Melasma – Management and Interventions Guide

Irregular, patchy darkening of the skin is called Melasma. It can affect the quality of life while the patch itself is rather safe. 

The usual presentation is brown to grey-ish brown inconsistent skin pigmentation on the forehead, nose, and the bridge of the nose, cheeks, chin, and above the upper lip areas. It may also appear in non-facial areas in the body that are exposed to sunlight, such as the forearms and neck.

These patches are similar to freckles and aging spots but unfocused and spread out. It commonly occurs in females of age group 20-30 years.

Facts about melasma:

• Melasma does not cause any pain or physical symptoms, but it is a big reason for mental distress and psychological unease in many.
• Up to 90% of the cases are women; particularly pregnant women are the most prone to this pigmentation secondary to the hormonal changes. Accordingly, it is sometimes referred to as the mask of pregnancy.
• The non-facial involvement is seen more in post-menopausal women.
• Men constitute less than 20% of the cases. Research suggests that low testosterone levels may be an important factor for melasma in men.
• Furthermore, people with darker skin tones are more likely to develop this condition due to the preceding abundance of melanocytes.
• Melasma is speculated to have a genetic factor that means it runs in the family.

The science behind melasma:

The human skin is made up of multiple layers to protect the body from the external environment. One kind of cell in these layers is called a melanocyte. These cells produce the pigment melanin that gives us distinctive skin colors.

Melasma appears when melanocytes produce melanin excessively and erratically. This can happen in response to exposure to the sun, visible light and heat, hormonal changes as in pregnancy, birth control pills or hormone replacement therapy, or by use of any irritant skincare product.

Management outline:

Treating melasma is a gradual and enduring process; the pigmentation is correctable to a great extent but the response to therapies can be fairly slow.

To start with, management involves a combination of preventive and treatment measures. Treating only the skin condition could be fruitless if we were to ignore the triggers that are causing the condition in the first place.

In cases where the trigger is removable, the melasma can fade away on its own following the removal of the triggering agent. An example of this is seen in women taking hormonal medicines where the melasma fades after discontinuing the medication. However, its persistence or slow fading can make the person bothered and seek a cure.

Preventing triggers:

The most important aspect of prevention is to block sun exposure. In reality, this may not be quite possible per se. Sunscreens, hats, and outerwear accessories are recommended to cover the exposed body parts.

Similarly, irritant skin care products should be avoided to further aggravate the condition. Doctors may be consulted for the continuity or replacement of the triggering medicines, where possible.

Medical options:

1. Topical medicines:

Several topical medicines are available for application in the form of creams, ointments, and gels. These medications include tretinoin, corticosteroids, and bleaching agents, such as hydroquinone, glycolic acid, kojic acid, azelaic acid, and salicylic acid. Research shows that instead of a single medicine, using a combination of two or three topical options gives better results.

The most commonly used combinations include hydroquinone, tretinoin, and glycolic acid. A possible side effect of these skin-lightening agents is temporary skin irritation. In persons suffering from Ochronosis, the bleaching agent can have an opposite result; darkening of the skin.

2. Oral medicines:

Though still under scrutiny, newer oral drugs are being developed as additional treatments for melasma. Tranexamic acid blocks the process of melanin production, thus acting as an oral skin-lightening agent. While Polypodiumleucotomos, melatonin, and glutathione are naturally occurring agents being used as an adjunct to other medicines.

3. Procedural treatments:

Medical procedures may be undertaken when melasma is resistant to conservative methods. Dermatologists perform these procedures in a controlled environment and each procedure is individualized keeping in view the patient’s need and skin type.

The procedures available include chemical peel, microdermabrasion, micro-needling, laser treatment, and light-based therapy. These are associated with both short- and long-term complications, especially in the darker skins. The possible side effects include skin burning and irritation, and darkening of the skin. For such risks, topical agents are used alongside the procedures. 

Higher concentrations of glycolic acid, salicylic acid, and hydroquinone are applied in chemical peels. This results in an intensified exfoliation-like effect with peeling the topmost layer of skin.

Microneedling and microdermabrasion involve creating small channels in the skin to deposit topical drugs into the deeper skin layers. This is usually done in sessions and this also implicates exfoliation of skin layers.

Laser and light-based therapies provide variable results in melasma treatment. they are opted either alone or in conjunction with each other. Lasers use thermal energy to target melanocytes while light-based therapy uses intense pulsed light. A type of laser called non-ablative laser is said to have better skin tolerance and lesser post-procedure pigmentation.

For an even skin tone:

Melasma can cause mental stress and may negatively impact a person’s self-esteem. Steps to even out the skin tone can help avoid this distress and help the person gain back their confidence. These steps involve:

1. Maintain a good skin cleansing routine and moisturize it regularly
2. Wear sunscreen, wide-brimmed hats, and sunglasses shielding the face and body from the triggering effects of sunlight
3. Use soothing and gentle skincare products to prevent irritation and consequently worsening of melasma
4. Use mild hair removal techniques that do not aggravate the underlying condition.

Melasma is a resistant yet treatable cause of undue and patchy skin pigmentation. Treatment is varied and personalized for each patient. It may take weeks and/or sessions to show the effects of treatment. Evading the triggers is as important as the medical management in treating melasma. A nourishing routine and proper protection help build healthy skin.