The Skin Center
26081 Merit Circle Suite #109
Laguna Hills, CA 92653
Fax (949) 582-7691
Nili N. Alai, MD, FAAD and Lauren Albert, B.S.
What is Melasma?
Melasma is a very common patchy facial skin discoloration, almost entirely seen in women. It typically appears on the face of women ages 20-50. Although possible, it is uncommon in males. Brown or tan skin discoloration called hyperpigmentation is typically seen in patches on the face of women, typically in the reproductive years. Melasma is identified by easily recognizable patterns of brown or gray-blue patches on the face, particularly on the upper cheeks, upper lip, forehead, and chin. It is thought to be primarily related to external sun exposure, external hormones like birth control pills, and internal hormonal changes as seen in pregnancy. Most people with melasma have a history of daily or intermittent sun exposure. People with olive or darker skin like Hispanics, Asians, and Middle Eastern have higher incidences of melasma.
There are several types of melasma including epidermal melasma where spots appear brown, dermal where spots appear blue-gray, and mixed where both colors are seen. Melasma is most common among pregnant women, especially of Latin and Asian descents. An estimated six million women are living in the U.S. with melasma and 45-50 million women worldwide with melasma; over 90% of all cases are women. Prevention is primarily aimed at facial sun protection and sun avoidance. Treatment requires regular sunscreen application and multiple fading creams.
What causes Melasma?
The exact cause of melasma remains unknown. Experts believe that the dark patches in melasma could be triggered by several factors including pregnancy, birth control pills, hormone replacement therapy (HRT), family history, race, anti-seizure medications, and other medications that make the skin more prone to UV light. Uncontrolled sunlight exposure is considered the leading cause of melasma, especially in individuals with a genetic predisposition to this condition.
- · Pregnancy
- · Birth control pills
- · Progesterone
- · Hormone replacement therapy (HRT)
- · Family history of melasma
- · Sun exposure
Uncontrolled sun exposure is considered the leading cause of melasma, especially in individuals with a genetic predisposition to this condition. Clinical studies have confirmed that individuals typically develop melasma in the summer months, when the sun is most intense. In the winter, the hyperpigmentation in melasma tends to be less visible or lighter.
When melasma occurs during pregnancy it is also called Chloasma, or “the mask of pregnancy”. Pregnant women experience increased estrogen, progesterone and melanocyte-stimulating hormone (MSH) levels during the second and third trimesters of pregnancy. However, it is thought that pregnancy related melasma is caused by the presence of increased levels of progesterone and not due to estrogen and MSH. Studies have shown that postmenopausal women who receive progesterone hormone replacement therapy are more likely to develop melasma. Postmenopausal women receiving estrogen alone seem less likely to develop melasma.
In addition, products or treatments that irritate the skin may cause an increase in melanin production and accelerate melasma symptoms.
People with a genetic predisposition or known family history of melasma are at an increased risk of developing melasma. Important prevention steps include sun avoidance and application of extra sun block to avoid stimulating pigment production. These individuals may also consider discussing their concerns with their doctor and avoiding birth control pills and hormone replacement therapy (HRT) if possible.
Where is melasma seen on the body?
Melasma is characterized by discoloration or hyperpigmentation primarily on the face. Three types of common facial patterns have been identified in melasma including centrofacial (center of the face), malar (cheekbones), and mandibular (jawbone).
Three Facial Melasma Patterns:
- · Centrofacial (center of the face)
- · Malar (cheekbones)
- · Mandibular (jaw area)
The centrofacial pattern is the most prevalent form of melasma and includes the forehead, cheeks, upper lip, nose and chin. The malar pattern includes the upper cheeks. The mandibular pattern is specific to the jaw.
The upper sides of the neck may less commonly be involved in melasma. Rarely, melasma may occur on other body parts like the forearms. One study confirmed the occurrence of melasma on the forearms of people being given progesterone. This was a unique pattern seen in a Native American study.
What are the types of melasma?
Four types of pigmentation patterns are diagnosed in melasma: epidermal, dermal, mixed, and an unnamed type found in dark complexion individuals. The epidermal type is identified by the presence of excess melanin in the superficial layers of skin. Dermal melasma is distinguished by the presence of melanophages (cells that ingest melanin) through out the dermis. The mixed type includes both the epidermal and dermal type. In the fourth type, excess melanocytes are present in the skin of dark skinned individuals.
- Unnamed type found in dark complexion individuals.
How is melasma diagnosed?
