Frequently asked questions about Melasma

Q: What is Melasma? Is there any gender predilection?

Melasma is an acquired skin condition characterized by development of symmetrical light to dark brown areas on the face and occasionally on the neck and forearms. It is derived from the Greek word “melas” meaning black, which refers to its brownish clinical presentation. Melasma affects females much more commonly than males and the majority of patients are in their third and fourth decades of life.

Q: What are the factors that pose an increased risk of acquiring melasma?

Some of the common risk factors include:

• Prolonged exposure to sunlight (UV radiation) is undoubtedly the most important factor that can stimulate increased production of melanin
• Endocrinologic abnormalities like Polycystic ovarian disease (PCOD) and thyroid dysfunction.
• Pregnancy
• Drugs like Phenytoin, Oral Contraceptive Pills (OCPs) and certain antipsychotics /antidepressants have been reported to exacerbate facial hyperpigmentation.
• People residing in geographic areas with heavy pollution.

Q: What is blue light and how does it affect our skin? Is there any role of laptop and mobile screens in exacerbating melasma?

Blue light, part of the spectrum of visible light, is a high-energy, short-wavelength light (not to be confused with UVA or UVB rays).The main source of the blue light we're exposed to is the sun, however, we also get a significant dose from our screens and indoor lighting.

Prolonged exposure to blue light contributes to brown spots on the skin and hyperpigmentation such as melasma, and possibly to photoaging and the breakdown of collagen, which leads to wrinkles and skin laxity. This underscores the importance of Iron-oxide containing sunscreens and tinted sunscreens that protect against visible light.

Q: Another thing people link to melasma is pregnancy and hormones. Why do so many women experience melasma during pregnancy?

Pregnancy is a classic trigger. Many women do not have issues until they get pregnant, or find that it worsens during pregnancy. Hormones fluctuate wildly during pregnancy, extending even to the breastfeeding period, are a powerful trigger for stimulating pigment production.

Q: Any genetic role in Melasma?

Yes, Melasma has a genetic predisposition. Overexpression of some genes can exacerbate melasma while under-expression of others may offer protection against this disorder.Several studies have found that patients with melasma often have one or more blood relative(s) who also had melasma.

Q: Many patients witness development of melasma or worsening of already existing facial pigmentation after periods of stress? Any specific relation between the two?

Stress causes the body to make more of the hormone ‘cortisol’ which may trigger melasma. This is the probable reason why patients who have periods of mental/emotional stress see upsurge in their facial pigmentation.

Q: Some people develop melasma on cheeks, some on forehead while others on nasal bridge. Are there any specific patterns of pigmentation in Melasma?

Clinically there can be 4 different patterns of pigment distribution in melasma:

• Centro-facial pattern: It is the most common pattern affecting the majority of the cases. It affects the forehead, nose, and upper lip, excluding the philtrum, cheeks, and chin.
• Malar pattern: It is restricted to the cheeks on the face
• Mandibular pattern: It involves only the jawline and chin. It is thought to occur in older individuals and may be more related to severe sun damage.
• Extra-facial Pattern: It is a recently recognized pattern that can occur on non-facial body parts, including the neck, sternum, forearms, and upper extremities.

Q: How can we tackle Melasma?

A consultation with a certified dermatologist is mandatory for a proper evaluation and subsequent treatment of Melasma. Most of the patients require a multi-modal treatment regimen, apart from observing photoprotection.

• Observe Sun protection
• Avoid staying in sun for long hours
• Use broad-brimmed hats and sun-glasses while outdoors.
• Use a broad-spectrum sunscreen twice /thrice daily (SPF>30)

An ideal sunscreen should be a combination of physical & chemical sunscreens, besides being photostable, non-irritant, non-comedogenic, water-resistant and cosmetically elegant.

