Melasma

The classical symptom of melasma is the appearance of brown to gray-brown patches primarily on the face. The expression of the patches is predominant in areas exposed to the sun, including the cheeks, upper lip, chin, and forehead.

In rare cases, melasma occurs on the jawline, neck, arms, or other areas. The color of the patches varies depending on the individual's skin tone and the severity of the condition. Sometimes, the patches appear bluish-gray in individuals with darker skin tones.

Patterns of Melasma Distribution

• Centrofacial: The most common pattern, with patches distributed over the cheeks, nose, forehead, upper lip, and chin.
• Malar: This pattern involves the cheeks and nose.
• Mandibular: This pattern involves the jaw.

Characteristics of Patches

Several conditions can cause patches on the skin. The specific characteristics of melasma include:

• The color of the patches is darker than the natural skin color.
• The patches develop symmetrically on both sides of the face.
• The size of the patches is large due to the merging of smaller, unevenly shaped patches.
• The patches are more visible in sunlight.
• The patches are neither itchy nor painful.

Melasma is a hyperpigmentation disorder characterized by the overproduction of a pigment called melanin, which is responsible for skin color. Increased melanin gets deposited in the layers of the skin, forming 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.

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

• Sunlight exposure: Exposure to the sun is the biggest risk factor for melasma. Sunrays contain UV radiation, which triggers the body to produce more melanin. The areas exposed to the sun, such as the face, neck, and arms, are more prone to melasma.
• Skin tone: Individuals with darker skin tones are more likely to develop melasma due to a higher number of melanin-producing cells.
• Race: Certain races are more prone to develop melasma, including those of Latin, Asian, Black, or Native American heritage.
• Family history: Melasma tends to run in families. Studies suggest that in 40% of cases, individuals have at least one close relative affected by this condition.
• Gender: Women between the ages of 20 and 40 are more susceptible to melasma.
• Pregnancy: Studies suggest that the chances of developing melasma during pregnancy range from 15% to 50%. This occurs due to hormonal fluctuations, with the risk being higher during the third trimester due to increased levels of estrogen, progesterone, and melanocyte-stimulating hormone. The patches usually disappear on their own after delivery; however, if melasma continues postpartum, it may predispose women to premenstrual hyperpigmentation.
• Medications: Certain medications may trigger melasma, including anti-seizure medications and birth control pills. Some antibiotics, antihypertensives, and retinoids can also increase the skin's sensitivity to sunlight, thereby increasing the risk of melasma.
• Certain cosmetics: The use of some cosmetic products may trigger melasma formation, particularly those containing chemical substances such as psoralen, tar derivatives, and hexachlorophene.
• Tanning beds: Tanning beds emit ultraviolet radiation to give people a tan and produce stronger UV rays than sunlight. Skin exposed to UV rays triggers the production of melanin, and frequent use of tanning beds increases the risk of melasma.
• Medical conditions: Individuals with thyroid disease are at an increased risk of developing melasma.
• Stress: Stress has a strong link to the development of melasma, often referred to as a "stress mask." Increased levels of the hormone cortisol due to stress can elevate melanin production. Long-term stress can adversely affect every system in the body.

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

1. Physical examination: Most diagnoses of melasma are made through physical examination of the skin. The color, texture, and border of the lesion are examined. Melasma is characterized by irregular borders with a "stuck-on" appearance. The color also indicates the type of melasma.
2. Wood lamp examination: This test uses ultraviolet radiation to closely examine the skin in a dark room. It assesses the clinical status of the lesions. A change in brightness of the lesion during examination indicates epidermal melasma, while dermal melasma is characterized by no change in color.
3. Hormonal assays: Some hormonal fluctuations can cause melasma to develop. Hormone levels are measured to identify the cause of melasma. The hormones that may be involved include follicle stimulating hormone (FSH), luteinizing hormone (LH), melanocyte-stimulating hormone (MSH), prolactin, and thyroid hormones.
4. Electron microscopy: This involves examining the cells of the lesion under an electron microscope. A high amount of melanin within all layers of the epidermis (the topmost layer of skin) and dermis (the layer of skin below the epidermis) indicates melasma.
5. Dermoscopy: This technique employs a device called a dermatoscope to examine skin lesions. It uses a computer screen to capture images of the patches, helping to analyze the severity of melasma by assessing the level of melanin deposition.