Melasma is usually readily diagnosed by the typical appearance of facial brown skin patches. Dermatologists are physicians who specialize in skin disorders and often diagnose melasma by visually examining the skin. A black light or Wood’s light (340-400 nm) can assist in diagnosing melasma. In most cases, mixed melasma is diagnosed, which means the discoloration is due to pigment in the dermis and epidermis. Rarely, a skin biopsy may be necessary to help exclude other causes.
How is melasma treated?
The most common melasma therapies include 2% hydroquinone creams like over the counter products Esoterica and Porcelana, and prescription 4% creams like Obagi Clear, Tri-Luma, and Solaquin. Products with HQ concentrations above 2% generally require a prescription. Clinical studies show that creams containing 2% HQ can be very effective in lightening the skin and less irritating than higher concentrations of HQ for melasma. These creams are usually applied to the brown patches twice a day. Sunscreen should be applied over the hydroquinone cream every morning. There are treatments for all types of melasma but the epidermal type responds better to treatment than the others because the pigment is closer to the skin surface.
- · Hydroquinone 2% (Esoterica, Porcelana)
- · Hydroquinone 4% (Obagi, Glyquin, Solaquin)
Melasma may clear spontaneously without treatment. Other times, it may clear with using sunscreens and sun avoidance only. For some people, the discoloration with melasma may disappear following pregnancy or if birth control pills and hormone therapy are discontinued.
In order to treat melasma, combination or specially formulated creams with hydroquinone (HQ), a phenolic hypopigmenting agent, azelaic acid, and retinoic acid (tretinoin), nonphenolic bleaching agents, and/or kojic acid may be prescribed. For severe cases of melasma, creams with a higher concentration of HQ or combining HQ with other ingredients such as; tretinoin, corticosteroids, or glycolic acid may be effective in lightening the skin.
- · Azelaic acid 15-20% (Azelex, Finacea)
- · Retinoic acid 0.025%- 0.1%(tretinoin)
- · Tazarotene 0.5%-0.1% (Tazorac cream or gel)
- · Adapalene 0.1-0.3% (Differin gel)
- · Kojic acid
- · Lactic acid lotions 12% (Lac-Hydrin or Am-Lactin)
- · Glycolic acid 10-20% creams (Citrix cream, Neo-Strata)
- · Glycolic acid peels 10-70%
Possible side effects of melasma treatments include temporary skin irritation. People who use HQ treatment in very high concentrations for prolonged periods (usually several months to years) are at risk of developing a side effect called ochronosis. Hydroquinone-induced ochronosis is a permanent skin discoloration that is thought to result from use of hydroquinone concentrations above 4%. Although ochronosis is fairly uncommon in the U.S., it is more common in areas like Africa where hydroquinone concentrations upwards of 10-20% may be used to treat skin discoloration like melasma. Regardless of the potential side effects, HQ remains the most widely used and successful fading cream for treating melasma worldwide. Regular medical follow-up appointments with a doctor are important for people using HQ treatment for melasma. HQ should be discontinued at the first signs of ochronosis.
What melasma treatments can I have at my doctor’s office?
In conjunction with home cream applications, in-office treatments include chemical peels (chemical exfoliation), microdermabrasion (mechanical exfoliation), and laser therapy. These additional treatments may be useful for some cases of melasma.
Many types and strengths of chemical peels are available for different skin types. The type of peel should be tailored for each individual and selected by the physician. In treating melasma, 30% to 70% glycolic acid peels are very common. Various combinations including a mix of 10% Glycolic acid and 2% HQ can be used to treat melasma.
Microdermabrasion utilizes vacuum suction and an abrasive material like fine diamond chips or aluminum oxide crystals to exfoliate the top layers of the skin. The vacuum pressure is adjusted depending on the sensitivity and tolerance of the skin. Typical microdermabrasion sessions can last anywhere from a few minutes to one hour. Minimal to no recovery time is needed after microdermabrasion. Microdermabrasion techniques can improve melasma, but dramatic results are not generally seen or expected after one or two treatments. Multiple treatments in combination with sunscreen and other creams yield best results.
There is no guarantee that melasma will be improved with these procedures. In some cases, if treatments are too harsh or abrasive, melasma can be induced or worsen. Additionally, these procedures are almost always considered cosmetic and may not be paid by medical insurance providers.
Do lasers work for melasma?
