Melasma, also known as chloasma, is a chronic condition that leads to dark patches on the face. These discolored patches are brown or grayish-brown in color and often affect the cheeks, nose bridge, forehead, and upper lip.
Melasma is also called the “mask of pregnancy,” as it often appears during pregnancy.
It is harmless and can be treated with topicals like hydroquinone, retinoids, and kojic acid, and in-office procedures like lasers and chemical peels. In addition, sun protection is a must to keep these blotchy patches under control.
Table of Contents
What is melasma?
Melasma is a chronic hyperpigmentation disorder of the skin resulting in dark patches. It affects women more than men. It can be incredibly challenging to treat and often reoccurs.
It can have a significant impact on the quality of life of anyone dealing with it.
Melasma vs. Chloasma: Melasma leads to dark patches on the skin and when melasma appears during pregnancy, it is called chloasma or mask of pregnancy.
Symptoms and pictures
Below, you can see pictures of melasma on the cheeks, upper lip, and forehead.
Melasma is most commonly diagnosed clinically. It is characterized by skin discoloration with irregular light to dark brown patches with a symmetric distribution. There are three patterns seen on the face [1]:
- Centrofacial (most common pattern, 50-80% cases) involves the forehead, cheeks, nose, upper lip, and chin.
- Malar involves solely the nose and the cheeks.
- Mandibular affects the jawline (thought to occur in older individuals) [1] [2] [3] [4].
It can be seen in other parts of the body including the neck, chest (sternum), and arms (upper extremities), where it’s called extra facial melasma. [1] [5]
The average age of onset ranges between 20 and 30 years. [1] [3]
It is known to occur in all ethnic and population groups. It preferably affects people with darker skin tones types III-V (Fitzpatrick classification), but is rare in extreme skin types. [6]
Causes
Melasma is caused by the interaction of a number of environmental and internal factors.
1. Genetic factors
Though there is a lot of variation in the relationship of melasma with family history, it is still considered an important factor. As seen in some studies, 55-64% of people with melasma have a positive family history. [6] [7]
2. Sun exposure
Both UV rays and visible light are known to be one of the most important trigger factors of melasma. They can increase pigmentation via the following mechanisms:
- Effect on melanin pigment forming cells – melanocytes [7]
- Effect on skin cells – keratinocytes [7]
- Production of reactive oxygen species (ROS) [8]
- Visible light can also lead to hyperpigmentation which is more intense and stable than UVA. [9]
- UV and visible light-induced dermal inflammation stimulate pigment formation. [10]
3. Hormones
Melasma is known to get worse during pregnancy. It is also commonly seen in women taking estrogen-containing oral contraceptive pills and hormone replacement therapy. [11] This is thought to be due to the presence of estrogen/hormone receptors on melanocytes. [7] [12]
4. Vascular factors
UV rays can induce the secretion of vascular endothelial growth factor (VEGF) from skin cells. Melanocytes express receptors for VEGF, and it enhances the process of pigment formation aka melanogenesis. [13] This is why prominent vessels are seen in melasma skin and the reason tranexamic acid is effective. [7]
5. Barrier dysfunction
In melasma skin, there is a downregulation of genes involved in lipid metabolism leading to impaired skin barrier function. There is also associated thinning of the stratum corneum (top layer of skin) as observed in skin biopsies. [14]
6. Mast cells and damaged elastic fibers
The melasma skin has increased mast cells (immune/ allergy cells) and damaged elastic fibers in the dermis. [15]
7. Damage to the basement membrane
Considerable damage is seen to the basement membrane (present between the epidermis/upper layer of skin and dermis/deeper layer of skin) in melasma skin. This leads to the migration of melanin pigment into the deeper layers of the skin and results in a persistent dermal component of melasma. [16]
8. Heat
The heat from sun rays, ovens, furnaces, etc., can lead to the dilation of blood vessels and inflammation stimulating pigment formation.
9. Pollution
Oxidative stress can be formed secondary to the presence of airborne pollutants. This can lead to an increase in melanin pigment. This is the reason why the incidence of melasma is high in geographic areas with heavy pollution. [7]
10. Cosmetics/skincare products
Exposure to certain cosmetics and skincare products especially the ones with fragrances, can irritate skin and exaggerate melasma. [18]
11. Other associations
It is thought to be associated with some thyroid disorders and certain medications.
Types
Melasma can be divided into 3 types or histologic variants (as seen under a microscope): epidermal, dermal, and mixed.
