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Tel: 212-772-9300
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קוסמדיספא
רחוב החי"ל 49
רעננה, NA 43316
Israel
Tel: 077-2100818
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Melasma

Treating Blotchy Skin Discolorations

by Nelson Lee Novick, MD, FAAD, FAACS

Melasma (sometimes also called chloasma) is a distressing disorder of abnormal, spotty overpigmentation. In 60 percent of cases it  affects the faces of women  who are either on birth control pills, hormone replacement therapy or are pregnant. For the latter reason, it is commonly referred to as the “mask of pregnancy.” However, in the remainder of instances its cause is unknown and it spontaneously appears in men and women with no glandular problems and on no hormonal medications. Sun exposure has been strongly implicated as an aggravating factor. And since it is seen more frequently seen in darkly pigmented Caucasions (eg. Hispanics and those of Mediterranean origin) and in certain Oriental populations, an inherited tendency is also believed to play a role.

Melasma usually appears as large, flat, irregularly-shaped, tan or dark brown colored patches involving the cheeks, upper lip and forehead. Medically, the condition is entirely benign and symptom-free. However, cosmetically, especially in certain cultural and ethnic groups, it can be a psychologically and socially a devastating problem. For example, among the Chinese of Singapore, it is considered a bad omen, a sign of “bad luck.”

The abnormal pigment deposits in melasma may be located higher up in the skin, within the epidermis,  more deeply situated within the dermis, or may be distributed throughout both locations . Approximately 30 percent of patients have at least some pigment within the dermis. Since it is much more difficult to treat the deeper pigment stains with our currrent therapies, dermatologists generally use a special lamp, known as a Wood’s light, to determine the location of the pigment and thereby assess the likelihood of treatment success. The test is simple. When the abnormal pigment stands out more intensely under the test light, the pigment is located in the epidermis. If it does not, the pigment is more likely deeper down.

The gold standard for treating melasma is sun protection coupled with the use of creams or lotions containing hydroquinone. Hydroquinone works in a number of ways to interfere with the production of the skin’s main pigment, melanin, the overproduction of which is responsible for the abnormal skin staining seen in melasma. Over the counter bleaching products containing a low  2 percent concentration of hydroquinone are generally of limited value. Prescription formulations by contrast, which contain either 3 percent or 4 percent concentrations (Melanex, Lustra, Solaquin-Forte) tend to be more successful. TriLuma, a combination of hydroquinone, a topical steroid and tretinoin is particularly effective and works well, in my experience, with even the most troublesome cases.

Not uncommonly, dermatologists will have pharamacists compound formulations with concentrations of hydroquinone between 5 percent and 10 percent to increase efficacy. Twice to three times dailly applications for several months are usually necessary to obtain cosmetically satisfactory fading or clearing.

After clearing, most patients will need to continue some regimen of therapy, if only periodically, for many years, owing to the chronic nature of the problem. Fortunately, melasma occurring as a result of pregnancy  sometimes clears spontanously after birth.

Since the sun is capable of darkening melasma lesions greater than hydroquinone’s ability to “bleach” them, strict avoidance of sun exposure is a must. Although sunscreens help against the ultraviolet light spectrum, visible light, too, may cause some pigment darkening. It is therefore best to use complete, physical blocking products, such as those containing micronized zinc oxide and titanium dioxide. Alternatively, an SPF 30 sunscreen may be used followed by the application of makeup.

Dermatologists frequently combine home therapy with a series of in-office peeling procedures. Varying concentrations of glycolic acid peels and beta hydroxyacid peels have been used successfully in this way. A series of two to six peels spaced at two to four week intervals may be required. Jessner’s peels, which is a combination of low concentrations of  lactic acid, salicylic acid and recorsinol has also been used with good results. Unlike with the use of stronger chemical peeling agents, which may result in actually worsening the discolorations when used in darkly pigmented individuals,  these milder peels have been used successfully in all skin types. Microdermabrasion has also been found helpful.

More recently, other bleaching agents have been employed alone or in various combinations. These include kojic acid, a fungus derivative, which has been shown to produce excellent lightening in some cases due to its ability to inhibit melanin synthesis.  Azelaic acid 20 percent (Azagel) either alone or combined with glycolic acid has also proven useful in select cases.And for those in search of “natural” products, arbutin, which is derived from the leaves of pears and certain other herbs, and glabridin, a licorice extract, have also been tested with some success.

While there is currently no panacea for melasma and therapies demand prolonged applications and strict sun protection, there is certainly good reason for optimism these days in treating this vexing problem.

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This information is for general educational uses only. It may not apply to you and your specific medical needs. This information should not be used in place of a visit, call, consultation with or the advice of your physician or health care professional. Communicate promptly with your physician or other health care professional with any health-related questions or concerns.

Be sure to follow specific instructions given to you by your physician or health care professional.

Additional Resources

Medications
Sunscreens
Medications: Topical
Hydroquinone
Retinoids: Topical
Procedures
Chemical Peels
Prevention
UV Index - Weather Forecast
En Espanol
Melasma
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