Behind the Mask of Melasma

Sweet summer. The time of year that invites us outdoors to enjoy all sorts of fun activities - beach trips, bike rides, picnics, the list goes on. Unfortunately for some, it’s also the time of year that brings on the appearance of uneven skin pigmentation, a condition known as melasma.

What we do know is that melasma is an acquired increased pigmentation of the skin, that look like grey-ish brown patches, mostly in the sun-exposed areas¹. Though we are aware of the triggers, what we don’t know is why certain people get it in the first place. This can be extra frustrating when it comes to diagnosing and treating the condition.

Luckily melasma isn’t dangerous, though it can seriously mess with your quality of life. But don’t fret. From causes to cover-ups, we’re going to take a look at what brings on melasma and what you can do to treat it and help prevent it altogether.  

Recognizing the Patterns of Melasma

Melasma can appear as freckles (sun spots) or larger flat brown patches with an irregular border. These spots of hyperpigmentation can happen anywhere on the face, though some areas are more common than others. Let’s take a look at the patterns:

Clinical Patterns

Where melasma decides to make its appearance differs from person to person, skin tone to skin tone. These are the 3 clinical patterns²:

• Centrofacial pattern is the most common, and affects the forehead, cheeks, nose and upper lips.
• Malar pattern is one that appears on the cheeks and nose.
• Mandibular pattern is the least common and affects the jawline.

Histological Patterns

With the help of Wood Lamp’s examination, certain histological patterns have been uncovered to help diagnose and treat the condition more specifically. The Wood’s lamp shines ultraviolet onto the skin in a dark room to observe fluorescence on the skin to determine how deep the condition lies³. Through this examination, Melasma is divided into 3 histological types:

Epidermal melasma: This is the most common form of melasma where the pigmentation appears more intense under the Wood’s light. Melanin is distributed throughout the epidermis (top layer of skin), so topical treatment may work best here^4.

Dermal melasma:  In this case, the pigmentation is not intensified under the Wood’s lamp as it lies in the second layer of the skin. This type may require more intense options for treatment⁴.

Mixed type melasma: A combination of both epidermal and dermal, Wood's light intensified pigmentation in some areas while other areas remain unchanged. This type may require combination treatment therapy⁴.

Transient vs. Persistent Patterns

Another way to classfiy melasma is to determine whether it is a transient or persitent condition. Hyperpigmentation patches that disappear within a year of removing risk factors, i.e. a year after pregnancy or by discontinuing the use of birth control, are referred to as transient. If melasma is still present after a year of removing these factors, it’s known as persistent, due to persistent exposure to risk factors like the sun⁵.

What Triggers Melasma?

As mentioned earlier on, we may not know what causes melasma to appear in the first place, but we are well aware of the stimuli that exacerbate the condition. Let’s take a look at the big ones:

The Sun

This is the most common aggravator in those who are affected by melasma. Why? Ultraviolet (UV) light from the sun stimulates the melanocytes, which are the cells responsible for producing melanin – a substance that gives skin and hair its natural colour⁶. Melasma occurs when these melanocytes produce too much colour, something that happens more often in the summer months as we spend more time outside with our skin exposed. Melasma caused by sun exposure often fades in the winter and then makes its return in the summer⁷.

Infrared Light

The type light that we can see with our eyes is only a tiny fraction of light that exists. Gamma rays, X-rays, ultraviolet light, microwaves, radio waves, even the heat you feel from the campfire are all examples of infrared light - all of which can affect the dermal layer of the skin⁸. While this type of light is nearly impossible to avoid, topical treatments containing antioxidants can help provide some protection against damage caused by infrared light⁹.

Hormonal Fluctuations

Like the sun, hormones have a big impact on melasma. And since women are most prone to hormonal changes, they are most affected by the condition – 90% to be exact¹⁰. This is where the “mask of pregnancy” term comes from, as those unsightly dark patches tend to crop up during this time. Hence, birth control pills and any other kind of hormone replacement therapy are also considered hormonal triggers for melasma.