- In the epidermal type, there is increased pigment throughout the top layer of the skin. This type shows a good response to treatment.
- The dermal subtype has pigment and melanophages in the superficial and deep dermis or deeper layers of skin. Additionally, inflammatory cells, increased blood vessels, and damaged elastic fibers may be seen in the dermis. This is very challenging to treat.
- Mixed melasma often displays combined features of the epidermal and dermal subtypes. This type shows a partial response to treatment [1]
General measures
In some cases, melasma is transient. Melasma, or chloasma, first presents in pregnancy and thereafter resolves. Similarly, discontinuing some medications like OCPs, or removing other triggers, can lead to their disappearance. However, in some cases it is persistent.
In studies, some degree of skin barrier dysfunction is seen in melasma skin. So, it’s important to be gentle with your skin.
- Avoid aggressive physical exfoliation, high pH cleansers, and too many actives at one time.
- Avoid fragrance in your skincare products as it can exaggerate melasma.
- A moisturizer can help your skin to rebuild its barrier.
- Do not use metal frame glasses as they can transfer heat to your skin, so look for other options.
Below, you will find treatment options for melasma, which include topicals and procedures that can be done in a doctor’s office. However, not all of these treatment options can be used during pregnancy.
Sun protection
UV rays and visible light are the key factors when it comes to the exacerbation of melasma. In several studies, it is seen that sun protection along with iron oxides which block visible light, show better results in controlling the relapses of melasma in comparison to a broad-spectrum sunscreen alone. So, look for a tinted broad-spectrum sunscreen. [20] [21] [22]
If you are a daily make-up wearer, the pigment in your powder and foundation can provide some protection from visible light, however, do not forget your sunscreen.
Prescription medications
Melanocytes are the cells present in between the skin cells. The melanin pigment is formed in the structures called melanosomes. These melanosomes are transferred to surrounding skin cells via the finger-like processes of melanocytes.
Topical treatments for facial hyperpigmentation are mostly aimed at inhibiting the enzyme (tyrosinase) involved in the formation of melanin. Some can downregulate the formation of tyrosinase enzyme or prevent the transfer of melanosomes from melanocytes to neighboring epidermal cells (keratinocytes).
1. Hydroquinone
Hydroquinone (HQ) is the most commonly used topical agent in the treatment of melasma. It works by inhibiting the tyrosinase enzyme, thus preventing the formation of melanin. It also destroys the melanosomes (structures that have melanin pigment in them).
Several studies have shown that 4% hydroquinone can lead to significant improvement in melasma. The effects are usually seen in 5-7 weeks. For best results, it should be used on and off with other topical agents to cut the risk of side effects. [1] [17] [23]
Since hydroquinone is an oxidizing agent, its color can change from white to brown over time. Any products with this color change should be discarded as they are not effective anymore.
It can have several side effects including irritation, erythema, allergic contact dermatitis, areas of hypomelanosis, and ochronosis (blue-black pigmentation). Due to concerns about its safety, it has been banned in cosmetic preparations in many countries.
In the US, it cannot be sold over the counter anymore. It is only available through a prescription. [17]
Caution: Should not be used by pregnant women due to its Category C characterization [Animal reproduction studies have shown an adverse effect on the fetus, but there are no adequate and well-controlled studies of humans].
2. Retinoids
Topical retinoids can help melasma by increasing cell turnover. Some studies have seen the benefits of 0.1% tretinoin in melasma patients, however, it alone takes longer to give results as compared to when used with other topicals. [17] It also reduces melanosome transfer from melanocytes to skin cells and downregulates tyrosinase transcription.
In one study, 0.1% tretinoin was found to be more effective than the vehicle for treating patients with melasma. However, it took longer, 24 weeks, to see significant improvement.
In another study, 0.1% tazarotene cream was found effective against post-inflammatory hyperpigmentation compared with vehicle. The results were evident in 18 weeks.
Caution: Should not be used by pregnant women due to its Category C characterization.
3. Combination Therapy
Combination topical therapies have shown better results than monotherapy. The Kligman-Willis formula (5% hydroquinone, 0.1% tretinoin, 0.1% dexamethasone) was one of the first combination treatments to be used for hyperpigmentation.
The triple therapy combination (TCC) containing 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide, has also proven to be fairly efficacious in melasma treatment.
Topical retinoids can help the melasma by increasing cell turnover, along with enhanced penetration of hydroquinone. Steroids can help melasma by reducing inflammatory mediators thus inhibiting pigment production. [17]
In one study, daily use of a triple combination of 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide was more effective than twice daily 4% hydroquinone.
