Melasma & Dark Spot: Finding The Treatment

What is Melasma?

Melasma is a common skin disorder. Loosely translated, the word means “black spot.” The condition causes dark, discolored patches on your skin. They can appear as flat patches or freckle-like spots. Melasma is sometimes called the “mask of pregnancy” because it frequently affects pregnant women. Another, less common name for melasma, is chloasma.

Melasma is a very common skin disorder. 15% to 50% of pregnant women get it. Between 1.5% and 33% of the population may get melasma and it happens more often during a woman’s reproductive years, and rarely happens during puberty. It usually starts between 20 and 40 years of age.

Types of Melasma

Melasma is divided into three types: epidermal, dermal, and mixed melasma.

• Epidermal melasma is the most superficial with an increase in the skin pigment (melanin) in the top layer of skin (epidermis). This type has a dark brown colour or well-defined border, which appears clear under black light and in most cases responds well to treatment.

• Dermal melasma, there is increased skin pigment in the second deeper layer of the skin (the dermis). Dermal melasma has a light brown or bluish colour, a blurry border that appears no differently under black light and does not react to treatment.

• Mixed melasma is a combination of epidermal and dermal melasma. It is the most common of all three types, that has both bluish and brown patches. Usually shows a mixed pattern under blacklight and shows the mild response to treatment.

Symptoms of Melasma

1. Melasma causes patches and spots that are darker than your natural skin color.
2. The unevenly shaped patches of melasma can join together, creating one or more large areas of melasma.

Melasma typically darkens and lightens over time, often getting worse in the summer and better in the winter. The skin discoloration doesn’t do any physical harm, but you may feel self-conscious about the way it looks.

Common Body Parts to Occur Melasma

It typically occurs on the face and is symmetrical, with matching marks on both sides of the face. Other areas of your body that are often exposed to sun can also develop melasma.

Melasma appears in six locations or a combination of locations on your skin:

• Brachial (Shoulder & Upper Arms): The melasma appears on your shoulders and upper arms.

• Centro facial (Forehead, Cheeks, Nose & Upper Lips): The melasma appears on your forehead, cheeks, nose and upper lip.

• Lateral cheek pattern (Cheeks): The melasma appears on both cheeks.

• Malar(Cheeks & Nose): The melasma appears on your cheeks and nose.

• Mandibular (Jawline): The melasma appears on the jawline. When melasma appears along the jawline, it may be a sign that the skin has been badly damaged by the sun’s rays.

• Neck: In people aged 50 or older, melasma can appear on all sides of the neck.

What causes Melasma?

The skin is made up of three layers. The outer layer is the epidermis, the middle is the dermis, and the deepest layer is the subcutis. The epidermis contains cells called melanocytes that store and produce a dark color (pigment) known as melanin. In response to light, heat, or ultraviolet radiation or by hormonal stimulation, the melanocytes produce more melanin, and that’s why the skin darkens.

Ultraviolet and infrared radiation from the sun is key in making melasma worse. Other possible causes of melasma include:

• Pregnancy

It is unclear why “the mask of pregnancy” happens to pregnant women. However, experts theorize that the increased levels of estrogen, progesterone and the melanocyte-stimulating hormones during the third trimester of pregnancy play a role.

• Genetics

About 33% to 50% of people with melasma have reported that someone else in the family has it. The majority of identical twins both have melasma.

• Hormones

Hormones like estrogen and progesterone may play a role in some people. Postmenopausal women are sometimes given progesterone, and have been observed developing melasma. If you aren’t pregnant, you likely have elevated levels of estrogen receptors found in your melasma lesions.

• LED Screens

Melasma may be caused by the LED lights from your television, laptop, cell phone and tablet.

• Makeup (cosmetics)

Some cosmetics can cause what’s called a phototoxic reaction.

• Phototoxic drugs (medicines that make you sensitive to sunlight)

These include some antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), diuretics, retinoids, hypoglycemics, antipsychotics, targeted therapies and some other drugs.

• Skin care products

A product that irritates your skin in general will likely make your melasma worse.

