed melasma

It is the most common type of melasma. It is characterized by a combination of blue-gray, light brown, and dark brown patches in both the dermis and epidermis. Treatment usually shows a partial improvement in such type of melasma. 

Causes Of Melasma 

Melasma is a hyperpigmentation disorder in which there is an overproduction of a pigment called melanin which is responsible for skin color. Increased melanin gets deposited in the layers of the skin and forms patches. The exact cause of melasma is complex, however, these structural and functional changes in the skin can be triggered by various risk factors discussed in the next section.

Risk Factors For Melasma 

Melasma is triggered by various modifiable and non-modifiable factors discussed below. 

I. Sunlight exposure

Exposure to the sun is the biggest risk factor for melasma. Sunrays contain UV radiations which triggers the body to produce more melanin. The areas exposed to sun such as face, neck, and arms are more prone to melasma. 

II. Skin tone

Individuals with darker skin tones are more likely to develop melasma due to more melanin-producing cells. 

III. Race

Some races are more prone to develop melasma. These include Latin, Asian, Black, or Native American heritage.

IV. Family history

Melasma tends to run in families. Studies suggest that in 40% cases of melasma individuals, there is one close relative affected with this condition. 

V. Gender

Women between the age of 20 to 40 are more susceptible to melasma. 

VI. Pregnancy

Studies suggest that the chances of developing melasma in pregnancy is as high as 15 to 50%. This happens due to hormonal fluctuations. The risk is even higher during the third trimester of pregnancy due increase in the level of estrogen, progesterone, and melanocyte-stimulating hormone during that phase. The patches usually disappear on their own after delivery. If the melasma continues postpartum, it predisposes the women to premenstrual hyperpigmentation. 

VII. Medications

Certain medications may trigger melasma. These include anti-seizure medications and birth control pills. Certain antibiotics, antihypertensives, and retinoids also make the skin more sensitive to sunlight and thus increase the risk of melasma. 

VIII. Certain cosmetics

The use of some cosmetics products may trigger melasma formation. It includes products containing chemical substances such as psoralen, tar derivatives, hexachlorophene etc. 

IX. Tanning beds

A tanning bed is a device that emits ultraviolet radiation to give people a tan. These beds produce stronger UV rays even than sunlight. Skin exposed to UV rays triggers the production of melanin. People who use tanning beds frequently have an increased risk of melasma.

X. Medical conditions

People with thyroid disease are at increased risk of developing melasma. 

XI. Stress

Stress has a very strong link in the development of melasma so it is also regarded as a “stress mask”. Stress increases the level of the hormone cortisol which increases melanin production.

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Diagnosis Of Melasma 

There are no laboratory tests for melasma. In most of the cases, diagnosis is based on clinical symptoms. Various steps of diagnosis include:

I. Physical examination

Most of the diagnosis of melasma is made upon physical examination of the skin. The color, texture, and border of the lesion is examined. Melasma is characterized by irregular borders with a “stuck-on” appearance. The color also indicates the type of melasma. 

II. Wood lamp examination

The test uses ultraviolet radiation to look at the skin closely in a dark room. It is used to assess the clinical status of the lesions. The change in brightness of the lesion during examination depicts epidermal melasma. Dermal melasma is characterized by no change in color.

III. Hormonal assays

Some hormonal fluctuations can also cause melasma to develop. Their levels are measured to identify the cause of melasma. The hormones that can be involved in melasma include follicle stimulating hormone (FSH), luteinizing hormone (LH), melanocyte-stimulating hormone (MSH), prolactin, and thyroid hormones.

IV. Electron microscopy

This includes examination of the cells of the lesion under an electron microscope. The high amount of melanin within all the layers of epidermis (topmost layer of skin) and dermis (skin layer below epidermis) indicate melasma. 

V. Dermoscopy

It is a device in which skin lesions are examined using an instrument called dermatoscope. The technique uses a computer screen to capture images of the patches. It helps to analyze the severity of melasma through assessing the deposition level of melanin. 

Specialist To Visit

Melasma does not lead to health complications, however, it affects quality of life by impacting self-esteem. 

Any change in the color of the face should be consulted with the doctor. A doctor consultation is also required to diagnose the exact condition due to its resembling symptoms with several other skin conditions. 

