What is melasma?
Melasma is characterized by hyperpigmentation (patches of skin becoming darker than surrounding skin). It is a skin condition that occurs due to hypermelanosis (i.e., excess production of melanin which results in dark coloration of skin). Melasma commonly affects sun-exposed areas of the skin, such as the face. Occasionally, it may affect the neck and forearms. Melasma is commonly seen in people with darker skin. It commonly affects more women than men, especially between the age of 20 and 30 years.
Melasma is characterized by light to dark brown hyperpigmentation with irregular borders. The hyperpigmented patches may range in number from one single patch to multiple patches located on the forehead, cheeks, nose, upper lip, chin, etc. These patches often fade in winter and can get worse during summer. Based on the distribution pattern of the patches, melasma is classified as centrofacial (central part of the face), malar (cheekbone), and mandibular (jawbone) (see Figure 1).
Alt text: Classification of melasma pattern
Types of melasma
1. Epidermal melasma – Light brown in coloration
2. Dermal melasma – Brown or bluish-grey by visible light
3. Mixed melasma – Dark-brown
4. Indeterminate or inapparent melasma – Found in individuals with dark-brown skin.
What causes melasma?
Several factors increase the risk of developing melasma. Genetic and hormonal factors and exposure to UV radiation are major factors causing melasma.
Ultraviolet (UV) exposure
UV exposure is a major factor in the development of melasma. While UV-induced hyperpigmentation usually recovers spontaneously, melasma does not! UV rays can stimulate the process of pigmentation. In addition to UV radiation, visible light may initiate and worsen melasma by inducing skin hyperpigmentation in individuals with darker skin types.
Increased or decreased levels of estrogen and/or progesterone, those induced by oral contraceptive pills or during pregnancy, are the major causative factors. Being the most common feature of pregnancy, melasma is also called a “mask of pregnancy”. During pregnancy, certain changes in the woman’s body prompt some changes in the skin, making them prone to develop melasma. Women undergoing hormonal therapy to prevent osteoporosis are also at risk of developing melasma.
Sun exposure and hormonal stimuli with certain genetic factors can lead to the development of melasma.
Other than the most common causes mentioned above, ingredients in cosmetics, some drugs, certain disorders (i.e., ovarian or thyroid dysfunction), liver abnormalities and nutritional deficiency can also cause melasma. Interestingly, one-third of cases of melasma in women are due to unknown causes!
Know if you are at risk of developing melasma
The following are some of the risk factors for developing melasma:
Family history of melasma
Women aged 20–40 years
Have a medium to dark skin tone
Frequently exposed to the sun.
How can you recognize melasma?
Though this condition is quite noticeable, it does not cause itchiness or pain. Melasma usually causes patches and spots that can look like freckles. The color of the patches varies with a person’s skin tone and the severity of the melasma. Melasma patches are slightly darker than your natural skin color.
Signs and symptoms of melasma
Patches and spots that are darker than your natural skin color
Patches that develop on both sides of your face
Unevenly shaped patches may join together, creating one or more large areas of melasma.
How different is melasma from other hyperpigmentary disorders?
Irrespective of age and gender, 80% of the Indian population has skin color variation on the face. This variation mainly results from hyper-pigmented spots, melasma, dark circles, etc. Melasma, postinflammatory hyperpigmentation (PIH), and actinic lentigines (flat brown patches/ sun spots) are the most commonly occurring hyperpigmentary disorders in the Indian population.
Postinflammatory hyperpigmentation (PIH)
Actinic lentigines (flat brown patches/ sun spots)
Brown to grayish-brown patches on the face
Distribution of the eruption
Light brown to dark brown, spots, even-colored or reticulated patches
Mainly in women (20–30 years of age)
Men and women (decrease with age)
Women aged >50 years
Exposure to UV, increased estrogen levels (during pregnancy or use of oral contraceptives), genetic and phototoxic drugs
A result of an inflammatory reaction, induced by various skin disorders (acne vulgaris, atopic dermatitis, psoriasis, impetigo and allergic contact dermatitis, etc.)
