What Is It?
Melasma appears as patchy shades of brown pigmentation on sun-exposed areas of the face. Melasma is more common in females and in darker skin types, and less common in fair or very dark skin. It may occur in any population, but it is more common in those of East Asian, Indian, Pakistani, Middle Eastern and Mediterranean-African, Hispanic-American and Brazillian origin.
What Causes it?
The exact cause of melasma is not known, but three factors contribute to melasma:
Genetic – some people are predisposed to this condition.
Hormonal – oestrogen from the pill or pregnancy stimulates the pigment-producing cells in the skin, resulting in excess pigmentation. Some individuals, despite having no history of pregnancy or being on the pill, have melanocytes which are just sensitive to normal amounts of hormones.
UV light exposure – even brief exposure to UV light can stimulate pigmentation. The regular use of sunscreen is a cornerstone of treating melasma.
How do patients present?
Patients usually give a history of the gradual onset of areas of dark facial skin. The pigmentation usually occurs on the face and is usually bilateral. The colour may vary from tan to brown, but it may be black or even have a blueish tinge. The distribution is usually symmetrical and three patterns are commonly seen – centrofacial, malar or mandibular.
The excess of melanin may be located in the superficial layers of the skin (epidermal melasma), the deeper layers of the skin (dermal melasma) but, more commonly, it is found in both layers of the skin (mixed melasma). The areas of skin most commonly affected are the forehead, cheeks and upper lip.
How is it diagnosed?
Melasma is usually diagnosed after examining the colour and pattern of the pigment. A Woods light (a special light used to assess the skin) may be used to determine the location of the pigment in those with lighter skin.
How is melasma treated?
Melasma is challenging to treat. It can be treated with a combination of various regimes – lasers, chemical peels and topical and systemic medications:
If hormonal factors appear to be causative, the use of the oral contraceptive pill should be discontinued.
Sun protection – strict sun protection is essential using a broad-spectrum sunscreen (SPF50+), with a high percentage of zinc oxide if possible. Sunscreen should be applied at least twice a day, twenty minutes prior to sun exposure. Broad-brimmed hats should also be worn when outdoors.
Cosmetic camouflage – colour-matched make-up may conceal the majority of melasma but this would be limited where the pigmentation is too dark to be successfully covered up.
Topical creams – Hydroquinone lotion (2 – 8%) in either a stand-alone formulation or mixed with other active ingredients is the most widely used method to treat melasma. It inhibits conversion of dopa to melanin and is applied to the affected areas at night for two to four months. It is more effective in combination with other agents, namely Tretinoin and mild steroid cream.
Azelaic acid (20%). This is applied twice daily and may be used long term. It may improve cases of superficial melasma.
Systemic medications – transexamic acid can be used orally. The oral form is now used by many dermatologists, but is not suitable for all patients.
Laser and light-based treatment: should only be used in cases where the abvementioned therapies appear to be refractive. Multiple treatments with laser are usually necessary to see a noticeable improvement. It is important that certain lasers should be used and these should be used with extreme care, under the guidance of a specialist laser dermatologist:-
– Picosecond lasers (Picoway) is currently the most promising laser treatment of melasma. Several treatments are required over many months to see improvements.
– Vascular laser treatment may be to treat melasma if it has a red component.
What is the prognosis for melasma?
Epidermal melasma has a much better prognosis than mixed or dermal melasma, but all types are recurrent and require ongoing maintenance therapy.
Melasma associated with pregnancy has the best chance of improvement, with pigment gradually fading over months. However, melasma often recurs in subsequent pregnancies.
What’s the next step?
If you already have an appointment booked at The Skin Specialist Centre, you can easily add a Melasma treatment consultation to your booking by calling our friendly team on (09) 524 5011. If you have never been to The Skin Specialist Centre, you can either give us a call on (09) 524 5011 or make an enquiry by clicking on the Enquire Now option below.