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Melasma, previously referred to as chloasma, is a pigment condition that affects both females and males, although its occurrence is more frequently seen in females. This skin condition is characterized by irregular brown spots of skin that are symmetrical on sun-exposed areas of the body, especially the facial area. It is commonly seen in those with darker skin types, and onset is commonly reported to be around pregnancy or starting oral contraception. 40-50% of female patients report the disease being triggered in pregnancy. Other contributors to research suggest inflammation, the use of cosmetics, steroids and photosensitizing medications can also play a role in this condition’s cause. There are strong genetic links, with many sufferers reporting that someone in their family also suffers from the condition (Handel et al., 2014).
Facial melasma lesions can be put into two categories: centrofacial and peripheral. Centrofacial melasma is predominant in the centre of the face. With Peripheral melasma the outside regions of the face are affected. This condition is characterised by epidermal (superficial) hyperpigmentation but can be located through all layers of the skin. Interestingly, the number of melanocytes (pigment cells) does not increase, they are simply enlarged (Handel et al., 2014).
Melasma triggered by pregnancy usually disappears within a year after the birth of the child. Reoccurrence is also common in subsequent pregnancies. Melasma can cause distress for its sufferers and can affect the quality of life for some.
Sun exposure is the most triggering factor for melasma. UV radiation increases pigment production within the skin. When the skin gets sun, areas of the skin darken, and so does the melasma. As a result, melasma seems to improve during the winter months and worsens during the summer months. Heat is also known to stimulate melasma. Because of this, as clinicians, the treatments that we choose in the clinic must be carefully selected to ensure that the condition is not exacerbated (Handel et al., 2014).
Hormones such as estrogen and progesterone are the main hormones associated with melasma formation. In the third trimester of pregnancy, there is an increase in pigment production in the skin with increased placental, ovarian, and pituitary hormones. With this, the increase of tyrosinase (pigment enzyme) is seen and plays a role in the development of increased pigment. The use of cosmetics, the intake of certain drugs and a wide variety of chemicals such as arsenic, iron, copper, bismuth, silver, and gold can cause hyperpigmentation of the skin (Handel et al., 2014).
Melasma is often a challenging skin condition to manage and treat. It has high rates of recurrence, and treatments can come with adverse reactions. Melasma sufferers often reach for prescribed medications such as hydroquinone, Tretinoin, Kligman’s formula and tranexamic acid to treat their skin. Hydroquinone is gold standard in research for the treatment of melasma. TCA peels, glycolic acid, salicylic acid, azelaic acid, niacinamide, cysteamine, Thiamidol, vitamin C, kojic acid, arbutin, phytic acid, mandelic acid and modified jessner peels are commonly documented in research to support skin conditions pertaining to pigmentation such as melasma (Lai, et al., 2022; Arora, et al., 2014; Cassiano et al., 2022; Neagu et al., 2022).
Skin needling via the SkinPen, Pico second lasers, Thulium lasers such as LaseMD and Q-switch lasers have all been reported to treat melasma successfully with a low thermal heat profile, meaning the lowered risk of exacerbating melasma. Often when treating melasma, a multimodality treatment plan is the best option to obtain the best results (Arora, et al.)., 2014; Cassiano et al., 2022; Li et al., 2022; Wanitphakdeedecha et al., 2020), meaning to treat melasma effectively you may require multiple types of treatment.
Some studies have found that people with melasma have significantly increased levels of luteinizing hormone and lower levels of serum estradiol, which suggests a mild ovarian dysfunction. The thyroid and melasma have also been reported to be linked but have been observed in women whose condition developed during pregnancy or whilst on oral contraceptives (Arora et al., 2014).
Physical sunscreen is recommended such as those containing iron oxides, titanium dioxide and zinc oxide for melasma sufferers. These help to hinder melasma pigmentation in summer (Espósito et al., 2022).
Low-dose UVA, UVB, and blue-violet radiation experienced during ordinary indoor activities far from a window and illumination from interior lamps and electronic devices are irrelevant for skin pigmentation. Infrared (IR) is non-ionizing radiation that accounts for half of the solar spectrum and is seen as heat. Its ability to induce redness and skin pigmentation is known well (Espósito et al., 2022).
The skin’s barrier has been shown to be compromised in melasma. The outermost layer of the skin, the stratum corneum (SC) is thinner in patients with melasma. Thinning of the stratum corneum is a common finding in photoaged skin, and it correlates with delayed skin barrier recovery, commonly seen in melasma. Melasma has been linked to individuals who suffer from lentigines (pigment spots) and nevi (moles) (Espósito et al., 2022).
As you can see this condition can be complex to manage, which can be frustrating to those that suffer with melasma. With a combined approach for treatment and the right professionals to assist, this condition can be managed, enabling patients to feel more confident in their own skin.
If you suffer from melasma and would like to speak to one of our clinicians contact our team on 6281 1155.
Brooke Worthy BHSc (Dermal Science)
References:
[1] Handel, A. C., Miot, L. D. B., & 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
[2] Lai, D., Zhou, S., Cheng, S., Liu, H., & Cui, Y. (2022). Laser therapy in the treatment of melasma: a systematic review and meta-analysis. Lasers in Medical Science, 1–12.
[3] Arora, P., Sarkar, R., Garg, V., Sonthalia, S., & Gokhale, N. (2014). Melasma update. Indian Dermatology Online Journal, 5(4), 426. https://doi.org/10.4103/2229-5178.142484
[4] Cassiano, D. P., Espósito, A. C. C., da Silva, C. N., Lima, P. B., Dias, J. A. F., Hassun, K., Miot, L. D. B., Miot, H. A., & Bagatin, E. (2022). Update on Melasma—Part II: Treatment. Dermatology and Therapy: Research, Treatment and Aesthetic Interventions in Dermatology, 1–24.
[5] Neagu, N., Conforti, C., Agozzino, M., Marangi, G. F., Morariu, S. H., Pellacani, G., Persichetti, P., Piccolo, D., Segreto, F., Zalaudek, I., & Dianzani, C. (2022). Melasma treatment: a systematic review. Journal of Dermatological Treatment, 33(4), 1816–1837.
[6] Li, Y., Yao, C., Zhang, H., Li, L., & Song, Y. (2022). Efficacy and safety of 755-nm picosecond alexandrite laser with topical tranexamic acid versus laser monotherapy for melasma and facial rejuvenation: a multicenter, randomized, double-blinded, split-face study in Chinese patients. Lasers in Medical Science, 1–9.
[7] Wanitphakdeedecha, R., Sy-Alvarado, F., Patthamalai, P., Techapichetvanich, T., Eimpunth, S., & Manuskiatti, W. (2020). The efficacy in treatment of facial melasma with thulium 1927-nm fractional laser-assisted topical tranexamic acid delivery: a split-face, double-blind, randomized controlled pilot study. Lasers in Medical Science, 35(9), 2015–2021.
[8] Espósito, A. C. C., Cassiano, D. P., da Silva, C. N., Lima, P. B., Dias, J. A. F., Hassun, K., Bagatin, E., Miot, L. D. B., & Miot, H. A. (2022). Update on Melasma—Part I: Pathogenesis. Dermatology and Therapy: Research, Treatment and Aesthetic Interventions in Dermatology, 1–22.
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