Melasma

Melasma is a common patchy tan, brown or blue-grey discolouration of the facial skin. It usually happens to women in their reproductive years. The skin condition mainly appears on the forehead, the cheekbones, the upper lip, and the chin of females at the age of 20 years to 50 years. It is not common in men. Only 10% of the patient are men. The major cause of melasma is still not known. Melasma is said to be mostly related to the external exposure to the sun, the use of medications like birth control pills, contraceptives or hormone replacement therapy (HRT) medications, and the hormonal changes that are seen during pregnancy. The skin condition can also be genetic.  Almost all the individuals with the skin disease have or had a history of regular exposure to the sun, heat as well is suspected as a factor contributing to the cause. The skin discolouration is most prevalent in the pregnant women, mostly the women who belong to Asian or Latin roots. People with darker or olive skin, like Middle Eastern, Hispanic, Asian or North African women, have a higher chance of having the skin condition during their pregnancy. There are more than 1 million cases of this skin disease in India alone. Melasma only causes the discolouration of the skin and no other symptoms in particular. This skin condition is also referred to as the pregnancy mask. The skin condition may also take place on the neck and or the forearms as well. The prevention of the skin condition is majorly aimed at protecting the face from sun rays and avoiding the sun. There are not many specific treatments for the skin condition. The treatment requires applying sunscreen regularly or applying medications like 4% hydroquinone or other fading lotions or creams. It is not uncommon for this skin condition to naturally disappear without requiring any form of therapy or medication. Many patients report a decrease in the spots after simply avoiding the sun. Others, who have hormonal Melasma, report that their symptoms relinquished after the birth of their child or they stopped taking hormone therapies. There are four types of melasma: Epidermal, Dermal, Mixed and an unnamed type in the individuals with a dark complexion. Treatments and medications are available for all the four types. Although, the epidermal type of melasma is the easiest to treat as the pigment is closer to the surface of the skin.

Symptoms and Signs

There are not many signs or symptoms of this skin disease. The only symptom is the discolouration of the skin or brown and tan patches on the skin of the patient. There are three distinct location patterns on the face where the discolouration occurs.

- Centro-facial pattern: The centre-facial pattern or the central face pattern is when the skin condition occurs right in the centre of the face. This is the most common pattern as it appears on the upper lip, forehead, chin, nose and cheeks.

- Malar pattern: The malar pattern is when the skin condition occurs on the cheekbones and the upper cheeks.

- Mandibular pattern: The mandibular pattern is when the skin condition occurs on the jawline of the patient.

Along with these patterns, there is a chance for the skin condition to occur on the upper side of the neck and the forearms of the patients.

The discolouration of the skin or the patches on the skin doesn’t harm the patient’s skin physically. But, many people may feel self-conscious about the way their skin looks. In that case, paying a visit to the doctor or a dermatologist will be helpful to the patient.

Types

There are four types of pigmentation patterns in melasma: dermal epidermal, mixed, and an unnamed type only found in individuals of dark complexion. The epidermal type occurs because of excess melanin being present in the superficial layers of skin. Dermal type of melasma is occurred because of the presence of cells that ingest melanin also known as melanophages throughout the dermis. The mixed type is a combination of both the epidermal and dermal type. In the fourth unnamed type is because of the excess melanocytes that are present in the skin of individuals with darker skin.

Causes

The exact reason for the skin condition is yet to be known. Doctors believe that these dark brown patches caused by the skin condition could occur due to many factors, including hormonal changes during pregnancy, use ofpills for birth control and contraceptives, history of the skin condition in the patient’s family, the race of the patient, and using medications to stop seizures. External exposure to the sunlight is thought to be the most prominent factor for the occurrence of this skin condition, especially in those individuals who are genetically prone to such skin conditions. Clinical studies and research show that the individuals will usually develop the skin condition in the months of summer, as the heat from the sun is the most intense during the summers. During the season of winter, the discolouration or pigmentation caused by the skin condition becomes normal.

The skin condition is also known as the pregnancy mask or chloasma when the skin condition occurs during pregnancy. Increased oestrogen levels, melanocyte-stimulating hormone levels and progesterone levels are experienced by the pregnant female patients mostly through the second trimester and third trimester. But, it is suspected that the skin disease during pregnancy is caused due to the increase in the amount of progesterone produced and not because of melanocyte-stimulating hormone or oestrogen. The cells in the skin that deposit the brown pigment are called melanocytes. Researches show that women post menopause who undergo progesterone HRT will likely develop the skin condition. Women post menopause receiving just oestrogen seem not likely to have the skin condition. Many treatments or products that cause irritation to the patient’s skin may also result in an increase in the production of melanin and accelerate the symptoms caused by the skin condition.