4. Azelaic Acid
Azelaic acid is a naturally occurring dicarboxylic acid that competitively inhibits the tyrosinase enzyme.
It has a direct cytotoxic effect on the melanocytes. It has selective action on the abnormal melanocytes, so it has no depigmentation effect on normal skin.
Oxidative stress is believed to contribute to hyperpigmentation, and since azelaic acid is an antioxidant, it can further help melasma. [24] In patients with melasma, 20% azelaic acid was found to be as effective as 4% and superior to 2% hydroquinone, but without side effects.
Azelaic acid is considered safe to use during pregnancy. It is available over the counter in lower percentages. It might take longer to show results but the side effects will be less as well.
Read more: Best products with azelaic acid
5. Tranexamic Acid
Tranexamic acid is a synthetic version of an amino acid – lysine. It blocks the conversion of plasminogen to plasmin and the binding of plasminogen to keratinocytes. This results in a decrease in melanin synthesis. It also decreases mast cells and the formation of new blood vessels in the dermis. [17] [24] [25]
It is currently used in melasma via several routes: oral, topical, intradermal, and micro-needling. The oral form is the one with the best results and the most data. The oral dose is around 250 mg twice daily, far less than what is used in bleeding disorders.
It is contraindicated in patients with clotting disorders or a history of thromboembolism. So, it should be taken in oral form only under the supervision of a physician.
The topical formulation has limited success and less efficacy than when used in oral form. [1] [17] In most studies, results are seen in 8 to 12 weeks.
Topical tranexamic acid doesn’t require a prescription and can be found in a few over-the-counter products. Most people tolerate it well, however patch test any new product.
There are several more over-the-counter ingredients that may help with melasma. You can read more about these ingredients here.
Chemical peels
Chemical peels are often used in combination with other topical agents to manage melasma, which doesn’t respond well to topicals alone.
The peeling agents used are – alpha-hydroxy acids like glycolic acid, beta-hydroxy acids like salicylic acid, Jessner’s original and modified solutions, and trichloroacetic acid.
Chemical peels use acids to break bonds between cells and remove dead skin cells and part of the top layer of skin. This means that the pigment is brought to the surface of the skin and eventually shed.
Depending on how much these affect the different layers of the skin, they can be either superficial, medium, or deep.
Among all peels, glycolic acid peels (20 to 70%) are the most studied. Caution should be taken when using high concentrations of glycolic acid in darker skin tones.
Sun protection is very important after these procedures. Due to the risks associated with deep peels, it’s best to get these procedures done by a professional. [1] [17] [24]
Lasers and IPL
Lasers are based on the principle of photo thermolysis, that is light is absorbed by pigment structures and causes thermal/heat damage. This is how it targets certain pigmented lesions, tattoos, and hair.
In melasma, melanosomes are the primary target and melanin is the main chromophore.
Therefore, it is important to choose wavelengths between 630 nm and 1100 nm which are preferentially absorbed by melanin, and pulse duration between 40 ns (nanosecond) and 750 ns. [1] [24] [26] [27] [28]
Lasers are used when the other treatments don’t give results. They can also be used in combination with other treatments. Various laser and light therapies used are:
1. Pigment-specific (Q-switched, IPL)
Q-switched (QS) lasers deliver their energy in nanosecond pulses; hence they selectively target melanosomes. The QS-Nd:YAG laser is the most commonly used laser for melasma, though they have a rapid relapse rate. QS-Nd:YAG lasers use a wavelength of 1064 nm, which is better absorbed by melanin than other skin structures.
The QS-Nd:YAG laser also damages the vascular plexus in the upper dermis, which is abnormal in melasma, and promotes collagen formation in the surrounding dermis. The number of treatments varies from 5 to 10 at 1-week intervals.
QS ruby fractional lasers (694 nm) have shown good results in dermal-type melasma.
IPL (Intense Pulsed Light) delivers a broad-spectrum light with varying wavelengths, ranging from 500 to 1200 nm. Absorption of light by melanin results in thermolysis. This results in the formation of crusts with melanin which move to the upper layer of the epidermis, from where they are shed.
