Melasma

Overview

Melasma is a common hyperpigmentation disorder found predominantly in women, resulting primarily from ultraviolet (UV) exposure and hormonal imbalances.

It is a symmetric hyperpigmentation disorder of face and other parts of the body, affecting chiefly the dark-skinned people; however, all skin types are vulnerable.

Patterns of melasma

 Melasma appear as symmetric reticulated hyper melanosis in three predominant facial patterns:

·      Centro facial

·       Malar

·      mandibular.

The main type of clinical pattern [50–80% ] found in women is the centro-facial pattern, which affects the forehead, nose, and upper lip, excluding the philtrum, cheeks, and chin.

The malar pattern is restricted to the malar cheeks on the face.

The mandibular pattern of melasma is present on the jawline and chin.

 Extra-facial melasma can occur on non-facial body parts such as the neck, sternum, forearms, and upper extremities

Morphologically, melasma presents as symmetric reticulated hyperpigmented patches with irregular borders on the centro-facial region, malar cheeks, mandible, and rarely upper chest and extremities.

Histology

Melasma on histological sections may show increased epidermal and/or dermal pigmentation, enlarged melanocytes, increased melanosomes, solar elastosis, dermal blood vessels, and, occasionally, perivascular lympho histiocytic infiltrates.

Diagnosis

A dermatologist can often diagnose melasma by inspection or looking at the face or other affected body parts.

Sometimes Wood’s lamp examination may be required to differentiate melasma from other skin diseases.Using a Wood’s lamp, the hyperpigmentation can be accentuated when the pigment is epidermal.

Prognosis &Treatment

Melasma is a skin condition with varying prognosis. In some types of melasma the pigmentation may go away on its own. This usually happens when a trigger, such as pregnancy or a medication, causes melasma. When you deliver your baby or stop taking the medication, melasma can fade. The etiological factor is a crucial determinant in predicting the progress of the disease. However, in some people, melasma can also last for years, or even a lifetime.

The recommendations by dermatologists is often a combination of  measures for sun protection and medications, topical applications. However, in intractable cases of melasma  the suggested treatment may include some procedures over the skin.

For patients who have melasma, dermatologists often recommend using a sunscreen that contains zinc oxide, titanium dioxide, iron oxide.

Topical applications or creams

Hydroquinone: This is a commonly used topical agent for melasma which can help to even out the skin tone reducing hyperpigmentation. Hydroquinone is no longer available in cosmetic products ,it should be prescribed by skin specialists in indicated cases of hyperpigmentation.

Tretinoin and a mild corticosteroid: This combination contains a retinoid and an anti-inflammatory, which can even out skin tone.

Triple combination cream: This cream contains three medications — tretinoin (a retinoid), a corticosteroid to reduce inflammation, and hydroquinone to even out your skin tone.

Other medications: Your dermatologist may prescribe drugs such as azelaic acid, kojic acid, or vitamins.

Peels &other procedures

Chemical peel: In this procedure, a chemical solution is applied  to the melasma or hyperpigmented patches and it may reduce pigmentation.

Microneedling: This minimally invasive procedure creates microscopic tears in your skin. As the skin heals, it tends to have a more even skin tone.

Laser treatments:

 A few studies have found that adding a laser treatment can improve the hyperpigmentation in patients using topical agents or medications for melasma.

Platelet-rich plasma: This procedure involves taking a small amount of your blood, placing the blood into a machine that separates the blood into layers, and then injecting the layer of blood known as plasma into the skin with melasma. This can help even your skin tone.

Only a board-certified dermatologist should perform all the above procedures for patient safety. 

Complementary & alternative medicine

Homeopathy  medications used for melasma include:

•        Arsenic album

•        Conium maculatum

•        Lycopodium clavatum

•        Plumbum metallicum

•        Sepia

These medications are to be prescribed by qualified or medical council certified homeopathic doctors. In appropriate and regular doses these may help to fade melasma spots . However, the results or treatment outcome vary in people, probably determined by the causative factors and triggers.

References

1.    Sanchez NP, Pathak MA, Sato S, Fitzpatrick TB, Sanchez JL, Mihm MC., Jr Melasma: a clinical, light microscopic, ultrastructural, and immunofluorescence study. J Am Acad Dermatol. 1981;4(6):698–710. doi: 10.1016/S0190-9622(81)70071-9.

           https://pubmed.ncbi.nlm.nih.gov/6787100/

2.    Guinot C, Cheffai S, Latreille J, Dhaoui MA, Youssef S, Jaber K, et al. Aggravating factors for melasma: a prospective study in 197 Tunisian patients. J Eur Acad Dermatol Venereol. 2010;24(9):1060–1069. https://pubmed.ncbi.nlm.nih.gov/20202051/

3.    Ritter CG, Fiss DV, Borges da Costa JA, de Carvalho RR, Bauermann G, Cestari TF. Extra-facial melasma: clinical, histopathological, and immunohistochemical case–control study. J Eur Acad Dermatol Venereol. 2013;27(9):1088–1094. doi: 10.1111/j.1468-3083.2012.04655.x.

4.    https://www.aad.org/public/diseases/a-z/melasma-treatment

5.    Image courtesy-https://www.freepik.com/free-photo/side-view-smiley-man-skin-texture_27621779.htm#page=2&query=hyperpigmentation&position=4&from_view=keyword&track=sph&uuid=8fe566bf-f9e0-416c-bc54-1cb51f56b74c