Melasma

Melasma, also known as chloasma faciei, is a form of irregular discoloration typically seen on the face. It is made up of brown or gray discolored spots, which preferentially affect the cheeks and forehead. Women and people with darker complexions are affected more often. Though the exact reason why these dark spots form is not known, they have been linked to genetics, pregnancy, hormone contraception (birth control pills), hormone replacement therapy, endocrine disorders and certain medications (anti-seizure medications) and ultraviolet light, like sunlight.

Melasma tends to be difficult to treat and can often come back. Melasma of pregnancy usually clears within months of delivering the baby. Melasma from birth control pills may persist despite stopping the pills.

Treatment:
Treatment is geared towards avoiding sunlight exposure and using a broad spectrum sunscreen that protects against UVA and UVB. Other treatments are listed below, but there is no real cure. No matter how successful the treatment is in clearing the melasma spots, unprotected sun exposure will cause dark patches to come back. Meticulous use of sunscreen is required after clearance of melasma.

Hydroquinone is a “bleaching” cream applied to the spots. It is considered the gold standard in treating melasma. It works by stopping the production of pigment. Creams containing 2% hydroquinone are available over the counter, while creams with higher concentrations are available by prescription. The cream is usually applied twice a day and it may take up to 2 months before results become evident. Some side effects include local irritation, like itching, burning and stinging, as well as allergy, very rare darkening of skin (known as ochronosis) or small cyst (milium) formation.

Tretinoin is a retinoid in the same family as Vitamin A. It can be used alone or in conjunction with hydroquinone. It works by helping the hydroquinone penetrate into the skin as well has having its own effect on breaking up the pigment or dark color. It is available in gel, cream and liquid and in strengths from 0.01-0.1%. The most common side effect is burning, redness, scaling, and dry skin.

Azelaic acid is a cream or gel that has anti inflammatory and antibacterial properties. However, the exact way it works is not known. Side effects include itching, burning, stinging and tingling.

Corticosteroids are anti-inflammatory medications that can affect pigment formation. They are often used with hydroquinone and tretinoin. The most common side effects include skin thinning and the formation of small blood vessels (telangiectasia).

Chemical peels work by removing the pigment in the upper layers of skin. They do not stop new pigmentation from forming. There are various types and strengths of peels. The most commonly used peels to treat melasma include glycolic acid, salicylic acid, trichloroacetic acid (TCA), tretinoin, and resorcinol. Caution should be placed when peeling darker skin as the peel may worsen melasma or cause new pigmentation to form in response to inflammation and irritation (post-inflammatory hyperpigmentation).

Laser treatments have been used for melasma, but studies looking at their use are small and results can vary. When a laser is used to treat melasma a certain wavelength of light energy is emitted which gets absorbed by the pigment in the skin. This damages the pigment structure.

References:
Gupta AK, Gover MD, Nouri K, Taylor S. The treatment of melasma: A review of clinical trials. J am Acad Dermatol 2006;55:1048-1065.

Angela Leo, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.

Stephen M. Purcell, D.O., F.A.O.C.D.
Professor and Chairman of the Department of Dermatology
Philadelphia College of Osteopathic Medicine

Philadelphia, Pennsylvannia
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