IPL targets all the pigment in the skin and, therefore, may damage normal skin around the skin lesion. For this reason, IPL is not recommended in patients with darker skin tones (Fitzpatrick skin types IV through VI). [1] [24] [26] [27] [28]
2. Vascular lasers (pulsed dye, Copper bromide)
Melasma treatment with pulsed dye laser and the newer antiangiogenic lasers (copper bromide laser) is based on the theory that melasma occurs due to the interaction between vascular growth factors and melanocytes. These are preferably used in melasma patients with dilated or increased blood vessels. [1] [24] [26] [27] [28]
3. Nonablative fractional lasers
Superficial/epidermal pigmentation is most likely to respond to nonablative fractional laser. These seem to be associated with the longest delay in recurrence, followed by intense pulse light (IPL) and quality-switched (QS) lasers, the last having the most rapid recurrence rate. [1] [24] [26] [27] [28]
4. Ablative laser
Ablative lasers remove the epidermis; this can be followed by the use of the Q-switched pigment selective laser which reaches deeper layers of the dermis without causing serious side effects.
Non-ablative lasers are preferred for the treatment of melasma over ablative lasers given the tendency to cause less inflammation and subsequently less post-inflammatory pigment alteration.
Lasers can lead to worsening of hyperpigmentation or areas of hypopigmentation. So, post laser, sun protection is very important. Post-inflammatory hyperpigmentation remains the most important side effect. Recurrences are common and are seen in up to 50%. [1] [24] [26] [27] [28]
Key points
Melasma, also known as chloasma and “mask of pregnancy,” is a chronic hyperpigmentation disorder that results in dark patches on the face. It is one of the common types of skin blemishes.
It can occur due to several external and internal factors. These include the sun, genetics, skin type, hormones, heat, pollution, skin barrier dysfunction, and certain medications.
Melasma can be very challenging to treat, and the results are often unpredictable. The relapse rate is very high as well, so proper patient education is necessary.
Topicals are the first line of treatment. Hydroquinone, when used on and off, can give promising results. In more severe cases, triple combination formulas can be helpful.
Chemical peels and lasers are reserved for more resistant cases, as they carry a high risk of post-inflammatory hyperpigmentation.
The importance of basic skincare should also be emphasized. Moisturizers can help to repair some of the barrier dysfunction in melasma-affected skin. Sunscreens, preferably tinted, should be worn every day to reduce the progression and prevent the relapse of melasma.
References
1. Ogbechie-Godec OA, Elbuluk N. Melasma: an Up-to-Date Comprehensive Review. Dermatol Ther (Heidelb). 2017;7(3):305-318. doi:10.1007/s13555-017-0194-1.
2. Sanchez NP, Pathak MA, Sato S, Fitzpatrick TB, Sanchez JL, Mihm MC., Jr Melasma: a clinical, light microscopic, ultrastructural, and immunofluorescence study. J Am Acad Dermatol.1981;4(6):698–710. doi: 10.1016/S0190-9622(81)70071-9.
3. Tamega Ade A, Miot LD, Bonfietti C, Gige TC, Marques ME, Miot HA. Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women. J Eur Acad Dermatol Venereol. 2013;27(2):151–156. doi: 10.1111/j.1468-3083.2011.04430.x.
4. Mandry Pagan R, Sanchez JL. Mandibular melasma. P R Health Sci J. 2000;19(3):231–234.
5. Ritter CG, Fiss DV, Borges da Costa JA, de Carvalho RR, Bauermann G, Cestari TF. Extra-facial melasma: clinical, histopathological, and immunohistochemical case–control study. J Eur Acad Dermatol Venereol. 2013;27(9):1088–1094. doi: 10.1111/j.1468-3083.2012.04655.x.
6. Handel AC, Miot LD, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014;89(5):771-782. doi:10.1590/abd1806-4841.20143063
7. Aishwarya K, Bhagwat PV, John N. Current concepts in melasma – A review article. J Skin Sex Transm Dis 2020;2(1):13-7.
8. Choubey V, Sarkar R, Garg V, Kaushik S, Ghunawat S, Sonthalia S, et al. Role of oxidative stress in melasma: A prospective study on serum and blood markers of oxidative stress in melasma patients. Int J Dermatol. 2017;56:939-43.
9. Mahmoud BH, Ruvolo E, Hexsel CL, Liu Y, Owen MR, Kollias N, et al. Impact of long wavelength UVA and visible light on melanocompetent skin. J Invest Dermatol. 2010;130:2092-7.
10. Kang HY, Hwang JS, Lee JY, Ahn JH, Kim JY, Lee ES, et al. The dermal stem cell factor and c-kit are overexpressed in melasma. Br J Dermatol. 2006;154:1094-9.