• Soaps

Some scented soaps are thought to cause or worse melasma.

• Tanning beds

The UV light produced by tanning beds damages your skin just as bad as the UV light from the sun, and sometimes worse.

• Hypothyroidism

A condition where your thyroid is underactive.

• Antiseizure medications

Drugs that prevent you from having seizures may be a cause of melasma.

• Contraceptive therapy (birth control)

Melasma has been observed in individuals who use oral contraceptive pills that contain estrogen and progesterone.

• Estrogen/Diethylstilbestrol

Diethylstilbestrol is a synthetic (man-made) form of the hormone estrogen. It’s often used in treatments for prostate cancer. Again, there’s a pattern between increased estrogen and melasma.

How is Melasma Treated?

The first thing you need to do to treat your melasma is to make sure that it doesn’t get any worse. Do this by avoiding the sun, tanning beds, LED screens, irritating soaps and birth control that includes hormones. If you are exposed to the sun, be sure to wear sunscreen with iron oxides and a SPF of 30-50 applied every two hours, as well as a wide-brimmed hat.

The second path to take is topical medications. There is no one universally effective treatment for melasma. Different ingredients work better for each individual. However, there are some ingredients that are consistently more effective.  They are-

• Retinoids ( Retinol)

***Caution:

Study found that Ratinol; It’s effective, but can cause dermatitis and should not be used during pregnancy & breastfeeding.

Retinoids, such as tretinoin, were first used in combination with HQ as penetration enhancers, but were later recognized to have their own effect on melanogenesis. Retinoids affect multiple steps in the melanization pathway. Tretinoin promotes the rapid loss of pigment through epidermopoiesis and increased epidermal turnover decreases the contact time between keratinocytes and melanocytes. Retinoic acid (RA) suppresses UVB-induced pigmentation by reducing tyrosinase activity. The most common side effects include erythema, burning, stinging, dryness, and scaling. The inflammation may cause hyperpigmentation, particularly in people with dark skin. Patients must be advised to use sunscreens during treatment with retinoic acid.

Available products:

• Glycolic acid

Glycolic acid is an alpha-hydroxy acid that is usually combined with other agents at a concentration of 5-10% for its skin-lightening property. The mechanism of its effect might be due to epidermal remodeling and accelerated desquamation, which would result in quick pigment dispersion on pigmentary lesions. It also directly reduces melanin formation in melanocytes by tyrosinase inhibition. A randomized controlled trial has demonstrated that a formulation containing 10% glycolic acid and 4% HQ had good clinical efficacy in treating melasma in a group of Hispanic patients. Irritation was a common side effect which resolved with the temporary cessation of application and application of moisturizers.

Available products:

• Ascorbic acid (L-Ascorbic Acid)

Ascorbic acid has antioxidant properties and affects melanogenesis by reducing dopaquinone to DOPA and preventing free-radical production and absorption of ultraviolet radiation. Comparing the efficacy of 5% ascorbic acid and 4% hydroquinone in 16 patients with melasma in a double-blind clinical trial, the authors concluded that although hydroquinone showed a better response, ascorbic acid may play a role in the therapy of melasma as it is almost devoid of side effects and it could be used alone or in combination therapy. In an open-label trial, 25% L-ascorbic acid formulated with a penetration enhancer, was found to have a significant effect in the treatment of melasma.

Available Products:

• Hydroquinone

Hydroquinone (HQ), also known as dihydroxybenzene, is a hydroxy phenolic compound that is structurally similar to precursors of melanin. HQ is the most frequently prescribed depigmenting agent worldwide and it has remained the gold standard for the treatment of melasma, particularly of the epidermal type. HQ preparations are commonly used in the treatment of melasma at concentrations varying from 2 to 5% applied once daily. Variably good yet reversible results are obtained in most of the patients treated with HQ. The depigmenting effects of the HQ treatment become evident after 5-7 weeks. HQ is also formulated in combination with other agents like sunscreens, topical steroids, retinoids, and glycolic acids for added benefits. Although very effective and dosed at different strengths, it can cause an irritant dermatitis in some individuals and chronic use can lead to exogenous ochronosis.

