Amit G. Pandya, MD

Melasma is a pigmentary disorder of the skin which appears as brown patches on the face of adults. Both sides of the face, especially the cheeks, bridge of nose, forehead, and upper lip, are involved. Some patients may have mild involvement in just a few of the above areas. This condition is very common, particularly those with darker skin types.

Who does melasma affect?
Melasma predominantly occurs in people with skin of color, and 90% are women. Latin- America, Asia, Middle East, and Northern Africa are areas with a higher prevalence of melasma. Patients with brown skin, particularly in areas of high sun exposure, are especially susceptible to getting melasma.

What is the cause of melasma?
Although the exact cause of melasma is unknown, affected people often have a family history of melasma. In addition, a change in hormonal status, particularly pregnancy and birth control pills, are commonly associated with melasma, and melasma is often referred to as the “mask of pregnancy”. Post-menopausal hormone replacement therapy has not been shown to cause melasma.

Sun and light exposure are some of the most common reasons for the appearance of melasma. Ultraviolet light from the sun and visible light from light bulbs can stimulate pigment-producing cells in the skin called melanocytes to produce more pigment. Melanocytes are particularly active in those with brown or black skin. Even small amounts of light exposure, such as driving in a car or walking in a parking lot to a store can induce melasma and may account for the long duration of this condition in many people. Irritation of the skin can produce a brown color as it heals, and any irritation of the face in those with melasma may cause it to worsen. Although melasma can cause significant brown staining of the skin as well as psychological stress and a negative impact on quality of life, it is localized only to the skin and is not associated with any internal diseases or organ malfunction.

How do I know if I have melasma?
Because of its characteristic appearance, melasma can usually be easily diagnosed by a dermatologist with a skin examination. Biopsy of the skin may be sometimes necessary in order to differentiate melasma from other conditions.

What are the best treatments for melasma?
Several treatments are available for melasma, but none work in every patient. While some patients have melasma only for a few weeks or months, many have it for years or decades. Pregnancy-associated melasma usually resolves within a few months after delivery, although women in sunny climates may have persistence of the pigmentation for many years. Because the sun and lighting are major causes of melasma, sunscreens are very important in any treatment plan. Broad spectrum sunscreens, which protect against UVA and UVB ultraviolet light should be used. A physical block, such as zinc oxide and titanium oxide, may be used on top of chemical sunscreens to block light even more. Daily use of sunscreens is important, since even small doses of light can worsen melasma. Visors and tinting can protect from ultraviolet light while driving.

Oral contraceptive pills may need to be discontinued if they cause melasma. Irritating creams or makeup should be stopped, and the skin should be treated as gently as possible.

While many bleaching creams are available for the treatment of melasma, these agents do not actually “bleach” the skin by destroying the melanocytes, but reduce their activity. Hydroquinone is the most commonly used depigmenting agent and is available in low strengths over the counter and in higher strengths through prescription from a physician. Hydroquinone is the most effective of all the depigmenting agents, and takes 3-6 months to reach maximum results. Combination creams containing tretinoin, steroids, and glycolic acid along with hydroquinone enhance its depigmenting effect. Azelaic acid and kogic acid are two other agents that have depigmenting effects and are effective for many patients. Several over the counter natural products are available to bleach the skin and may be effective for mild cases of melasma. Various procedures, including chemical peels, microdermabrasion, and laser surgery have been used in patients with melasma, but results so far have not been consistent. Procedures like these, which remove layers of the skin, have the potential of causing significant irritation, which can worsen melasma. If done properly, however, these procedures may produce some benefit in selected patients. Generally, these procedures should be performed with great care by those who are familiar with their use in patients with skin of color.

In summary, while melasma can be a persistent, frustrating and difficult skin disorder, a comprehensive management approach, including avoidance of sun and irritants, use of sunscreens, depigmenting agents, occasional procedures, and close supervision by your dermatologist can lead to a successful outcome.

Melasma is a skin condition where brown patches appear on the face, often on both sides. It usually shows up on the cheeks, nose, forehead, and upper lip. It's more common in people with darker skin. Mostly, it affects people with colored skin, and about 90% of those are women. It's seen a lot in Latin America, Asia, the Middle East, and Northern Africa.

We don't know exactly what causes melasma, but it's often seen in families. Changes in hormones, like during pregnancy or when taking birth control pills, can make it appear. It's also called the “mask of pregnancy”. Being in the sun or around a lot of light can make melasma worse because these lights make skin cells that create color (called melanocytes) more active, especially in people with brown or black skin. Even a little light, like from driving or walking in a parking lot, can trigger melasma. Skin irritation can also make it get worse. Melasma doesn't mean there's something wrong inside your body, but it can make people feel stressed or unhappy about their skin.

A dermatologist can usually tell if you have melasma just by looking at your skin. Sometimes, they need to take a small sample of skin to make sure it's melasma and not something else.

There are many treatments, but not all work for everyone. Some people have melasma for a short time, but others for many years. Melasma from pregnancy often goes away after giving birth, but it can last longer in sunny places. Sunscreens are really important in treatment. They should protect against both UVA and UVB rays. Wearing things like a zinc oxide or titanium oxide layer on top of sunscreen can help block more light. Sunscreen should be used every day because even a little light can make melasma worse. Wearing a visor or having tinted windows can help protect from UV light when driving. If birth control pills are causing melasma, you might need to stop taking them. Avoid creams or makeup that irritate your skin and treat your skin gently.

There are creams that help with melasma but they don't actually bleach the skin. They just make the color-producing cells less active. Hydroquinone is a common ingredient, available in different strengths, usually needing 3-6 months to work well. Creams that combine hydroquinone with other ingredients like tretinoin, steroids, and glycolic acid can be more effective. Azelaic acid and kogic acid are also helpful for many people. Some natural products available over the counter might work for mild melasma. Treatments like chemical peels, microdermabrasion, and laser surgery can help, but they don't always work and can sometimes make melasma worse. These should be done carefully by someone experienced with treating skin of color.

In short, melasma can be tough to deal with, but with careful management like avoiding sun and irritants, using sunscreens, special creams, and sometimes other treatments, and by working closely with your dermatologist, you can get good results.