11. Pérez-Bernal A, Muñoz-Pérez MA, Camacho F. Management of facial hyperpigmentation. Am J Clin Dermatol. 2000;1:261-8.
12. Kim NH, Cheong KA, Lee TR, Lee AY. PDZK1 upregulation in estrogen-related hyperpigmentation in melasma. J Invest Dermatol. 2012;132:2622-31.
13. Kim EJ, Park HY, Yaar M, Gilchrest BA. Modulation of vascular endothelial growth factor receptors in melanocytes. Exp Dermatol. 2005;14:625-33.
14. Lee DJ, Lee J, Ha J, Park KC, Ortonne JP, Kang HY, et al. Defective barrier function in melasma skin. J Eur Acad Dermatol Venereol. 2012;26:1533-7.
15. Hernández-Barrera R, Torres-Alvarez B, Castanedo-Cazares JP, Oros-Ovalle C, Moncada B. Solar elastosis and presence of mast cells as key features in the pathogenesis of melasma. Clin Exp Dermatol. 2008;33:305-8.
16. Torres-Álvarez B, Mesa-Garza IG, Castanedo-Cázares JP, Fuentes-Ahumada C, Oros-Ovalle C, Navarrete-Solis J, et al. Histochemical and immunohistochemical study in melasma: Evidence of damage in the basal membrane. Am J Dermatopathol. 2011;33:291-5.
17. Grimes PE, Ijaz S, Nashawati R, Kwak D. New oral and topical approaches for the treatment of melasma. Int J Womens Dermatol. 2018;5(1):30-36. Published 2018 Nov 20. doi:10.1016/j.ijwd.2018.09.004.
18. Duarte I, Campos Lage AC. Frequency of dermatoses associated with cosmetics. Contact Dermatitis. 2007;56:211–213.
19. Kang HY, Bahadoran P, Suzuki I, Zugaj D, Khemis A, Passeron T, et al. In vivo reflectance confocal microscopy detects pigmentary changes in melasma at a cellular level resolution. Exp Dermatol. 2010;19(8):e228–e233. doi: 10.1111/j.1600-0625.2009.01057.x.
20. Lakhdar H., Zouhair K., Khadir K., Essari A., Richard A., Seite S. Evaluation of the effectiveness of a broad-spectrum sunscreen in the prevention of chloasma in pregnant women. J Eur Acad Dermatol Venereol. 2007;21(6):738–742.
21. Boukari F, Jourdan E, Fontas E, Montaudié H, Castela E, Lacour JP, Passeron T. Prevention of melasma relapses with sunscreen combining protection against UV and short wavelengths of visible light: a prospective randomized comparative trial. J Am Acad Dermatol. 2015 Jan; 72(1):189-90.e1
22. Dumbuya H, Grimes PE, Lynch S, Ji K, Brahmachary M, Zheng Q, Bouez C, Wangari-Talbot J. Impact of Iron-Oxide Containing Formulations Against Visible Light-Induced Skin Pigmentation in Skin of Color Individuals. J Drugs Dermatol. 2020 Jul 1;19(7):712-717. doi: 10.36849/JDD.2020.5032. PMID: 32726103.
23. Bandyopadhyay D. Topical treatment of melasma. Indian J Dermatol. 2009;54(4):303-309. doi:10.4103/0019-5154.57602
24. Damevska, Katerina. “New Aspects of Melasma/Novi aspekti melazme.” Serbian Journal of Dermatology and Venereology 6 (2014): 18 – 5.
25. Ebrahimi B., Naeini F.F. Topical tranexamic acid as a promising treatment for melasma. J Res Med Sci. 2014;19(8):753–757.
26. Sarma N, Chakraborty S, Poojary SA, et al. Evidence-based Review, Grade of Recommendation, and Suggested Treatment Recommendations for Melasma. Indian Dermatol Online J. 2017;8(6):406-442.
27. Arora P, Sarkar R, Garg VK, Arya L. Lasers for treatment of melasma and post-inflammatory hyperpigmentation. J Cutan Aesthet Surg. 2012;5(2):93-103. doi:10.4103/0974-2077.99436.
28. Trivedi MK, Yang FC, Cho BK. A review of laser and light therapy in melasma. Int J Womens Dermatol. 2017;3(1):11-20. Published 2017 Mar 21. doi:10.1016/j.ijwd.2017.01.004.
Disclaimer: This blog post is for information purposes only and does not replace medical advice.