Skincare Products

Outside of hormones and pregnancy, there may be something in your skincare products that are bringing on the blotches. It’s a condition known as pigmented contact dermatitis. Typically, contact dermatitis appears when skin is aggravated by a product being used in the area, resulting in red and scaly patches of skin¹². Pigmented contact dermatitis is clinically characterized by hyperpigmentation with little or no signs of dermatitis¹³. Meaning instead of dry patches of skin, there are hyperpigmented patches.

What Can You Do to Prevent Melasma?

Though not ideal, avoiding the big visible light triggers like the sun, can really help. If you can’t completely avoid it, you should do whatever you can to help protect yourself from aggravating the condition even further. Using the right sun protection and minimizing irritating influences can work wonders in controlling melasma and even help it from appearing in the first place.

Use Sunscreens that Block Visible Light

To date, only sunscreens containing iron oxide protect efficiently against UV radiation and VL¹⁴.  How? The latest research shows that the blue wavelength of the visible light is the culprit of recurrent pigmentation. Iron oxides have been shown to block this blue wavelength which also helps prevent melasma relapses, combining protection against UV and VL¹⁵. 

Use Non-irritating Skincare Products

Common sense tells us that any product that irritates the skin, will irritate a skin condition. So discontinuing the use of harsh facial products that aggravate melasma is highly recommended.

Avoid waxing

Waxing, particularly in the upper lip area, is not an ideal mode of hair removal when trying to treat melasma. Again, anything that causes skin inflammation or irritation can not only set you back in treatment, but it can also worsen the condition¹⁶. Ask a dermatologist about other types of hair removal that might be right for you.

What Can You Do to Treat Melasma?

As we discussed, transient melasma (present during pregnancy or through the use of birth control pills) can clear up within a year after the stimulus is removed¹⁷. There are also treatment options to help minimize the appearance of any type of melasma at any stage.

Topical Creams: Your First Line of Treatment

It’s recommened to start with topical creams to help diminish discolouration and won’t sting or burn the skin. Here are some ingredients to look for:

Beta-T
Beta-Thujaplicin is a proven antibiotic, anti-oxidant, anti-melanogenic and anti-inflammatory ingredient. Gentle, yet powerful, Beta T inhibits the formation of pigment by blocking the enzyme tyrosinase, acting as nature’s whitening agent¹⁸. 

Hydroquinone
Available in a cream, lotion, gel or liquid, this medication works by lightening the skin and is considered as one of the most effective ingredients used in the treatment of hyperpigmentation¹⁹. Hydroquinone can be found in over-the-counter treatments, but you can get a more powerful version from your dermatologist.

Retinoids have long been touted as beneficial ingredients in treating a host of skin conditions, including melasma. Amongst the retinoids, tretinoin possibly is the most potent and certainly the most widely investigated retinoid for all kinds of skin pigmentation disorders²⁰.

A topical corticosteroid is an anti-inflammatory ingredient that has an anti-metabolic effect on melanocytes, meaning it has a mild pigment-reducing quality²¹. Tretinoin and corticosteroids enhance the skin lightening process when added to hydroquinone. This triple threat, also known as “triple combination cream”, is known to produce very effective results in the treatment of melasma²².

In-Office Dermatology Procedures for Extreme Cases

When topical treatments don't do the trick, you may want to see a dermatologist for an in-office procedure to help speed up results. These types of procedures intend to remove the outer layers of the hyperpigmented skin so fresh, new skin can grow. Whether through laser treatment, chemical peels or through microdermabrasion, these procedures must be done very carefully or they can cause increased pigmentation²³. Hence, only an experienced cosmetic dermatologist should perform them for best results.

Melasma is a frustrating skin condition that can affect anyone at any time. However, by avoiding the triggers outlined in this article combined with the advancement of treatment options, it can also be extremely manageable. As with any skin condition, we recommend speaking with a professional dermatologist to determine exactly what type of skin condition you may have so you can get the best possible treatment options out there. 

