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Melasma

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  3. Melasma

Overview of Melasma

Melasma also known as (Kalay Dagh / کالےداغ ), commonly forms dark brownish patches on the skin due to hyperpigmentation, particularly on the face.  It can also affect other areas of the body such as:

  • Forearms
  • Neck
  • Shoulders

Another name for melasma is “chloasma” and also called “mask of pregnancy,” (during pregnancy).  The condition is more prevalent in women than in men.

Prevalence of Melasma

 

The American Academy of Dermatology defines that melasma is commonly present in 90% of women and 10% of cases of men worldwide. Generally, it begins from the age of 20 to 40. People with a dark complexion and pregnant women are at high risk of this skin problem.  The prevalence rate varies from region to region, depending upon the population analysis of skin tone or sensitivity of melasma in pregnant women.  In rare cases, melasma may appear in children.

 

Signs and Symptoms of Melasma

The associated signs and symptoms have not been observed in melasma patients. Only the brown or grey-brown patches form on different areas of the face are as follows:

  • Forehead
  • Cheeks
  • Bridge of the nose
  • Around upper lips
  • Chin

Less commonly,  patches appear on forearms, shoulders, or neck areas.

Types of Melasma

The skin consists of two layers, epidermis and dermis. The types of melasma are based on these two skin layers in which the pigmentation pattern is different from each other.

Epidermal Melasma: This type represents the production of excess melanin in the epidermal layer of the skin.  It is characterized by:

  • Well-organized border
  • Dark brown color
  • Appears more clear under the black light of a UV lamp
  • Responds well to treatment

Dermal Melasma: This type is identified as melanophages (cells that ingest melanin) present on the dermis layer. Characteristics of recognition are:

  • The irregular pattern on the border
  • Light brown or bluish
  • Unchanged under black light
  • Responds poorly to treatment

Mixed Melasma: It is the combination of both the epidermal and dermal types, which is characterized by

  • Most common type among both types
  • Combination of bluish, light, and dark brown patches
  • A mixed pattern is seen under black light
  • Partial improvement with treatment

Causes of Melasma

What causes melasma is not clearly known. Generally, females with dark-skinned tones are more prone to this disease as compared to fair-tone females. Especially, people living in Latin/Hispanic, North African, African-American, Asian, Indian, Middle Eastern, or the Mediterranean affect more. However, there is a list of triggers that enhances the melanomas of these people under different conditions such as:  

  • Hormonal changes such as overproduction of estrogen and progesterone
  • Using birth control pills, taking hormone therapy or hormonal changes during pregnancy can enhance melasma
  • In stress conditions and thyroid disease 
  • Skin exposed to the sun because ultraviolet rays affect the melanocytes cells and cause excessive pigmentation
  • By using some skin products that a person may be allergic to them
  • A person can get melasma inheritably
Happniness

Risk Factors of Melasma

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Prevention

Some of the ways that can help to prevent melasma include:

  • Avoid using harsh skincare products including soaps etc
  • Limit direct exposure to sunlight
  • Don’t go for tan baths
  • Always apply sunscreen while staying outdoors
  • Avoid hormone-containing birth control pills
Happniness

Diagnosis

The diagnosis of melasma is rapidly conducted by visual examination of the skin and skin biopsy if required. After visual inspection of the skin through wood light, a dermatologist can recommend a skin biopsy to rule out other skin diseases.

A skin biopsy is performed to scrap a small fragment of skin from affected women and the samples are sent to labs for further analysis. 

Treatment of Melasma | When to Consult a Doctor

Melasma can be treated by various techniques, depending on the condition and cause of a problem.

Applying the natural herbs on the skin may discolor the dark skin patches at home: 

  • Lemon juice
  • Aloe vera gel
  • Apple Cider Vinegar
  • Turmeric
  • Orange juice
  • Oatmeal 
  • Papaya

1. Topical Therapies:

Below are the main topical therapies of melasma that dermatologists usually suggest.

