Melasma

  • Medical Author: Joel Schlessinger, MD
  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Melasma facts

  • Melasma is most common in women 20-50 years of age.
  • Melasma looks like brown, tan, or blue-gray spots on the face (hyperpigmentation).
  • Melasma is characterized by three location patterns (central face, cheekbone, and jawline).
  • 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.

What is melasma? What are signs of melasma?

Melasma is a very common patchy brown, tan, or blue-gray facial skin discoloration, usually seen in women in the reproductive years. It typically appears on the upper cheeks, upper lip, forehead, and chin of women 20-50 years of age. Although possible, it is uncommon in males. Most of those with melasma are women. 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, although heat is also suspected to be an underlying factor. Melasma is most common among pregnant women, especially those of Latin and Asian descents. People with olive or darker skin, like Hispanic, Asian, and Middle Eastern individuals, have higher incidences of melasma.

Prevention is primarily aimed at facial sun protection and sun avoidance. Treatment requires regular sunscreen application, medications such as 4% hydroquinone and other fading creams.

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Melasma Treatment

Who is a good candidate for a chemical peel?

The most common candidate for a chemical peel is a person with sun-damaged skin, uneven pigmentation, and/or actinic keratoses.

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 and progesterone), family history of melasma, race, antiseizure medications, and other medications that make the skin more prone to pigmentation after exposure to ultraviolet (UV) light. Uncontrolled sunlight exposure is considered the leading cause of melasma, especially in individuals with a genetic predisposition to this condition. Clinical studies have shown 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. Melanocytes are the cells in the skin that deposit pigment. 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 methods for these individuals include sun avoidance and application of extra sunblock 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).

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-complexioned 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) throughout 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.

How is melasma diagnosed?

Melasma is readily diagnosed by recognizing the typical appearance of brown skin patches on the face. 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, although is not essential for diagnosis. 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 of this local skin hyperpigmentation.

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What is the treatment for melasma?

The most common melasma therapies include 2% hydroquinone (HQ) creams like the over-the-counter products Esoterica and Porcelana and prescription-strength 4% creams like Obagi Clear, Tri-Luma, NeoCutis Blanche, and 4% hydroquinone. Certain sunscreens also contain 4% hydroquinone, such as Glytone Clarifying Skin Bleaching Sunvanish SPF 23 and Obagi's Sunfader sunscreen. Products with HQ concentrations above 2% sometimes require a prescription or are dispensed through physician's practices. Clinical studies show that creams containing 2% HQ can be effective in lightening the skin and are 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.

Melasma may clear spontaneously without treatment. Other times, it may clear with sunscreen usage and sun avoidance. 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, 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, NeoStrata)
  • Glycolic acid peels 10%-70%
  • Other proprietary ingredients and mixtures of ingredients as in Elure, Lumixyl, and SkinMedica's Lytera products

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 exogenous ochronosis. In this condition, the skin actually darkens while the bleaching agent is used. 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 upward 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. 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, although the beneficial effects are not very impressive.

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%-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 covered by medical insurance providers.

Do lasers work for melasma?

Lasers may be used in melasma, but they generally produce only temporary results. Laser therapy is not the primary choice to treat melasma as studies reveal little to no improvement in the hyperpigmentation for most patients. Lasers may actually 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 breastfeeding 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.

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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%-20% azelaic acid was very effective and safe in melasma, although the overall results are significantly less impressive than 4% hydroquinone. There are no major complications reported with azelaic acid. Possible minor side effects include itching (pruritus), redness (erythema), scaling (dry patches), and a temporary burning sensation that tends to improve after 14-30 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 six to eight weeks from starting treatment. Tri-Luma should not be used for prolonged periods exceeding eight weeks without your doctor's recommendation. It should not be used by pregnant or breastfeeding women unless specifically instructed by your physician. According to the label, it must also be refrigerated.

Other combination creams include the Kligman formula which is a triple cream including a retinoid, a hydroquinone, and a topical steroid (for example, fluocinolone acetonide 0.01%, hydroquinone 8%, and tretinoin 0.1%). These triple combination creams may be compounded in different strengths by specialty pharmacists according to a physician's prescription. Triple creams are highly effective for melasma.

What SPF is recommended for melasma?

A daily sun protection factor (SPF) of at least 50 that contains physical blockers, such as zinc oxide and titanium dioxide, is recommended to block UV rays, but it is important to have a sunblock that also covers for UVA protection. 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 melasma. 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 sunblock 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. Just as 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. Melasma cases that do not successfully respond to treatment are due to excessive sun exposure.

Medically reviewed by Norman Levine, MD; American Board of Dermatology

REFERENCE:

Freedberg, Irwin M., et al. Fitzpatrick's Dermatology in General Medicine. 4th ed. Vol. 1. New York: McGraw-Hill, 1993.

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Reviewed on 2/23/2015
References
Medically reviewed by Norman Levine, MD; American Board of Dermatology

REFERENCE:

Freedberg, Irwin M., et al. Fitzpatrick's Dermatology in General Medicine. 4th ed. Vol. 1. New York: McGraw-Hill, 1993.

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