References

1. Indian J. Dermatol (2011) Melasma: A clinic-epidemiological study of 312 cases Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178998/
2. Bagherani N, Gianfaldoni S, Smoller B (2015) An Overview on Melasma. Pigmentary Disorders https://aestheticsjournal.com/feature/melasma-a-brief-overview-of-classification-and-treatment-modalities
3. Can Fam Physician (2012) Wood lamp examination. Retrieved from:   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3440273/
4. Indian J Dermatol (2009) Topical Treatment of Melasma. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807702/
5. Clin Cosmet Investig Dermatol (2016) Assessment of efficacy, safety, and tolerability of 4-n-butylresorcinol 0.3% cream: an Indian multicentric study on melasma. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4725640/
6. Postepy Dermatol Alergol (2013) Skin melanocytes: biology and development. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834696/
7. American Academy of Dermatology Inc. Retrieved from: https://www.aad.org/public/diseases/color-problems/melasma#causes
8. J.S Sweitzer (1994) What is Infrared Light. Retrieved from: http://astro.uchicago.edu/cara/about_cara/defn/irlight.html
9. Schalka (2017) New data on hyperpigmentation disorders. Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/jdv.14411/full
10. Dermatol Reports (2017) Retrospective Analysis of Endemic Melasma Patients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5475413/
11. Goglia L, Bernacchi G, Gianfaldoni S (2014) Melasma: A Cosmetic Stigma During Pregnancy. Pigmentary Disorders. Retrieved from: https://www.omicsonline.org/open-access/melasma-a-cosmetic-stigma-during-pregnancy-2376-0427.1000S1007.php?aid=37172
12. Prabha,  Mahajan, Mehta, Chauhan, Gupta (2014) Cosmetic Contact Sensitivity in Patients with Melasma: Results of a Pilot Study. Retrieved from: https://www.hindawi.com/journals/drp/2014/316219/
13. S. Shenoi, R. Rao (2007) Pigmented contact dermatitis. Retrieved from: http://www.ijdvl.com/article.asp?issn=0378-6323;year=2007;volume=73;issue=5;spage=285;epage=287;aulast=Shenoi
14. S. Shalka (2017) New data on hyperpigmentation disorders. Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/jdv.14411/full
15. R. Bissonnette MD, FRCPC. Update on Sunscreens. Retrieved from: http://www.skintherapyletter.com/2008/13.6/2.html
16. American Academy of Dermatology (2014) Melasma: tips to make it less noticeable. Retrieved from: https://www.aad.org/media/news-releases/melasma-tips-to-make-it-less-noticeable
17. An. Bras. Dermatol vol.89 no5 Rio de Janeiro (2014) Melasma: A clinical and epidemiological review. Retrieved from:  http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962014000500771
18. Beta-Thujaplicin (Pacific Red Cedar). Retrieved from: https://www.riversol.ca/pages/beta-thujaplicin
19. Photodermatol Photoimmunol Photomed. (2014)  Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/24313385
20. Clin Interv Aging (2006) Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699641/
21. Dermatol Ther (Heidelb). (2014) Evidence-Based Treatment for Melasma: Expert Opinion and a Review. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4257945/
22. Indian J. Dermatol (2009) Triple Combination Of Hydroquinone, Tretinoin And Mometasone Furoate With Glycolic Acid Peels In Melasma. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800888/
23. International Journal of Women's Dermatology Volume 3, Issue 1 March 2017, Pages 11-20. (2017) A review of laser and light therapy in melasma. Retrieved from: http://www.sciencedirect.com/science/article/pii/S2352647517300047

1. Introduction
2. Recognizing the Patterns of Melasma
3. What Triggers Melasma?
4. What Can You Do to Prevent Melasma?
5. What Can You Do to Treat Melasma?