Treatments available for melasma
Melasma, though not a harmful condition, may negatively affect your psychological and emotional well-being if not treated. It may affect your social life, emotional well-being, and physical health. Therefore it is important to treat this condition.
Melasma treatment aims to eliminate already existing pigmentation and block new pigmentation. The treatment options mainly depend on the type of melasma, the effectiveness of prior treatments, and the expectations of the patient.
The objectives of melasma therapy include protection from sunlight and depigmentation.
Protection from sunlight
The use of sunscreens remains an important aspect throughout the treatment and post-treatment to prevent hyperpigmentation and worsening of melasma. You may require a broad-spectrum sunscreen that covers UV-A, UV-B and visible light (VL), with a sun protection factor (SPF) of at least 30 such as a DermDoc sunscreen.
Melanocytes (cells generating melanin pigment that are responsible for skin coloration) in melasma are easily stimulated not only by UV-B but also by UV-A and visible radiation. To maintain good treatment results and prevent recurrences, it is important to consider major lifestyle changes. Sunscreens are crucial for sun protection; therefore, the use of mineral sunscreens containing titanium dioxide or zinc oxide, with a sun protection factor (SPF) of 30 or higher, is recommended.
Indian dermatologists strongly believe that "sunscreens should be used by all melasma patients, as it effectively reduces pigmentation following sun exposure"
Hydroquinone (HQ) is a depigmenting agent that limits melanin synthesis. It is often used as 2–4% in monotherapy. A concentration of more than 5% may cause more irritation and worsening of hyperpigmentation if used for a longer time.
Azelaic acid (AA) helps reduce the growth of melanocytes that generate melanin pigment. It does not affect the normally pigmented skin.
Kojic acid (KA) has antioxidant and photoprotective properties. Kojic acid is used in a concentration of 1–4%. Combination with 2% HQ may offer the highest possible benefit from Kojic acid.
Ascorbic acid (vitamin C) helps reduce the growth of melanocytes that generate melanin pigment. It has antioxidant effects and photo-protective properties that protect skin from hyperpigmentation.
Niacinamide: An active form of Vitamin B3 that reduces pigmentation by inhibiting the transfer of melanosomes to keratinocytes.
Topical retinoids stimulate cell turnover and promote rapid loss of melanin. It promotes the penetration of depigmenting agents in the epidermis, leading to increased depigmentation. Tretinoin used at 0.05–0.1% concentrations, applied once nightly, can be effective as monotherapy.
Topical corticosteroids reduce pigmentation by decreasing the epidermal turnover and its anti‑metabolic effect on melanocytes.
As many of the above-listed components may have adverse effects, the use of sunscreen is a suitable treatment to protect your skin from melasma. Also, darker skin types can be highly sensitive to certain agents like HQ.
In fact, in the opinion of expert dermatologists, "the use of broad-spectrum sunscreen during and post-treatment is compulsory, along with protective clothing and hats."
DermDoc’s UVA & UVB Broad Spectrum Sun Protection Gel Cream with SPF 50 & PA+++ protects against harmful sun rays by blocking 98% of UV rays! It works by blocking the absorption of the sun's damaging rays that cause sunburn and premature skin aging. It gets absorbed easily and takes care of your skin for a longer period. Compared to other sunscreens, this broad-spectrum sunscreen protects the skin from both UV-A and UV-B rays.
As currently there is no universally effective treatment for melasma, the use of sunscreens along with topical medications that reduce pigmentation is the mainstay of treatment.
Things to remember when you are on treatment for melasma
Avoid sunbathing, as even a few minutes of sunbathing can reverse the benefits of months of therapy.
When using sunscreen, it needs to be applied liberally (teaspoon rule) and repeatedly throughout the day every 2–3 hours.
The use of sunscreen is recommended even if you stay indoors, as infrared light can also aggravate melasma.
Now that you know the easiest way to protect your skin, keep melasma away with a broad-spectrum sunscreen protector such as DermDoc’s UVA & UVB Broad Spectrum Sun Protection Gel Cream with SPF 50 & PA+++!