The specialist doctors that can help with this condition include: 

• General physician

• Dermatologist - The doctor who has a specialization in managing and treating skin disorders.

• Gynecologist (in case of pregnancy)

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Prevention Of Melasma 

Melasma has multiple causes and triggers. Most of the triggers of melasma are uncontrollable and cannot be avoided. However, preventing the exposure of sun can play a role in preventing the disease. 

The following measures can be taken to prevent exposure of the sun:

I. Spend less time in sun

Exposure to the sun should be restricted to prevent melasma. The person should avoid going outdoors when the sun is at its peak, which is usually 11 am to 3 pm. 

II. Cover yourself up 

The following measures should be kept in mind while wearing clothes for the best sun protection: 

• Wear lightweight clothing
• Use wide-brimmed hats
• Wear long-sleeved shirts and long pants
• Use clothes made from tight woven fabric
• Use thoroughly dry clothes
• Prefer darker-colored clothes. They prevent more rays overall from reaching your skin. Within the same color, more saturated hues outperform paler ones.

The level of photoprotection offered by clothes can be measured by a factor called ultraviolet protection factor (UPF). It’s similar to SPF (Sun Protection Factor), the rating system used for sunscreens. UPF measures a fabric's effectiveness at filtering both ultraviolet A (UVA) and ultraviolet B (UVB) light. Look for a UPF above 15 and greater for good sun protection.

III. HAT FACTS!

How effective are hats at providing protection from the sun? Did you know that protection from the sun is dependent on the brim width of the hat?

• Brim width of more than 7.5 cm has an SPF of 7 for the nose, 5 for the neck, 3 for the cheeks, and 2 for the chin. 
• Brim width of 2.5 to 7.5 cm has an SPF of 3 for the nose, 2 for the neck and cheek, and 0 for the chin. 
• Brim of less than 2.5 cm has an SPF of 1.5 for the nose and a minimal amount for the chin and neck.

IV. Find shade from the sun 

Staying under an umbrella, tree, or any surface also protects the skin to get exposed to the sun when needed. 

V. Wear sunglasses

Sunglasses not only protect eyes but they also protect the soft skin around the eyes. They should be used while moving out under the sun. 

VI. Use sunscreens diligently

A strict sunscreen regimen is the cornerstone of sun protection. All individuals (older than 6 months) should wear high-quality sunscreen to protect their skin while spending time under the sun. The following points will help you in choosing the right sunscreen as well as the correct method of application:

A. Type of sunscreen 

There are broadly two types of sunscreens:

1. Chemical (organic) sunscreens: These sunscreens contain ingredients that absorb UV radiations and convert them to a very low level of heat.

UV-A filters

• Benzophenones (UVB and UVA2 absorbers) - Oxybenzone, Sulisobenzone, Dioxybenzone
• Avobenzone or Parsol 1789 (UVA1 absorber) 
• Meradimate (UVA2 absorber)

 UV-B filters

• PABA derivatives – Padimate O 
• Cinnamates – Octinoxate, Cinoxate
• Salicylates – Octisalate, Homosalate, Trolamine salicylate 
• Octocrylene
• Ensulizole

Newer generation broad spectrum (UVA + UVB) filters 

• Ecamsule (Mexoryl SX)
• Sila Triazole (Mexoryl XL)
• Bemotrizinol (Tinosorb S)
• Bisoctrizole (Tinosorb M)

2. Physical (inorganic) sunscreens: These sunscreens function by reflecting, scattering or absorbing UV radiation. Their opaque nature gives a “whitening effect” which is an inherent disadvantage. However, this demerit can be minimized by the use of microfine particles. Examples include:

• Zinc oxide
• Titanium oxide
• Iron oxide
• Calamine
• Talc
• Kaolin
  
  

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B. Sun protection factor (SPF): Sunscreens are assigned a sun protection factor (SPF), which is a number that rates how well they filter out UV-B rays. Higher numbers indicate more protection. A broad-spectrum sunscreen that blocks both UV-A and UV-B rays should be used with a SPF 30 or more.

C.Protection factor (PA+): PA stands for protection grade of UV-A. It measures the ability of sunscreen to block UVA rays.This is an important distinction because SPF (sun protection factor) measures only UVB protection while the PA rating only measures UVA protection.