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

The following measures can be taken to prevent sun exposure:

• Spend less time in the sun: Limit outdoor activities during peak sun hours, typically between 11 am and 3 pm.
• Cover yourself up: Consider the following clothing measures for optimal sun protection:
  • Wear lightweight clothing.
  • Use wide-brimmed hats.
  • Wear long-sleeved shirts and long pants.
  • Choose clothes made from tightly woven fabric.
  • Ensure clothes are thoroughly dry.
  • Prefer darker-colored clothes, as they block more rays than lighter shades. Within the same color, more saturated hues are more effective than paler ones.
  The level of photoprotection offered by clothing is measured by the Ultraviolet Protection Factor (UPF), similar to SPF (Sun Protection Factor) for sunscreens. Look for a UPF of 15 or higher for effective sun protection.
• Hat facts: The effectiveness of hats in providing sun protection is influenced by brim width:
  • 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 cheeks, and 0 for the chin.
  • Brim width of less than 2.5 cm has an SPF of 1.5 for the nose with minimal protection for the chin and neck.
• Find shade from the sun: Utilize umbrellas, trees, or other surfaces to protect your skin from sun exposure when necessary.
• Wear sunglasses: Sunglasses protect not only your eyes but also the delicate skin around them. Always wear them when outdoors in the sun.
• Use sunscreens diligently: A strict sunscreen regimen is essential for sun protection. All individuals over 6 months should use high-quality sunscreen while outdoors. Consider the following when choosing a sunscreen:
  • Type of sunscreen: There are two main categories:
    • Chemical (organic) sunscreens: These absorb UV radiation and convert it to heat. Common ingredients include:
      • Benzophenones (UVB and UVA2 absorbers) - Oxybenzone, Sulisobenzone, Dioxybenzone
      • Avobenzone (UVA1 absorber)
      • Meradimate (UVA2 absorber)
      • PABA derivatives – Padimate O
      • Cinnamates – Octinoxate, Cinoxate
      • Salicylates – Octisalate, Homosalate, Trolamine salicylate
      • Octocrylene
      • Ensulizole
      • Newer generation broad spectrum filters - Ecamsule (Mexoryl SX), Sila Triazole (Mexoryl XL), Bemotrizinol (Tinosorb S), Bisoctrizole (Tinosorb M)
    • Physical (inorganic) sunscreens: These reflect, scatter, or absorb UV radiation. Examples include:
      • Zinc oxide
      • Titanium oxide
      • Iron oxide
      • Calamine
      • Talc
      • Kaolin
  • Sun Protection Factor (SPF): Sunscreens are rated by SPF, indicating their effectiveness in filtering UVB rays. A broad-spectrum sunscreen that blocks both UVA and UVB rays should have an SPF of 30 or higher.
  • Protection factor (PA+): PA measures the ability of sunscreen to block UVA rays, with ratings as follows:
    • PA+ = Some UVA protection
    • PA++ = Moderate UVA protection
    • PA+++ = High UVA protection
    • PA++++ = Extremely high UVA protection
  • Dosage and application: Sunscreen efficacy can be compromised by insufficient application. The FDA recommends applying 2 mg/cm² to exposed skin and allowing it to dry completely before sun exposure.
  • Reapplication: Sunscreen should be applied generously to all sun-exposed areas daily and reapplied every 2 hours, especially after swimming, vigorous activity, excessive sweating, or toweling.
  • Will sunscreen application reduce Vitamin D levels? Although sun rays are responsible for over 90% of Vitamin D production in the skin, research indicates that daily sunscreen use does not significantly reduce Vitamin D production in healthy individuals. However, screening for vitamin D levels and supplementation is advised for patients with photosensitivity disorders.
  • Avoid sunbathing: UVB, UVA, and visible light can easily stimulate melasma cells. Sunbathing should be avoided to maintain an even skin tone.
  • Preventing sun exposure for employees working outdoors: Workers exposed to sunlight are at higher risk for developing melasma. To mitigate this risk, consider the following measures:
    • Provide sun protection when possible.
    • Set up tents, shelters, and cooling stations at worksites.
    • Create work schedules that minimize sun exposure.
    • Allow breaks in shaded areas for sunscreen reapplication.

