What is melasma?

• Melasma is a common skin disorder characterized by dark patches on the skin that may resemble freckles
• According to the American Academy of Dermatology, 90% of those affected are women, primarily between the ages of 20 and 40, especially pregnant women, where 15% to 50% of pregnant women develop it. Although the majority of those affected are women, men can also be affected

How does melasma develop?

The pigment-producing cells responsible for melanin production are stimulated by female sex hormones (estrogen and progesterone), leading to an increase in melanin pigment production

What are the causes?

1. Genetic factors: 60% of those affected have a family history
2. Sun exposure (UV radiation): It enhances the secretion of melanin pigment
3. Thyroid gland disorders
4. Pregnancy: Occurs due to hormonal changes during pregnancy and may fade naturally after childbirth
5. Use of certain medications, such as oral contraceptives
6. Excessive smoking
7. Psychological issues (anxiety and stress)
8. Severe skin dryness
9. Hair removal using wax

Where does it appear?

In most cases, it appears on the face: on the forehead, cheeks, nose bridge, chin, and lower jaw. It can also appear on the elbows, shoulders, or areas exposed to the sun frequently

How do we treat melasma?

There are three treatment approaches:

First, Skin Lightening Agents:

1. Hydroquinone:
   • Chemical source
   • Available in cream form at concentrations of 2% or 4%
   • Inhibits the enzyme involved in melanin production, preventing pigmentation
   • Plays a role in evening out skin tone
   • Increases skin sensitivity to light, so it is used only at night

Note: It can be used during the day if the cream contains sunscreen, as in Hydropaque

2. Azelaic Acid:
   • Natural source (derived from wheat)
   • Inhibits the enzyme involved in melanin production, reducing the activity of pigment-producing cells
   • Also reduces pigmentation resulting from acne and red spots
   • Acts as an antioxidant and antibacterial agent (kills the bacteria causing acne)
   • Reduces skin inflammation, rosacea, and blackheads
   • Considered a gentle exfoliant
   • Suitable for sensitive skin

Note: Azelec at 20% has been found to be as effective as hydroquinone at 4% in treating pigmentation

3. Kojic Acid:
   • Natural source (a byproduct of certain fungi)
   • Works to inhibit the formation of amino acids involved in melanin production
   • Considered a gentle exfoliant
4. Lactic Acid:
   • Organic source
   • Treats hyperpigmentation and acne spots
   • Has a gentle role in skin cell renewal

Note: Mela Clear product contains both Kojic Acid and Lactic Acid

5. Tretinoin:
   • A compound similar to vitamin A
   • An exfoliant that works to renew cells
   • Not to be used during pregnancy as it has a potential teratogenic effect on fetuses

Note: If pigmentation is accompanied by an inflammatory condition, a treatment combining 4% hydroquinone, 0.025% tretinoin, and 0.01% fluocinolone is utilized

Secondly, Chemical Peeling:

• It is used for patients who do not respond to skin lightening agents

Note: Skin lightening agents are used before and during chemical peeling as priming agents; however, the response to peeling varies, and caution must be exercised to avoid adverse outcomes

• The treatment starts with applying a low concentration and is gradually increased based on the response and skin irritation
• Chemical peeling is done using one of the following agents:

1. Glycolic Acid: Prevents the formation of pigment cells, stimulates cell renewal, and promotes healthy cell production
2. Salicylic Acid: Highly effective exfoliant that enhances cell renewal

Note: When following your treatment plan, it may take between 1 to 3 months to see results

Thirdly, Laser Treatment:

For severe and resistant cases, laser treatment is utilized

How do we prevent melasma?

• Use a sunscreen with SPF>30 and remember to reapply it every two hours
• Maintain skin hydration by using a suitable moisturizer for your skin type
• Choose fragrance-free skincare products
• Avoid waxing in affected areas
• If you are pregnant or using oral contraceptives, skin pigmentation is likely temporary. It is advisable to consult your doctor for appropriate treatment

References:

1. Herndon J. Understanding Melasma Healthline2023 [Available from: https://www.healthline.com/health/melasma.
2. Goldstein BG, Goldstein AO, Callender VD. Melasma UpToDate2017 [Available from: https://teksmedik.com/uptodate20/d/topic.htm? path=melasma.