• Topical Ointments / Creams
• Various topical formulations containing arbutin, kojic acid, tranexamic acid, glycolic acid, azelaic acid and Silymarin can be used.
• Triple combination creams containing hydroquinone, retinoid and less potent steroid should be restricted only for initial 4-6 weeks. Prolonged application of over-the-counter steroid based creams must be avoided as it may lead of skin atrophy, facial hair growth and telangiectasias.
• Vitamin C, Niacinamide and retinol serums can be helpful during maintenance therapy of melasma.
• Cysteamine cream (recently launched in India)

(C)Oral Medications

Certain oral medications like tranexamic acid, glutathione, astaxanthin help in downregulating melanogenesis and have a beneficial role in managing melasma.

Q: A lot of people want to know about peels, and if they can work to fade melasma?

Yes, a peel, when done properly, can fade melasma. This has to be balanced with skin sensitivity as stronger peels can “burn” the skin which can in turn cause rebound pigmentation. Therefore, a proper selection of the right peel is of paramount importance. Not every peel is for everybody.

Q: What is your take on lasers in the treatment of melasma?

• Yes, lasers can be helpful, but don’t expect them to eradicate melasma completely. They can fade and help control the patches, but may need multiple sessions.
• A combination of pulsed CO 2 laser (to remove superficial pigment) and Q-switched Nd:YAG laser or pico-laser (to remove deeper pigment) gives better results than either laser used alone.
• Nowadays, technique called “laser toning” or “laser facial” has become increasingly popular for the treatment of melasma.

Q: Are there certain patients for whom these therapies work best?

Melasma responds best when it is newer. We usually have a much harder time clearing melasma when it is long standing (>7 years). In people who are more deeply pigmented, it usually takes longer to see results. Fairer skin patients are a little more likely to respond to topicals.

Q: Are these treatments permanent? Or will the patient need to come back for maintenance?

There is no permanent cure for melasma. The limitation is while we often improve melasma, we have to educate our patients that this is something that tends to recur and needs ongoing maintenance and ongoing sun protection.

Q: What treatments are safe during pregnancy?

During pregnancy, topical treatments containing vitamin C or azelaic acid “are helpful to lighten the patches. Also, prefer physical/mineral sunscreens over chemical ones.

Q: Many salons have mushroomed up offering treatments for melasma including peels & lasers. What is your take on that?

Prefer going to a specialist. A specialist is one who has done MBBS followed by MD/DNB Dermatology from a recognized institution. After all it is Skin, don’t take risk. There is a very thin line between treating the face with lasers and devastating it altogether.

Q: Many people resort to online products for correcting their facial hyperpigmentation. How do you see that?

A big NO to over-the-counter products. Most of them are not backed by strong medical research, development and clinical trials. Never resort to self-medication if you don’t want to land yourself into trouble. Protect your skin from all sorts of pirated and cheap serums and brightening agents that come across your Instagram & facebook reels.

Q: Can you share some tips and take-home messages for tackling melasma?

1. Establish a good cleansing regimen to thoroughly remove the pollutant particulate matter
2. Moisturize your skin regularly
3. Combat Skin stress with antioxidants like vitamin C and vitamin E
4. A big NO to over-the-counter Fairness creams
5. Prefer medicated sunscreens over cosmetic ones
6. Avoid face washes /cleansers that are irritant
7. Use minimal make-up and avoid unnecessary bleaching creams
8. Be patient. Even with treatment, it may take months for melasma to clear up. There’s no overnight fix.

Melasma remains a chronic, therapeutically challenging, and universally relapsing condition. This psychologically devastating disorder should be treated with a multimodality approach that incorporates photoprotective agents, antioxidant treatments, skin lighteners, exfoliants, and resurfacing procedures in severe cases. A myriad of new oral, topical, and combination therapies for melasma have been introduced to expand our repertoire of therapies, and warrant additional trials to substantiate their efficacy and safety.

By Dr, Mir Shahnawaz

Dr. Mir Shahnawaz (MBBS, MD) Dermatologist, Laser Expert & Hair Transplant Surgeon Director & Founder - DERMIS Skin & Hair Clinic Bemina, Srinagar