Melasma
A common skin condition among women, Melasma causes brown, grey, and tan patches on the face, particularly the cheeks, forehead, and chin. It is believed to be caused by daily sun exposure and hormonal events such as pregnancy and hormone treatments. It is a type of hyperpigmentation that causes your body to produce too much pigment. Melasma is also referred to as The Mask of Pregnancy, and Chloasma. The condition generally appears in women between the ages of 20 and 50 (though one in 20 patients are men), and although it isn’t harmful, it can cause embarrassment and distress. Melasma can be treated via a number of different methods.
Symptoms
Melasma appears as either large, flat, irregular patches on various parts of your face, or freckle-sized spots that are called macules. They may appear on the bridge of your nose, above your upper lip, on your cheeks, forehead, and chin, and sometimes on your neck and forearms (though this is not as common). Melasma is simply an excessive amount of dark pigmentation. There are no physical ailments associated with the condition beyond the cosmetic symptoms.
Who is Affected
Most of the cases of melasma appear in women, likely because hormones (in particular progesterone) have a great deal to do with the onset of the condition. Women of child-bearing years are most commonly affected, although men can (and do) develop the ailment. It often appears in pregnant women in their later trimesters, as well as women who are undergoing hormone replacement therapy, taking oral contraceptives, and getting excessive sun exposure.
People who are of Asian or Latin descent are the most likely to be affected, as are those with olive-colored skin such as Hispanics and those of Middle-Eastern descent. Individuals with thyroid disease are also known to have a higher incidence of melasma.
Causes
Melasma itself is due to an increase in the amount of pigment in your skin. What causes it is not entirely known, but experts are fairly certain that a variety of factors can trigger it. Melasma can be brought on by:
- An excessive amount of sun exposure
- Being in the second or third trimester of pregnancy
- Taking oral contraceptives
- Receiving hormone replacement therapy
The most common reason for getting melasma is excessive exposure to sunlight (ultraviolet rays), and the condition is often triggered during summer months.
If the condition is caused by hormonal events, it is believed that progesterone is the trigger. During the second and third trimester of pregnancy, women experience an increased level of progesterone. Also, postmenopausal women receiving progesterone while undergoing hormone replacement therapy have a higher incidence of developing melasma. Those receiving only estrogen (and not progesterone) during hormone replacement therapy have a much lower incidence of developing the skin disorder.
Medications and cosmetics may be to blame for aggravating melasma by increasing the amount of melanin produced in your body. Scented soaps, deodorants, and various scented lotions and irritating toiletries can all increase the risk of developing the condition. It’s also possible for you to have an increased risk for developing melasma because you are genetically predisposed to the condition.
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How to Diagnose Melasma
Due to the distinguishable characteristics of melasma, diagnosing it is fairly straightforward for doctors. Usually, a diagnosis can be made visually. On occasion, the doctor may order a skin biopsy to confirm a melasma diagnosis and to rule out other conditions that may mimic melasma. It can also be diagnosed with the help of a Wood’s Lamp: a black light that allows the doctor to see the existence of an overabundance of melanin in the epidermis.
There are other conditions that may appear to be melasma and a doctor could order a biopsy of your skin to rule out these possibilities:
- Postinflammatory hyperpigmentation (PIH)
- Hydroquinone-induced exogenous ochronosis
- Actinic lichen planus
How to Treat Melasma
There are different options for melasma treatment. If melasma is due to pregnancy, the skin condition usually starts to fade away soon after delivery. If it is caused by taking oral contraceptives, it slowly fades away after discontinuing their use. In other situations, there are a few topical treatments that have proven to be effective:
- Bleaching creams, also known as depigmenting agents, can be purchased over the counter or with a doctor’s prescription. The most commonly used depigmenting cream is hydroquinone. You can expect to see results after many months of use.
- Hydroquinone (which lightens the skin) is sometimes coupled with other effective chemicals such as glycolic acid and tretinoin (pure retinoic acid) to increase the affects. When all three are used together it is called “triple cream” and may take 6-8 weeks to see results.
- Microdermabrasion: This works by use of a vacuum suction accompanied with an erosive material to peel off the top layer of your skin.
- Chemical peels: usually, a light glycolic peel is used, but sometimes peels can contain salicylic acid. A dermatologist can determine the correct strength to use based on your skin type and the severity of your melasma.
- Lasers: although laser treatments for melasma may provide temporary results, it is not the preferred method of treatment by dermatologists because it may worsen the condition.