This is what each PA rating means:

• PA+ = Some UVA protection.

• PA++ = Moderate UVA protection.

• PA+++ = High UVA protection.

• PA++++ = Extremely High UVA protection.
  
  

D. Dosage and application: It is commonly seen that the efficacy of sunscreens fails due to insufficient application or less practice of reapplication. According to the Food and Drug Administration (FDA), 2 mg/cm2 of sunscreen should be applied to the exposed skin. It should be allowed to dry completely before sun exposure.

E. Reapplication: Sunscreen should be applied generously to all the areas exposed to sun. It should be applied daily to in order to prevent any skin damage. It should be reapplied after every 2 hours after swimming, vigorous activity, excessive sweating, or toweling.

VII. Will sunscreen application reduce Vitamin D levels?

Sun Rays are responsible for more than 90% of Vitamin D production in the skin. There have been concerns that the use of sunscreens may lead to a reduction in Vitamin D production. However, research suggests that the daily use of sunscreen does not compromise Vitamin D production in healthy individuals. Although, screening for vitamin D status and supplementation are recommended in patients with photosensitivity disorders.

VIII. Avoid sunbath

The cells of the melasma are easily stimulated by ultraviolet B, ultraviolet A, and visible light. Sunbath should be avoided in order to maintain a good skin tone. 

IX. Preventing sun exposure in the employees working under the sun

Workers who work at the sites are more likely to develop melasma. However, the following measures can help prevent the same:

• Sun protection should be provided when possible
• Tents, shelters, and cooling stations should be provided at worksites
• Works schedule that minimize sun exposure should be created
• Breaks in the shade should be given to reapply sunscreen
  
  

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Treatment Of Melasma

The identification of cause and triggers plays a very pivotal role in the type of treatment given to the person. The basic principle of all the treatment options is to reduce melanin in the skin. There are numerous treatment options available for melasma. The choice of treatment depends upon: 

• Type of melasma
• Financial status of the individual
• Response to prior treatments
• Expectations of the patient
• Skin tone
• Severity of melasma

Aim of the treatment

• Eliminate already existing pigmentation
• Block new pigmentation
• Restoring the natural color of the skin
  
  

I.Topical agents

These are the preparations that are directly applied to the affected skin. They are the first-line agents for treating melasma and are mostly available as creams and ointments. 

1. Bleaching agents

These are the preparations that lighten the skin by blocking the production of melanin.

Hydroquinone (HQ) is the most commonly prescribed depigmenting agent worldwide and it has remained the gold standard for the treatment of melasma. 

Note: HQ comes with its own adverse reactions like irritation, redness, stinging, and allergic contact dermatitis, nail discoloration, etc and should only be used under strict medical supervision.

2. Epidermal turnover enhancers

These medications increase the turnover of the outer layer of skin. The pigmented cells of the outer layer get peeled off and the skin replaces them with normally pigmented cells. Examples include

• Retinoids (tretinoin, adapalene and isotretinoin)
• Alpha hydroxy acids like mandelic acid, glycolic acid
• Beta hydroxy acid like salicylic acid 

3. Ingredients that target various pathways of melanin synthesis

Excessive melanin production is responsible for melasma. Some examples of agents that block the various ways of melanin production include:

• Retinoids (tretinoin, adapalene and isotretinoin)
• Arbutin (α or β Arbutin)
• Azelaic acid
• Kojic acid
• Niacinamide (Vit B3)

4. Antioxidants

They work via scavenging the free radicals in the skin. Examples include: 

• Vitamin E (α-Tocoferol acetate)
• Vitamin C (Sodium ascorbyl phosphate, Ascorbyl Palmitate, Ascorbyl Glucoside)

5. Topical steroids

Steroids are used usually due to its anti-inflammatory effect. They are used along with other topical medications. The common examples include Fluocinolone acetonide and Dexamethasone.