People who are genetically prone or have a history of such skin conditions in their family have a higher chance of developing the skin condition. Important methods of prevention for such individuals include avoiding the sun and applying extra sunscreen to avoid stimulation of pigment-producing hormones like melanocytes. These people should also consider meeting a doctor and discuss their concerns regarding the skin condition and regarding avoiding the hormone replacement therapy (HRT) and the birth control pills if possible.

Diagnosis

A visual examination of the patchy or pigmented areas is usually enough to diagnose the skin condition. The doctor or dermatologist may also perform some tests to check for other specific causes. Although not necessary in diagnosing melasma, the testing technique of a Wood’s lamp examination can be used to make it easier to diagnose the skin condition. Wood light is a special type of black light that is held up to the patient’s skin. It allows the dermatologist or the doctor to check for any bacterial infections or for any fungal infections and then determine the number of layers of the patient’s skin affected by the skin condition. Also, to check for any other serious skin condition causing the pigmentation in the skin, the doctor may also perform a skin biopsy. Skin biopsy is done by removing a small piece of the skin affected for tests.

Treatment

The most used treatment for the skin condition includes the use of hydroquinone (HQ) creams.These creams such are available OTC without prescriptions and are also prescribed by the doctors. Medicines such as 4% hydroquinone are prescribed by the doctors. There are many sunscreens that might contain a 4% or above concentration hydroquinone as well. Products with above 2% concentration of hydroquinone sometimes may need a prescription from a doctor and sometimes can be found only at the physicians. Clinical researches have shown that these creams that contain 2% hydroquinone are very effective in the skin lightening process and cause less irritation than those creams with high concentrations of hydroquinone for the skin condition. These hydroquinone creams are applied on the discoloured patches or the affected areas twice every day. The doctors suggest that sunscreen should also be applied after applying these hydroquinone creams each morning. Treatments for each type of melasma is available, although the epidermal skin condition responds the best to these treatments than the other types as the problem is present closer to the surface of the skin.

The skin condition usually clears without any treatments being required. Many times, it might clear on the use of sunscreen and avoid the sun. For many female patients, the symptoms caused by the skin condition will disappear after the pregnancy or after discontinuing pills used for birth control, contraceptives, progesterone intake and hormone replacement therapy.

To treat the skin condition, a specially formulated combination of creams with the most essential ingredients such as hydroquinone, azelaic acid (Azelex, Finacea), a phenolic hyper pigmenting agent, nonphenolic bleaching agents and kojic acid might be prescribed by the doctors. In cases of the severe intensity of this skin condition, the medications with a high concentration of hydroquinone or combining hydroquinone with different components such as corticosteroids, retinoic acid,or glycolic acid may prove useful in the process of skin lightening.

There are many different chemical peels with varying strengths and types which can be found for different types of skin. The variant of chemical peel needs to be chosen by the patient’s doctor and tailored for the patient differently. The most commonly used peels in treating this skin condition are peels which contain glycolic acid in amounts ranging from 30% to 70%. There are many combinations that can be used to treat the skin condition such as a mixture of 2% hydroquinone and 10% of glycolic acid.

Microdermabrasionis a simple, painless and quick treatment which uses abrasive materials such as aluminium oxide crystals or fine chips of diamond and vacuum suction toremove the dead skin cells fromthe uppermost layers. The pressure created by vacuum will be adjusted according to the skin tolerance and skin sensitivity. Usually, a microdermabrasion session can last from a couple of minutes to an hour. There is close to no time for recovery required after the procedure of microdermabrasion is completed. Microdermabrasion procedures can improve the skin condition, but good results cannot be expected or seen after just a few sessions. Many sessions with the combination of hydroquinone creams and sunscreens will have the best results.

Complications

There is not any given guarantee that the skin condition will improve after these procedures are done. In a few cases, if the treatments are abrasive or too harsh, the skin condition can reoccur or get worse. Also, these treatments are mostly considered as cosmetic and the medical insurance companies might not cover for them.

Side effects of treatments for melasma may include temporary irritation of the skin. The individuals who use hydroquinone medications or creams with very high concentrations for many months or years have higher chances of developing a condition known as exogenous ochronosis. In this condition, the bleaching agent used darkens the skin instead of lightening it. Hydroquinone-induced ochronosis is a chronic skin pigmentation which is thought to take place due to the use of above 4% concentrations of hydroquinone. Regardless of the possible side effects, hydroquinone is still the most successful and most commonly used fading cream for treating this skin condition all over the world. The use of hydroquinone creams should be put to a stop after noticing the early signs of ochronosis.

Laser therapies and treatments may also result in the skin condition getting worse rather than getting better. In many cases, external exposure to the sunlight or consuming birth control pills and result in the recurrence of this skin disease. Stress and thyroid disease are also suspected to be the causes of this skin condition. Irritating cosmetic products can also boost colour-producing cells causing the dark spots on the skin. The individuals with a history of Melasma in their family are advised to especially be careful with the use of such cosmetic products or to just avoid these products.

Last updated on : 30-01-2019

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