- Glycolic acid creams (10-20%)
- Kojic acid: generally used in concentrations between 1-2.5%, kojic acid works differently than hydroquinone acid and is usually just as effective.
- Lactic acid lotions (12%)
- Azelaic acid (15-20%): this is a non-hydroquinone cream that is proven to be safe and effective against melasma. Side effects may include redness, itching, and a burning sensation that nevertheless improves after two weeks to a month of use.
- Retinoic acid (.025-.1%)
- Research is being done on the effectiveness of other topical agents such as licorice extract, resveratrol, zinc sulfate mequinol, arbutin and deoxyarbutin (extracted from berries), among others.
Even though there are effective melasma treatments available, treatments can take several months to produce an effect. It’s also important to note that the two different kinds of melasma – dermal melasma and epidermal melasma – are treated differently. Treatment for epidermal melasma tends to be more successful.
Certain treatments can cause skin irritation. If you use hydroquinone treatments above 4% for a long period of time you may be at risk of developing exogenous ochronosis—a condition whereby the skin darkens and becomes permanently discolored. This is not very common in the United States.
How to Prevent Melasma
Even though the exact causes of melasma remain unclear, and complete prevention might not be possible, there are ways to help decrease the risk of developing it. These include:
- Keeping your skin shielded from direct sunlight by wearing a wide brim hat and protective clothing when outside.
- Avoiding UV rays: the most common cause of melasma is too much exposure to UV rays. For this reason, use a broad spectrum sunscreen of SPF 30 or higher that contains titanium dioxide or zinc oxide. Ultraviolet light easily passes through clouds so wear sunscreen daily–especially during swims and extended outdoor activity. Reapply sunscreen every two hours for optimal effectiveness.
- Avoiding waxing: for hair removal, choose methods other than waxing because waxing can irritate the skin and cause melasma to become even worse. If hair removal is important to you, talk to your dermatologist about safer methods.
- Discontinuing the use of irritating topical products: mild soaps, lotions, shower gels, and other skin care products should be mild and non-comedogenic. Anything that irritates, stings, or burns your skin will likely make melasma worse.
Prognosis/Outlook
The outlook for most cases of melasma is good. However, just as the condition itself takes a long time to develop, treatment also takes place over a long period of time and completely clearing all appearances of melasma may be difficult. Sometimes, pigmentation is not entirely eliminated but with treatment is much less noticeable.
The grey and tan blotchy patches that characterize melasma are likely to reappear during sun exposure, during pregnancy, while taking oral contraceptives, and while undergoing progesterone hormone replacement therapy. Your response to treatment is also based on your skin type.
Clinical Studies With Natural Ingredients
There have been clinical studies on natural ingredients that, when taken orally, help prevent or relieve melasma. This is important because, while aggressively using topical sunscreen lotion can improve melasma, complete compliance is difficult, and simply taking natural ingredients that work continuously can be a convenient and effective regimen.
In particular, Polypodium leucotomos, grape seed extract, and other natural ingredients including Vitamin A (from beta-carotene), Vitamin C, and Vitamin E, have all shown good clinical results in patients. A Mediterranean-type diet and drinking green tea have also shown good results. Here are the summaries from a few of these studies:
Polypodium Leucotomos
We know that oral Polypodium leucotomos protects skin from sun damage, and its photoprotective activity has been assessed in healthy volunteers. It has also been shown to be an effective treatment in patients suffering from several cutaneous diseases such as vitiligo, psoriasis, idiopathic photodermatosis, atopic dermatitis, and melasma, by adding extra protection when UV radiation exposure cannot be avoided.
In many studies, Polypodium leucotomos extract appears to have a beneficial effect on melasma.
In one study, Polypodium leucotomos significantly improved the severity of melasma in women after 12 weeks. In addition to preventing many harmful effects associated with sunlight exposure, orally administered Polypodium leucotomos also appears to provide adjunctive benefits in treating and managing vitiligo and melasma, and may have the potential to help with postinflammatory hyperpigmentation.
Polypodium leucotomos extract (PLE), derived from the tropical fern of the Polypodiaceae family, has properties ranging from immunomodulatory and antioxidative to photoprotective. It is these multiple mechanisms of action, in combination with a favorable side effect profile, which makes PLE a promising adjunctive treatment for several dermatologic disorders.