  Here are some common sunscreen mistakes that you may be making daily and should avoid.

The identification of cause and triggers plays a pivotal role in determining the type of treatment provided. The fundamental principle of all treatment options is to reduce melanin in the skin. There are numerous treatment options available for melasma. The choice of treatment depends on:

• 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 existing pigmentation
• Block new pigmentation
• Restore the natural color of the skin

I. Topical agents

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

1. Bleaching agents: These preparations lighten the skin by blocking melanin production. Hydroquinone (HQ) is the most commonly prescribed depigmenting agent worldwide and remains the gold standard for the treatment of melasma. Note: HQ can cause adverse reactions such as irritation, redness, stinging, allergic contact dermatitis, and nail discoloration, and should only be used under strict medical supervision.
2. Epidermal turnover enhancers: These medications increase the turnover of the outer layer of skin, allowing pigmented cells to be replaced with normally pigmented cells. Examples include:
   • Retinoids (tretinoin, adapalene, isotretinoin)
   • Alpha hydroxy acids (mandelic acid, glycolic acid)
   • Beta hydroxy acid (salicylic acid)
3. Ingredients that target various pathways of melanin synthesis: Excessive melanin production is responsible for melasma. Some agents that block melanin production pathways include:
   • Retinoids (tretinoin, adapalene, isotretinoin)
   • Arbutin (α or β Arbutin)
   • Azelaic acid
   • Kojic acid
   • Niacinamide (Vitamin B3)
4. Antioxidants: They work by scavenging 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 for their anti-inflammatory effects and are often combined with other topical medications. Common examples include Fluocinolone acetonide and Dexamethasone.
6. Combination formulas: Various topical agents can be combined for improved therapeutic effects. A particular drug may reduce the side effects of another. Examples of combinations available in the market include:
   • HQ + Tretinoin + Fluocinolone acetonide
   • HQ + Tretinoin + Dexamethasone + Modified Kligman's formula (KF), 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 utilized when individuals do not see improvement with topical treatments. Tranexamic acid is used orally to reduce melasma patches. Those on oral medication can also use topical creams and sun protection to enhance the treatment.

III. Newer agents

This category includes recently researched medications for melasma that have shown promising results, both alone and in conjunction with other therapies. More research is needed for their use. Examples include:

• Melatonin
• Glutathione
• Cysteamine
• Methimazole
• Flutamide

IV. Device-based therapies

Laser and light-based therapies are usually reserved for resistant cases and considered third-line agents in melasma treatment. This approach is most effective for light-skinned individuals. Types of lasers used 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)
• 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 centrifuge, which rapidly spins the blood, separating the platelets from other components and concentrating them within the plasma. A small volume of this plasma, rich in platelets, is injected back into the patient's body. PRP has shown promise when used alone or in combination as a treatment for melasma.

Special considerations - Treatment during pregnancy:

Treatment may not be necessary as melasma during pregnancy can be transient, with considerable improvement often occurring after childbirth. Additionally, melasma is more resistant to treatment during pregnancy due to persistent hormonal triggers, so treatment is generally deferred until after delivery.