6. Combination formulas

Various topical agents can be combined for a better therapeutic effect. In addition to having a synergistic effect, a particular drug may reduce side effects of another drug. For example, topical steroids may reduce the irritant effects of HQ or retinoids. On the other hand, retinoids may prevent steroids induced skin degeneration or atrophy. Some examples of combinations that are available in the market to treat melasma include:

• HQ + Tretinoin + Fluocinolone acetonide
• HQ+ Tretinoin  + Dexamethasone+ Modified Kligman's formula (KF) which is a  triple combination of 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide
• Modified KF + Glycolic acid 
• Kojic Acid + Glycolic Acid 
• HQ  + Glycolic acid
• Azelaic acid + Retinoic acid 

II.Oral agents

Oral agents are used when the individual is not finding any improvement with topical agents. Tranexamic acid is used orally to reduce the patches of melasma. Individuals taking oral medication can use topical creams and sun protection to augment the process.

III.Newer agents

It includes recently researched medications for melasma. They have shown promising evidence in the management of melasma, both alone and in conjunction with other melasma therapies. However more research is warranted for their use. Few examples include: 

• Melatonin
• Glutathione
• Cysteamine
• Methimazole
• Flutamide
  
  

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IV. Device-based therapies

Laser and light-based therapies are usually reserved for resistant cases and are considered as third-line agents in the treatment of melasma. This approach is most effective in light-skinned individuals. Various types of lasers used in the management of melasma include:

• Intense pulsed lights (IPLs)
• Fractional lasers (Er:Glass laser, Er:YAG laser, CO2 laser)
• Ablative lasers
• Q-switched lasers (QSL)
• Picosecond lasers
• Sublative lasers(fractional 1927 nm, thulium fiber laser)
• Other lasers - copper bromide laser
• Various combinations of lasers

V. Platelet-rich plasma therapy (PRP)

In PRP, the patient's blood is drawn and placed into a device called a centrifuge. The centrifuge rapidly spins the blood, separating the other components of the blood from the platelets (a type of blood cells) and concentrating them within the plasma. A small volume of this plasma containing a high concentration of platelets is injected back into the body of the patient.

PRP has shown promise when used in combination or alone as a treatment for melasma.

Special considerations- Treatment during pregnancy

Treatment may not be necessary because melasma in pregnancy may be transient and removal of the hormonal trigger after childbirth may result in considerable improvement. Moreover, melasma is more resistant to treatment during pregnancy because of the persistent hormonal trigger. Hence, treatment for melasma is mostly deferred until after delivery.

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Home Care For Melasma 

The following home remedies are known to decrease hyperpigmentation associated with melasma. However, they should be tried only after consent from the doctor.

1. Turmeric (Haldi): Studies have shown reduction in the appearance of facial hyperpigmentation, fine lines and wrinkles after applying topical extract of turmeric. 

It can also be mixed with milk and applied directly on the skin. 

2. Aloe-vera: Aloe vera contains an ingredient called aloesin which is known to reduce the synthesis of melanin. Apart from this, the highly moisturizing effect of the aloe vera prevents dryness and irritation as well. 

3. Licorice (Mulethi): The compound liquiritin possesses properties that help in reducing pigmentation associated with melasma. It is shown to reduce inflammation and UV-B-induced pigmentation. The powder of mulethi can be mixed with water to make a face pack.

4. Green tea: Green tea is known for its antioxidant and anti-inflammatory properties. Studies have shown its effect in treating melasma also. Apply the wet green tea bags to the pigmented areas of the skin, and massage in gentle circular motions until the tea is absorbed. You can also mix it with some water to make a face pack.

5. Soyabean: The application of soy extract has been shown to reduce the pigmentation of melasma. 

6. Red lentils (Masoor daal): The face mask made of red lentils can be used in skin pigmentation. It can be applied as a paste by mixing the grinded paste of soaked lentils with water or milk. 

7. Mulberry (Shahtoot) leaves: The extract of mulberry leaves is known to be used traditionally for the management and prevention of diabetes. Recent studies suggest its role in melasma as it helps in reducing the synthesis of melanin. 

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8. Tomato: It contains lycopene which is a potent antioxidant that neutralizes free radicals. It helps in preventing the redness caused by UV radiation. It also reduces the damaging effect of UV light and protects the skin from sunburn and thus melasma.  

The tomato pulp can be applied directly on the face or as a paste mixed with olive oil. 