  • Tyrosinase Inhibitors- These are used to block the melanocytes that prevent hyperpigmentation in the skin.
  • Hydroquinone( 2–4%)- It is used in the form of cream or lotion, applied directly on the pigmented areas at night for 2–4 months. Contact dermatitis (stinging and redness) may result in 25% of patients, after hydroquinone usage.

Note: Do not apply hydroquinones in a higher amount or for a longer time. It may cause ochronosis (a bluish-grey discoloration) and other skin problems. So consult with doctors before usage.

  • Azelaic Acid Cream- It is used in lotion or gel form. The cream can be applied twice daily and is safe during pregnancy. Also, it causes a pungent smell after application on the skin. This can be used for the long term.
  • Ascorbic Acid (Vitamin C)- It is a highly unstable and well-tolerated component that is used to block pigment production through copper. 
  • Methimazole (Antithyroid Drug)-It is a useful compound for melanin synthesis reduction and pigmentation those individuals who are hydroquinone-resistant melasma.
  • Topical Corticosteroids- These are beneficial for pigment discoloration and reduce the contact dermatitis that is usually associated with other agents such as hydrocortisone.
  • Soybean Extract- It blocks the melanocyte receptors. This eventually reduces the transfer of pigment from melanocytes to keratinocytes (skin cells). 
  • Tranexamic Acid- This has been used as a cream or in the form of injections. Allergy or irritation may be caused after application.

If the pigmentation remains superficial or epidermal then it can be peeled off. As tyrosinase inhibitors penetrate the skin, it allows peeling of the skin. So, the below compounds must be handled with care, otherwise, they may cause peeling or stimulate post-inflammatory pigmentation effects. 

  • Topical Alpha Hydroxy Acids- These are used as creams to inhibit tyrosine due to its low ph that causes removal of the superficial skin that includes: Glycolic acid and Lactic acid 
  • Topical Retinoids- Such as tretinoin (a prescription medicine) are effective for peeling skin but difficult to tolerate. It sometimes causes contact dermatitis. Do not use it during pregnancy.

Interestingly, the best treatment of melasma on the face is a combination of hydroquinone, tretinoin, and a moderate-potency topical steroid. This has become the most successful treatment and shows improvement or clearance in patients up to 60–80%. Many other combinations of topical agents are also commonly used but this treatment is much more effective than a single agent. Undoubtedly, All these products are available at an expensive price.

  1. Oral Treatment of Melasma:

Researchers are still experimenting with the new development in oral medications including tranexamic acid. Tranexamic acid is a lysine analog that blocks plasmin. When it is taken orally it helps to prevent bleeding and decreases the prostaglandins (tyrosine precursor)  production. It can be used in a low dose, tranexamic acid has been considered as a safe and effective treatment of melasma. 

This treatment is care provided to the patients with the doctor’s consultation. Tranexamic acid may have less chance of causing thromboembolic disease.  

Another component is that glutathione acts as a skin-whitening agent but has potentially severe adverse effects.

  1. Melasma Laser Therapies: 

The best treatment for melasma on the face is laser therapy that only eliminate the pigment without damaging the skin cells. Unfortunately, this is very difficult to achieve. Various laser devices can be used for the removal of epidermal pigmentation, but have to apply with caution. Over usage of laser treatment may cause postinflammatory pigmentation. Before laser therapies, a dermatologist is treated with tyrosinase inhibitors.

Fractional lasers, picosecond lasers, and intense pulsed light (IPL) are the most suitable choice for therapy. Besides all, several other treatments are combined with these therapies and post-inflammatory hyperpigmentation may complicate recovery.

Dermatologists may also recommend carbon dioxide therapies with the caution that helps to reduce melasma such as: 

  • YAG resurfacing lasers
  • Pigment lasers (Q-switched ruby and Alexandrite devices) 
  • Mechanical dermabrasion 
  • Microdermabrasion

 

 In case you exhibit any concerning signs and symptoms of melasma, consult a medical professional as soon as possible.

 

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