Melasma: A Closer Look Into These Dark And Pigmented Patches

Melasma is often referred to as the “mask of pregnancy”, a hyperpigmentation condition that commonly manifests in expectant mothers. With that said, it can still develop in non-pregnant women, and even some men.

It is also more prevalent among and lasts longer in people with deeper skin tones. While it is not a harmful condition, there may still be an impact on one’s self-esteem due to these patches.

The causes of melasma

Hormones

The pathogenesis of melasma is multifactorial, although estrogen is considered to be a key element in this skin condition. When the pigment-producing cells (melanocytes) in the skin produce too much melanin, it can lead to darkening of the skin – and the underlying hormone responsible for this is Melanocyte-Stimulating hormone (MSH).

The levels of MSH are raised during pregnancy and in women who are using birth control pills or hormone replacement therapy (HRT), which lead to increased production of melanin and thereby hyperpigmentation of the skin. Women in a peri-menopausal state also experience melasma that could be caused by hormonal fluctuations.

Other hormones are also suspected of playing a role in melasma. Specifically, those with thyroid disorders have a higher incidence of melasma. The mechanism of how thyroid hormones affect melasma is still unclear, but studies have reported more melasma patients with thyroid disorders compared to the control group.

Sunlight exposure

But it’s not just the elevated hormonal levels. Ultraviolet (UV) light from the sun also stimulates the melanocytes – no thanks to the UVA and UVB exposure. UV radiation induces the increase of melanogenic activity, which causes the development of pigmentation that occurs more intensely in locations with melasma. This is why melasma pigmentation usually worsens during the summer seasons and tropical climates.

Just a small amount of sun exposure, combined with the sun’s heat, is enough to trigger melasma since it increases vascular dilatation: widening of the blood vessels that increases blood flow. But unlike rosacea, this vascularity is mediated by mast cells that degranulate chemokines – in other words, it creates photodamage.

Then, there is also the vascular endothelial growth factor, a protein that promotes the growth of new blood vessels, which are found in high levels in melasma-affected skin. Combined with the heat, the sun also leads to more inflammation in the skin, further stimulating melanocyte pigment production.

Recognising melasma

How to know if you have melasma? There are 3 types of melasma: epidermal, dermal and mixed.

Epidermal – occurs at the top layer of the skin where the hyperpigmentation is brown and has well-defined borders
Dermal – occurs at the deeper dermis level and can be identified by blue-gray patches
Mixed – a combination of both, showing as a brown-gray pigment which can be harder to treat

The patches can be sharply marginated and roughly symmetrical. There are also 3 predominant facial patterns:

Centrofacial – the forehead, nose and upper lip
Malar – the cheeks
Mandibular – the jawline and chin

Symmetry is an important clinical feature that dermatologists look out for – melasma has to affect both sides of the face. The same goes for non-facial body parts, such as the neck, forearms and sternum, which are prone to sun exposure.

In general, melasma rarely impacts any facial bony contours like above the cheekbone or in the periorbital area. These characteristics help doctors to avoid a misdiagnosis.

But to see how deeply the melasma penetrates the skin, one testing technique that is used is Wood’s lamp examination. It uses transillumination (light) to help detect any bacterial or fungal skin infections as well as skin pigment disorders. In a darkened room, Wood’s lamp will highlight the changes of pigmentation of the skin. This allows dermatologists to determine which treatments are more suited to the condition of melasma.

Coping with melasma

In some women, melasma can disappear on its own, especially when the cause is removed. For example, once the baby is born and the hormones have settled, or if they stopped taking birth control pills. But, there are times when the pigmented patches can last for many years or even become permanent.

To make sure the condition doesn’t get worse, you can do a few things to minimise the appearance of the discolouration, including:

Applying sunscreen daily with at least SPF 30
Using makeup to cover areas of discolouration and even out skin complexion
Wearing protective clothing to shield or provide shade from the sun for extended periods
Choosing skincare products that are gentle and does not cause stinging or burning effects as it can cause skin inflammation

And since melasma can be caused by other conditions, such as thyroid disease, it is wise to get it checked out so you can be sure of the underlying cause.

Treating melasma

Treatments for melasma are aimed at different aspects of how it develops, including vascularity, photodamage, inflammation and pigmentation. It can take in the form of oral, topical, procedural or a combination of treatments. The goal is not only to lighten the existing melasma patches, but to also prevent future patches from forming – and sun protection plays a big role here.

