Melasma: An overview 

                
Any health condition that affects your skin, especially your face can make you more self-conscious about your appearance. Melasma is one of those skin problems. It is a very frustrating and stubborn skin condition. It typically doesn't cause any pain or discomfort but can significantly hamper the quality of life for those who suffer from it. In this blog, we will try to make you understand what melasma is, what are its causes, and what are the options available for its treatment.

What is Melasma?

Melasma, which is also known as chloasma, is a common hyperpigmentation skin disorder that causes dark, gray-brown patches to appear on the skin. It usually appears on the face, including the cheeks, upper lip, and forehead but it can also affect other parts of the body that are usually exposed to the sun like the forearms and neck. Melasma is found to be more prevalent among individuals with light brown skin to darker skin tones and it mainly affects women more than men.

The word melasma and the word melanin come from the same Greek word melas which means black. Actually, it is the amount of melanin (a type of pigment) in your skin that determines the color of your skin. In melasma, the pigment-producing cell melanocytes become overactive and increase the production of melanin which causes dark patches to appear on your skin.

Even though it is not a harmful skin condition that causes any serious medical concern, still it can change the way your skin looks and affect your physical appearance.

What are the Symptoms of Melasma?
Melasma usually has no physical symptoms other than visible brownish-colored patches and discoloration of the skin. The affected skin is not painful or itchy but the condition may cause cosmetic concerns that can lead to depression and low self-esteem. 

In melasma, people generally complain about the slow appearance of the dark patches of pigmentation on the skin, especially on the face. The distribution of pigmentation is usually symmetrical and has some of the following patterns 

●      Centrofacial: The melasma affects your forehead, cheeks, nose, and upper lip.

●      Brachial: The melasma occurs on your shoulders and upper arms.

●      Lateral cheek pattern: The melasma affects both cheeks.

●      Malar: The melasma pops up on your cheeks and nose.

●      Mandibular: The melasma affects your jawline.

●      Neck: melasma can appear on all sides of the neck, especially in people aged 50 or older.

What are the Causes of Melasma?

What exactly causes melasma is still completely not understood. however, certain elements can provoke this condition which include:

Genetics

 
Some genetic factors contribute to the development of melasma, for example, people with darker skin tones are more prone to develop this condition.

Recent studies show that melasma can run into families and can be inherited by both men and a woman. One study shows that 70 percent of Latino men who were diagnosed with melasma also had family members with this condition.

Gender

Gender is another factor that affects the susceptibility of melasma. Women are more prone to this condition. The female preponderance ratio may vary from one population to another based on different factors such as skin type and sun exposure. However, according to one study, the female to male prevalence ratio is approximately 4: 1.

Sun exposure 

Sunlight is one of the major factors that trigger melasma. When ultraviolet light from the sun hits your skin, it stimulates melanocytes (pigment-producing cells) by producing certain pro-inflammatory chemicals. The stimulated melanocytes then cause overproduction of the melanin (pigment cells), which are the reason to give your skin a tan but they also provoke the melasma condition by making it darker. That's why during the summer season people often notice their melasma become worse as they are exposed to more sunlight.

Besides sun exposure, melasma could also get worse by extreme artificial light. Those people who have melasma and work under these kinds of lighting situations are difficult to treat. 

Melasma can also intensify by infrared radiation.

Hormones 

Hormones are another most common factor that can trigger melasma. The mechanism behind it is not yet fully understood. However, it is thought that it is because of the presence of estrogen and progesterone receptors on pigment-making skin cells melanocytes.

When estrogen stimulates melanocytes, they increase the production of skin pigments. At the same time, estrogen also increases the production of a pigment-forming enzyme known as tyrosinase, in the body which further increases the amount of melanin. Estrogen also makes melanocytes more sensitive to sun radiation by increasing the number of skin melanocortin receptors. Research has established the effect of estrogen on melanocytes and the induction of hyperpigmentation in melasma. Since women naturally have a higher level of estrogen in the body, this is one of the reasons that melasma develops more frequently in women than men.

To some extent, higher progesterone levels can also be the culprit to trigger melasma. Because it is seen that greater numbers of progesterone receptors are present in the affected area of skin among individuals with melasma.  It increases their skin sensitivity toward high progesterone levels.

Because of the high hormonal influence on melasma, it seems that most women experience some degree of melasma during or after pregnancy. It is estimated that about 70% of pregnant women suffer from melasma and that's why this condition is sometimes referred to as a “mask of pregnancy.”

The contraceptive pill and other hormone replacements may increase your risk of developing melasma.

Stress

Stress doesn't cause skin irritation directly, but according to some researchers it is considered to be a possible trigger that causes melasma.  Actually, in stress, the amount of cortisol hormone increases in your body which further influences the amount of estrogen and indirectly affects the production of melanin. So, if you want to prevent this situation then take it easy on yourself – and don't stress too much.