Grape Seed Extract
A study in Japan investigated the effect of grape seed extract (GSE), a powerful antioxidant, on melasma. The proanthocyanidin-rich grape seed extract was orally administered for 5-6 months to Japanese woman with melasma. Clinical observation, skin lightening, melanin index, and size measurements of the melasma were performed throughout the study period. GSE intake improved or slightly improved chloasma in 16 of the 23 women. Skin lightening also increased after GSE intake, and melanin index significantly decreased.
The authors concluded that grape seed extract is effective in reducing hyperpigmentation in women with melasma. The beneficial effects of GSE were maximally achieved after 6 months but there was no further measured improvement after this period. GSE is safe and useful for improving melasma; taking grape seed extract may prevent melasma from becoming worse prior to the summer season.
Vitamins A (fFom Beta-Carotene), C, E, And Procyanidin
One promising therapeutic option in the treatment of melasma is oral procyanidin. It is the main active constituent of French maritime pine (Pinus pinaster) bark extract. Cyanidins are also found in green tea and grape seed extract. They contain polymer chains of flavonoids and have both antioxidant and anti-inflammatory properties.
In the trial, fifty-six Filipino women taking oral procyanidin + Vitamin A, Vitamin C, and Vitamin E demonstrated a significant decrease in the degree of pigmentation on their cheeks. In the 8-week trial the ingredients proved to be safe and effective for patients with epidermal melasma.
Mediterranean Diet
In this controlled study, the researchers assessed the impact of a Mediterranean diet on melasma in patients in Italy. After carefully controlling for several sun exposure and pigmentary characteristics, the results found a protective effect for weekly consumption of fish, shellfish, fish rich in omega-3 fatty acids, daily tea drinking, and high consumption of vegetables and fruits. Among vegetables and fruits, carrots, cruciferous and leafy vegetables, and citrus fruits showed the best results.
Overall, the findings suggested that some dietary factors present in the Mediterranean diet might protect you from cutaneous melanoma.
Sunsafe Rx
There is one nutritional supplement that contains many of the ingredients shown clinically to help protect against exposure to the elements (when taken orally). It’s called Sunsafe Rx and it contains Polypodium leucotomos, grape seed extract, green tea extract, Vitamin A (from beta-carotene), Vitamin C, and Vitamin E. It also includes cyanidins from grape seeds and green tea. By combining some of the other solutions mentioned in this article with the supportive properties of the ingredients in Sunsafe Rx, and avoiding sun exposure as much as possible, defending against some of the effects of environmental exposure is possible.
Summary
Melasma, also known as chloasma and the mask of pregnancy, is a common skin condition that usually develops in women between 20 and 50 years old. It is believed to be caused by excessive sun exposure as well as hormonal events such as pregnancy, taking oral contraceptives, and hormone replacement therapy. Even though women make up the vast majority of cases, men can also develop the condition.
While melasma may not be completely preventable, you can actively take steps to prevent it by limiting your sun exposure, wearing SPF 30+ sunscreen, and shielding your skin from UV rays. It is also recommended that you eliminate cosmetics, medications, and hygiene products that irritate your skin.
There are several treatments for melasma including over the counter creams, prescription medications, and medical procedures such as laser therapy and chemical peels.
Other melasma treatment methods include discontinuing the use of oral contraceptives and stopping hormone replacement therapy. If your melamsa is caused by pregnancy, the condition generally clears up after several months.
Depending on the severity of the condition, a doctor may prescribe a hydroquinone cream that is coupled with tretinoin or corticosteroids to increase the effects.
It is recommended that pregnant women delay melasma treatment until after giving birth due to possible complications from the medications.
There are two types of melasma: epidermal, which is located solely in the outer layer of your skin, and dermal, which includes pigmentation in deeper layers of your skin. Dermatologists treat each type differently. Oftentimes, a combination of both types are present at the same time.
The strict avoidance of sunlight is strongly recommended during the treatment process.
References
Current knowledge in Polypodium leucotomos effect on skin protection
Polypodium leucotomos as an Adjunct Treatment of Pigmentary Disorders
Role of oral Polypodium leucotomos extract in dermatologic diseases: a review of the literature
Blockade of melanin synthesis, activation and distribution pathway by a nonprescription natural regimen is equally effective to a multiple prescription-based therapeutic regimen
Effects of ascorbic acid on gingival melanin pigmentation in vitro and in vivo
Oral intake of proanthocyanidin-rich extract from grape seeds improves chloasma
A randomized, double-blind, placebo-controlled trial of oral procyanidin with vitamins A, C, E for melasma among Filipino women
A protective effect of the Mediterranean diet for cutaneous melanoma