Below are some of the treatments your dermatologist might recommend.

Topical

Topical treatments are chosen based on the mechanism of action, such as increasing cell turnover and preventing melanogenesis (or the production of melanin in the skin). For instance, lightening agents like Azelaic acid and Kojic acid help to reduce abnormalities in skin pigmentation due to the accumulation of melanin.

Often, various topical therapies are used synergistically alongside each other to produce more significant results compared to individually – such as corticosteroid, tretinoin and hydroquinone to help with skin lightening.

Hydroquinone is a common skin-bleaching agent that decreases the formation of melanin in the skin by inhibiting tyrosinase, responsible for melanin production. Studies have shown that it has led to significant improvement in melasma dyspigmentation.

Though it is effective and available in different strengths, the use of hydroquinone is best supervised by your doctor since it can cause skin irritation and the risk of exogenous ochronosis, which is a permanent form of hyperpigmentation.

Oral

Oral therapies are also emerging to provide more treatment options for melasma. Tranexamic acid (TA) can decrease the production of arachidonic acid to reduce MSH and lower pigmentary production.

Recent studies have suggested that around 90% of patients who receive oral treatment improve after 2 to 6 months. However, there are side effects of oral TA such as an increased risk of clotting in those with pre-existing hypercoagulable disorders, and you should only have this if the doctor feels that it is a safe and suitable option for you.

Chemical peels

Chemical peels are generally done over several sessions for a period of time to remove unwanted melanin by exfoliating the skin.

Glycolic acid (GA) is one of the most common options used to increase epidermal remodelling and keratinocyte turnover, essentially to restore a healthier skin status and a more even complexion. Depending on the severity of your melasma and skin condition, different strengths of GA may be recommended, and other suitable options include Mandelic acid, Pyruvic acid and Jessner’s peel.

Laser treatments

When melasma is resistant to other treatment options, lasers can be considered. But, it should be noted that that the efficacy of lasers for treating melasma has been associated with adverse effects, including inflammation and post-inflammatory hyperpigmentation.

However, in experienced hands, lasers can be carried out safely and may even produce results faster than topical medications. Non-ablative lasers are preferred, given the tendency to cause less inflammation and, subsequently, hyperpigmentation.

The PicoSure laser is one example that works quickly to treat melasma by producing an intense photoacoustic impact that will break down the hyperpigmentation in the skin – all in trillionths of a second. With its ultra-short pulse duration, it uses patented PressureWave^TM technology to magnify pressure that greatly optimises the shattering of pigments.

Final thoughts

Regardless of the treatment option you go for, one rule remains unchanged: sun protection is key. During the recovery process, it is important that you avoid sun exposure and protect your skin adequately – otherwise, any treatment will be unsuccessful since the melasma can return or worsen.

Here at Angeline Yong Dermatology, we understand how skin conditions can greatly leave emotional and psychological impacts, and having a clear complexion is a skin goal almost everyone is striving towards. Dr Angeline Yong is a Singapore-based, MOH-accredited dermatologist with extensive experience in dermatological and laser surgery, skin cancers, and hair transplant surgery, just to name a few.

With a ‘patients first’ philosophy, Dr Yong will work closely with you to assess the condition of your melasma, its intensity and pattern of discolouration, potential causes, and other personal factors that could affect the treatment plan. Our dermatology clinic also provides all-round dermatological services for other common skin conditions such as wrinkles, acne, mole removal and rosacea.

No matter your skin concerns, trust that you will be in good hands with Dr Yong! Give us a call for any questions or book an appointment to kick-start your journey to healthy, happy skin.

References

Ogbechie-Godec, O. A., & Elbuluk, N. (2017). Melasma: an Up-to-Date Comprehensive Review. Dermatology and therapy, 7(3), 305–318. https://doi.org/10.1007/s13555-017-0194-1

Fatima S, Braunberger T, Mohammad TF, Kohli I, Hamzavi IH. The role of sunscreen in melasma and postinflammatory hyperpigmentation. Indian J Dermatol 2020;65:5-10

Handel, A. C., Miot, L. D., & Miot, H. A. (2014). Melasma: a clinical and epidemiological review. Anais brasileiros de dermatologia, 89(5), 771–782. https://doi.org/10.1590/abd1806-4841.20143063

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Melasma: A Closer Look Into These Dark And Pigmented Patches