Thyroid problems

The thyroid gland is a vital endocrine gland. It is located in your mid-lower neck. It releases a hormone called ‘thyroxine’ which is required for the proper functioning of many body cells, including your skin. Studies show that among the patients with melasma 20.3% of people have thyroid disorders.

Certain Medications and Skin Products

According to research, taking certain medications can flare up melasma such as anticonvulsants. One of the most studied causes of melasma is skin irritants, products that cause skin irritation. These include certain fragrances, soaps, and cosmetics. So If you have melasma due to genetics, gender, and skin type, it is advisable to choose those products that are unscented and gentle on the skin.

How to Treat Melasma?

We have already discussed melasma and its causes in detail, now let’s look at what are the treatment options available for it. Unfortunately, this condition can't be cured totally. However, there are certain precautionary steps, medications, and procedures available which are helpful in its management and eventually lessen the impact of melasma.

It is important to know that these treatment options will not be beneficial for everyone and don't promise complete results. It means some of the dark patches may be faded while some remain unaffected. In addition, relapse of melasma can happen even after successful treatment.

Preventive Measures 

The first step you should take to treat melasma is to make sure it doesn't get any worse. You can do this by taking the following preventive measures:

Limit your Sun Exposure

Sometimes prevention is better than cure so it is good if you limit your sun exposure at most. Definitely, you can not stay at home 24/7 but try to avoid sun exposure as much as possible. Whenever you head outside, be sure to wear sunscreen of at least SPF 30 or above and cover your head with a wide-brimmed hat.

Avoid Irritants

Try to avoid any cosmetics or toiletries that irritate your skin, as inflammation can exaggerate melasma and can make your skin even darker.

Avoid Stress 

As we discussed in the causes of melasma, stress can make your condition even worse. So you shouldn't take too much stress as it will not do any good for you, try to manage it with yoga or exercise.

Avoid Estrogen-containing Pills 

Hormones, especially estrogen can trigger melasma. That's why taking birth control pills can increase the severity of your condition. So it is best for you if you consult with your doctor to either change your contraceptive method, as the non-hormonal contraceptive method will not affect your condition, or switch to another birth control pill. All birth control pills don't use estrogen, so you can switch to a progestin-only mini pill from a combined birth control pill. 

Both of these methods will help in improving the melasma condition caused by hormonal influence. However, these options work only for reducing the symptoms caused by the intake of birth control pills and will not treat the skin that is already affected by the melasma. 

Topical and Oral Medical Agents

After taking all the preventive measures that are mentioned above,  the second step you can take to cure melasma is the use of topical and oral treatment. They produce their effects by different mechanisms of action such as decreasing melanin production, increasing skin turnover rate, decreasing excess blood vessels in the skin that contribute to melasma, and reducing inflammation. 

Most commonly used topical agents that are effective for melasma are 

●      Hydroquinone

●      Tretinoin

●      Corticosteroids

●      Kojic acid

●      Azelaic acid

●      Methimazole, Vitamin C (L-Ascorbic acid)

●      Niacinamide (Vitamin B3)

Some drugs can also be given by oral route such as: 

●      Tranexamic acid

●      Melatonin 

●      Glutathione

There are many other oral and topical agents that are under investigation for their role in the treatment of melasma. 

Like every medication, medical agents used for melasma can also have possible side effects. This includes extra darkness of the skin caused by treatment-induced inflammation or extra lightening of the skin. However, it is important to use them under the supervision of a dermatologist to gain maximum benefits and fewer relapses.

Medical Procedures 

Sometimes following medical procedures are also required for treating melasma, especially if topical treatment is not working for you. These procedures should have been performed by licensed professionals for obtaining the best results.

Chemical Peels

Chemical peeling is a method in which the outermost layer of skin (epidermis) is removed by applying a chemical solution.

As a result of this process, new smooth skin will be formed without any unwanted pigmentation. The peeling agents which most commonly used are 

●      Trichloroacetic acid

●       Glycolic acid

●       Salicylic acid

●      Tretinoin and 

●      Jessner’s solution

It is always recommended that the procedure must be done by a board-certified dermatologist to avoid unwanted side effects.

Microdermabrasion

This is a cosmetic procedure in which with the help of a special device that has an abrasive surface the very top layer of the skin is gently removed. It is best if it is done by a licensed specialist but home kits are also available on the market.

Lasers

In laser therapy, a beam of light is targeted to destroy the pigment cells in the skin. It makes your skin lighter by decreasing the amount of pigmentation. It should have to be done by a professional who has the best laser device.

Micro-Needling 

Microneedling is a minimally-invasive treatment in which small needles are used to make tiny pores in the outermost layer of the skin. This procedure stimulates the production of collagen and elastin which help in making the skin better and also increases the penetration of certain topical creams for enhancing their effects. 

Conclusion 

Living with melasma can be very tough. It is a very annoying skin condition that may recur after complete recovery. However, you can see better results if you follow the right skincare routine as instructed by your dermatologist and also take all the preventive measures like avoiding sun exposure, and the other irritants that can lead to melasma.

 By: Dur-e-Sameen