• Azelaic acid

Azelaic acid is a naturally occurring, nonphenolic, saturated, nine-carbon dicarboxylic acid that competitively inhibits tyrosinase. Azelaic acid was initially developed as a topical anti-acne agent but because of its effect on tyrosinase, it has also been used to treat hyperpigmentary disorders like melasma. Free radicals are believed to contribute to hyperpigmentation, and azelaic acid acts by reducing free radical production. A combination of azelaic acid with 0.05% tretinoin or 15-20% glycolic acid may produce earlier, more pronounced skin lightening. This cream, lotion or gel is applied twice a day. It’s safe for pregnant women to use. Adverse effects of azelaic acid include pruritus, mild erythema, and burning.

• Kojic acid

***Caution:

Never use kojic acid on damaged or broken skin. Some countries have banned this product because of a potential connection to the development of cancer.

Kojic acid (5-hydroxy-2-hydroxymethyl-4-pyrone) is a naturally occurring, hydrophilic fungal product derived from certain species of Acetobacter, Aspergillus, and Penicillium. It acts by inhibiting the production of free tyrosinase; it is also a potent antioxidant. Kojic (KA) acid is used at concentrations ranging from 1 to 4%. In one double-blind study, KA 2% combined with HQ 2% was shown to be superior to glycolic acid (GA) 10% and HQ 2% Another double-blind study compared GA 5% with either HQ 4% or KA 4% for three months. Both combinations proved equally effective with a reduction of pigmentation in 52% of the patients. KA may be effective if a patient has difficulty tolerating other first-line therapies. It may cause contact dermatitis and erythema. You should never use kojic acid on damaged or broken skin. Some countries have banned this product because of a potential connection to the development of cancer.

• Niacinamide

Niacinamide (nicotinamide), the biologically active amide form of niacin (vitamin B3), can reduce pigmentation by reversibly preventing the transfer of melanosomes from melanocytes to the keratinocytes. It has no effect on tyrosinase activity. Some research has found 5 percent niacinamide concentrations can be helpful in lightening dark spots. In clinical studies, niacinamide significantly decreased hyperpigmentation and increased skin lightness compared with vehicles alone after four weeks of use.

Available Products:

• Liquorice derivatives

Liquorice is the root of the perennial herb Glycyrrhiza glabra. Glabridin is an oil-soluble derivative of liquorice extract. Glabridin has been shown to have tyrosinase inhibitory as well as anti-inflammatory properties in experimental studies. A clinical trial with Liquiritin, another liquorice derivative, has also shown benefit in treating melasma.

If these topical medications don’t work for you melasma you can go for the oral medications. Oral medications, including tranexamic acid, are usually considered in more severe melasma cases. This medication is thought to help melasma by reducing pigment production and by reducing excess blood vessels in the skin.

If your melasma does not improve with topical or oral medications, adding procedures such as chemical peels and laser therapies to a treatment regimen could be beneficial.

• Chemical peels use substances like glycolic acid, alpha-hydroxy acids, and salicylic acid to remove the superficial layer of the skin that contains excess pigment in melasma patients. The effects of a chemical peel are temporary, since this procedure removes a layer of skin without reducing the production of pigment in regenerating deeper layers. Salicylic acid is an ingredient that can be derived from plants such as white willow or wintergreen leaves. It treats melasma as an anti-inflammatory and also has an effective exfoliation function to promote new skin growth.

• Laser therapies can destroy pigment cells in skin and therefore lighten the dark spots in melasma. However, as with any other treatment option for melasma, there is considerable risk of relapse post-treatment.

Management of melasma can be challenging and requires long-term treatment with topical agents. The results are often unsatisfactory and topical agents may sometimes cause significant adverse reactions. Hydroquinone has remained the gold standard of topical treatment but concerns regarding its side effects remain. A triple combination of hydroquinone, retinoic acid, and corticosteroids has been suggested to be the first-line topical treatment for this pigmentary disorder. Many new agents that inhibit melanogenesis have been developed.