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

• Turmeric (Haldi): Studies have shown a 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 to the skin.
• Aloe Vera: Aloe vera contains an ingredient called aloesin, which is known to reduce the synthesis of melanin. Additionally, the highly moisturizing effect of aloe vera prevents dryness and irritation.
• Licorice (Mulethi): The compound liquiritin possesses properties that help reduce 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.
• Green Tea: Green tea is known for its antioxidant and anti-inflammatory properties. Studies have shown its effect in treating melasma. Apply wet green tea bags to the pigmented areas of the skin and massage in gentle circular motions until absorbed. It can also be mixed with water to make a face pack.
• Soybean: The application of soy extract has been shown to reduce the pigmentation of melasma.
• Red Lentils (Masoor Daal): A face mask made of red lentils can be used for skin pigmentation. It can be applied as a paste by mixing the ground paste of soaked lentils with water or milk.
• Mulberry (Shahtoot) Leaves: The extract of mulberry leaves is traditionally used for the management and prevention of diabetes. Recent studies suggest its role in melasma as it helps reduce the synthesis of melanin. Mulberries are a powerhouse of nutrients.
• Tomato: It contains lycopene, a potent antioxidant that neutralizes free radicals. It helps prevent redness caused by UV radiation and reduces the damaging effects of UV light, thus protecting the skin from sunburn and melasma. The tomato pulp can be applied directly to the face or as a paste mixed with olive oil.
• Cucumber (Kheera): The extract of cucumber has strong moisturizing abilities and 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 to the affected areas as a grated piece.
• Indian Beech Tree: Studies have shown that the extract of leaves from the Indian beech tree has potential sunscreen activity with good absorption of UV rays.
• 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 create a face pack.
• Saffron (Kesar): The dried pollen of the saffron plant can protect the skin from the sun. Take water in a bowl, sprinkle a few strands of saffron in it, add 2 tablespoons of turmeric powder, and make a paste. The paste can be directly applied to the affected skin.
• Jojoba Oil: This oil is known for its effectiveness in treating skin conditions such as eczema, psoriasis, and dry skin. It also contains myristic acid, which provides sun protection.
• Carrot Seed Oil: This oil possesses significant antioxidant, antiseptic, and antifungal properties. It provides natural sun protection when applied topically to the skin.

Melasma does not lead to any complications, but it has a significant 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 quantify melasma’s impact on a patient's quality of life.

Microneedling (Mesotherapy)

Microneedling is a technique that creates small channels in the skin to deliver medication directly into the skin layers. Studies suggest that microneedling, when combined with topical medications, can lead to an improvement in melasma.

Cosmetic Camouflage

Cosmetic camouflage involves the use of concealers and other pigmented cover-ups to even out skin complexion. This approach serves as an adjuvant therapy and has been shown to enhance psychosocial effects and improve quality of life.

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 essential to protect the skin from the sun even on cloudy days. Sunscreen should be applied daily, irrespective of the weather.

III. Apply skincare correctly

Individuals with melasma should apply skincare and make-up in the correct order. The recommended sequence by dermatologists includes:

• Topical medication
• Sunscreen
• Camouflage make-up

IV. Establish a good face-cleansing regimen

Individuals with 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, making it more susceptible to sun damage. Patients should cleanse their skin regularly with a gentle cleanser before going to bed and after returning home.

V. Combat skin stress with antioxidants

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

VI. Moisturize your skin regularly

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

VII. Avoid waxing

Waxing the skin area affected by melasma should be avoided, as it may cause skin inflammation and aggravate hyperpigmentation.

VIII. Managing emotions

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

The following measures might help:

• Engage in activities you enjoy, such as crafting, painting, and singing.
• Exercise regularly to help reduce stress.
• Join a support group, either online or offline.
• Seek help from a professional counselor.
• Connect with others undergoing similar treatments.
• Be patient; even with treatment, it may take months for melasma to clear up.
• Be diligent; melasma can quickly return if sun protection is neglected. Long-term maintenance requires ongoing commitment to skin protection.