Lasers may be used in melasma. Laser therapy is not the primary choice to treat melasma as studies reveal little to no improvement in the hyperpigmentation for most patients. Laser may actually temporarily worsen some types of melasma and should be used with caution. Multiple laser treatments may be necessary to see results, as treatments are most effective when they are repeated.
To ensure that treatment doesn’t fail, people must minimize sun exposure. People who treat their melasma report a better quality of life because they feel better about themselves. As with any treatment, people should consult their physician. Pregnant women or mothers breast feeding may need to wait to treat melasma. Many melasma creams need to be discontinued in pregnancy and breastfeeding because of possible risks to the developing fetus and newborn. These people may consider cosmetics to temporarily conceal the skin discoloration.
How does hydroquinone work in melasma?
Researchers believe that the hydroxyphenolic chemical (HQ) blocks a step in a specific enzymatic pathway that involves tyrosinase; Tyrosinase is the enzyme that converts dopamine to melanin. Melanin gives skin its color.
Are there non-hydroquinone alternative treatments for melasma?
Azelaic acid is a non-hydroquinone cream that can be used to treat melasma. Studies have reported that 15% to 20% azelaic acid was very effective and safe in melasma. There are no major complications reported with azelaic acid. Possible minor side effects include pruritus (itching), erythema (redness), scaling (dry patches), and a temporary burning sensation which tends to improve after 14 to 30 days of use.
Tretinoin cream (Retin A, Renova, Retin A Micro) is a non-hydroquinone cream used to treat melasma. Most often, tretinoin is used in combination with other creams like azelaic acid or hydroquinone. Mild localized side effects are fairly common and include peeling, dry skin, and irritation. Overall, melasma may respond slower to treatment with tretinoin alone than with hydroquinone.
Other retinoid creams include tazaratone and adapelene. These are prescription creams used much like tretinoin (Retin A).
What is Tri-Luma?
Tri-Luma is a combination prescription cream containing fluocinolone acetonide 0.01%, hydroquinone 4% and tretinoin 0.05%. It is used to treat melasma and other skin discoloration. Results may be seen in usually about 6-8 weeks from starting treatment. Tri-Luma should not be used for prolonged periods exceeding 8 weeks without your doctor’s recommendation. It should not be used by pregnant or breastfeeding women unless specifically instructed by your physician.
Other combination creams include the Kligman formula which is a triple cream including a retinoid, a hydroquinone, and a topical steroid. These triple combination creams may be compounded in different strengths by special pharmacists with a physician’s prescription. Triple creams are highly effective for melasma.
Kligman formula: combine three ingredients into one cream at compounding pharmacy
Example: fluocinolone acetonide 0.01%, hydroquinone 8% and tretinoin 0.1%.
What SPF is recommended for melasma?
A daily sun protection factor (SPF) of at least 30 that contains physical blockers, such as zinc oxide and titanium dioxide, is recommended to block UV rays. Chemical blockers may not fully block both types of UV-A and UV-B as effectively as zinc or titanium. The regular use of sun protection enhances the effectiveness of melasma treatments.
Can Melasma be prevented?
Sometimes melasma may be preventable by avoiding facial sun exposure. In most cases, prevention is difficult. Individuals who have a family history of melasma must take extra precautions to prevent it from developing. The most important way to prevent the onset of melasma and premature aging is to avoid the sun. If exposure to sunlight cannot be avoided, then hats, sunglasses, and sun block with physical blockers should be worn.
What is the prognosis for melasma?
Although melasma tends to be a chronic disorder with periodic ups and downs, the prognosis for most cases is good. Since melasma develops slowly, clearance also tends to be slow. The gradual disappearance of dark spots is based on establishing the right treatment combination for each individual skin type. Cases where melasma is not successfully treated are generally due to individuals who do not avoid sun exposure entirely.
Melasma at a Glance:
- · Melasma is most common in women ages 20-50.
- · Melasma looks like dark or tan spots on the face (hyperpigmentation).
- · Melasma is characterized by three location patterns (central face, cheekbone, and jaw line).
- · Melasma is caused partly by sun, genetic predisposition, and hormonal changes.
- · The most common treatment is topical creams containing hydroquinone.
- · Melasma prevention requires sun avoidance and sun protection with hats and sunscreen.
Freedberg, Irwin M., and Thomas B. Fitzpatrick. Fitzpatrick’s Dermatology in General Medicine. 4th ed. Vol. 1. New York: McGraw-Hill, Health Professions Division, 1999. Print.
For more information, please call (949) 582-7699 or visit the practice website at www.lagunaskincenter.com.
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