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. Prevention is primarily aimed at facial sun protection and sun avoidance.

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 (HRTand 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.

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.

What is the treatment for melasma?

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

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.

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.

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.