9. Cucumber (Kheera): The extract of cucumber has strong moisturizing abilities. It is known for its ability to remove dead skin cells. Recent studies have also shown its effect on protecting the skin from sun exposure. It can be simply applied on the affected areas as a grated piece.

10. Indian beech tree: Studies have shown that the extract of leaves of the Indian beech tree have a potential sunscreen activity with good absorbance of UV rays. 

11. Almond (Badam): Topical application of almond extract has significant photoprotective activity. Soak almonds overnight. Peel them and make a paste with water or honey to make a facepack.

12. Saffron (Kesar): The dried pollen of the saffron plant can be used to protect the skin from sun. Take water in a bowl and sprinkle a few strands of saffron in it. Add 2 tablespoons of turmeric powder and make a paste. The paste can be directly applied on the affected skin. 

13. Jojoba oil: This oil is known for its effect in treating skin conditions such as eczema, psoriasis and dry skin. It also contains a chemical called myristic acid which provides sun protection. 

14. Carrot seed oil: This oil possesses significant antioxidant, antiseptic, and antifungal properties. It provides natural sun protection when applied topically to the skin.

Complications Of Melasma 

Melasma does not lead to any complications but it has a huge impact on the emotional health of the individual. Individuals often feel conscious or distressed about their appearance. Self-image and self-esteem may suffer as a result of this condition. 

Note: There is a tool known as The Melasma Quality of Life Scale (MelasQOL) that is designed to provide quantification of melasma’s impact on a patient's quality of life.

Alternative Therapies For Melasma 

Microneedling (mesotherapy)

It is a technique in which small channels in the skin are created to deliver the drug. This is used to deliver the drug in the layers of the skin. Studies suggest an improvement in melasma when micro-needling is used with topical medications. 

Cosmetic camouflage

It includes the use of concealers and other pigmented cover-ups to even skin complexion. This approach is used as an adjuvant therapy that has been proven to improve psychosocial effects and quality of life.  

Living With Melasma 

I. Seek help from a professional

Melasma should be treated strictly under a medical practitioner. Over-the-counter medications can prove to be ineffective or damaging to the skin. 

II. Protect your skin from the sun every day

Sunrays are the most important trigger for melasma. It is very important to protect the skin from the sun even on cloudy days. Sunscreen should be applied daily irrespective of the weather.  

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III. Apply skincare correctly

Individuals with melasma should apply skincare and make-up in the right order. The recommended order that the dermatologist recommends includes first the application of topical medication followed by sunscreen and camouflage make up. 

IV. Establish a good face-cleansing regimen

Individuals having melasma should follow a good cleansing regimen since dirty skin is prone to melasma. Pollution can contribute to melasma by corroding the protective surface of the skin. The corroded skin is more susceptible to sun damage. Patients should clean their skin regularly with a gentle cleanser before going to bed. The skin cleansing regimen should also be followed after coming home from the outside.

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V. Combat skin stress with antioxidants

Antioxidant serums containing Vitamin C and E help in healing the damage from sunlight. Individuals with melasma should apply these serums to protect the skin from photodamage. 

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VI. Moisturize your skin regularly

Dry skin is more prone to sun damage. So, use a good moisturizer after applying serum to restore the lipid barrier of the skin. 

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VII. Avoid waxing

Waxing the skin area having melasma should be avoided as it may cause skin inflammation and aggravation of hyperpigmentation

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VIII. Managing the emotions

Melasma impacts emotional well-being due to the presence of prominent facial lesions. Counseling focusing on the duration of treatment is proven to be helpful for emotional stability. The condition can be frustrating to both the patient and the doctor because of its slow response to treatment and recurrence. Studies revealed that melasma affects quality of life (QoL) negatively. QoL includes physical, mental, and social well-being of an individual. Many people affected emotionally may spend a lot on medical and cosmetic treatments without satisfactory results. 

The following measures might help: 

• Engage yourself in activities you like such as crafting, painting, and singing
• Do regular exercise as it helps in reducing stress
• Join any support group either online or offline
• Ask help from a professional counselor
• Meet someone who is undergoing the same type of treatment
• Be patient. Even with treatment, it may take months for melasma to clear up. 
• Be diligent. Melasma will be quick to return if you're not careful about sun protection. So, long-term maintenance requires an ongoing commitment to protecting your skin.