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Unmasking Melasma

"The cosmetic appearance of melasma can be upsetting and can affect quality of life."
By: Risa Caldoza-De Leon MD, FPAPSHPIUnmasking Melasma

Here you are at your early teens, flashing your flawless face that is baby soft, smooth and even-toned. During your reproductive years, gradually, or even suddenly, you’re plagued with annoying ugly dark blotchy patches all over your face. You get pregnant, and the splotches worsen! Fret not, for you are not alone. What you have is melasma, one of the most common skin conditions to beset adult women. Even “Friends” star American actress Courtney Cox is well known for her long fight with melasma and often publicly addresses her affliction.

The name comes from ‘melas’, the Greek word for black. Melasma is sometimes called chloasma, which means green skin. Melasma is essentially too much dark pigment. Most people get freckle-like spots or larger flat brown or grayish patches over the cheeks, bridge of nose, forehead, chin, and above the upper lip.

Jera, a 36-year-old bank manager laments her faux-‘stach . “I have this dark strip of skin over my upper lip. I know everyone secretly thinks I have a moustache. They keep staring at it. I think it worsens every time I have my upper lips waxed.”

Less commonly, melasma can appear in the forearms and neck. It’s typically symmetrical in distribution, so you get it in both sides. Disease descriptions can be found in the medical literature as far as the reports of Hippocrates in 470-360 BC.

Melasma is not an infection and so, is not contagious. It is not an allergic reaction and it is not cancerous. The affected skin is neither itchy nor sore. Melasma often persists long-term.

The cosmetic appearance of melasma can be upsetting and can affect quality of life. Patients report that even clinically mild melasma interferes with their leisure time activities and their emotional and psychological well-being. Patients reveal feelings of shame, low self-esteem, dissatisfaction, and the lack of motivation to go out. Suicidal ideas have also been reported in literature.

According to American Academy of Dermatology, women are far more likely than men to get melasma. Just 10% of people who get it are men. People with darker skin, such as Asians, Hispanic and African-Americans are more prone to it. It is very common in Southeast Asia, where 4 of 10 women and 2 in 10 men can have it. A study in 2005 revealed that in Southeast Asia, melasma accounts for up to 4% of patients seen in skin institutes, peaking at age 30 to 44 years. In Asia, melasma accounts for half of all aesthetic consults.

Mask of pregnancy

That pregnancy glow may grow dimmer when melasma strikes. Melasma is so common during pregnancy that it is called the mask of pregnancy. According to the US National Institutes of Health, 50 to 70 percent of pregnant women will have melasma. This vexing condition does not discriminate. A recent survey of females from nine countries found that 41% of females developed melasma after pregnancy but before menopause, and a mere 8% said their melasma faded over time.

Melasma gravidarum is considered an early sign of pregnancy, as more than half of all pregnant women develop these dark patches in their first or second trimester. It is usually associated with the female hormones estrogen and progesterone, which shoot up during pregnancy and generate more melanin. The effects of chloasma may become more noticeable each time you get pregnant. Good news, it does not harm your baby!

The ghastly patches usually fade on its own once you deliver your baby and your hormone levels go less crazy and revert to normal. Sadly, some cases persist. Women who are pregnant or mothers who breastfeed need to wait awhile to address their melasma because some treatments may pose a risk to their child.

Face off with the causes

Our skin has color-making cells called melanocytes that produce melanin. This gives our complexion its particular shade. Ideally, the melanocytes manufacture a steady stream of melanin. In melasma, the melanocytes go haywire and make a lot of melanin, more than what is normal. People with darker skin are more prone to melasma since their melanocytes are more active than those with lighter skin.

Sun lovers, beware! One very important trigger for melasma is sun exposure. Lifelong sun exposure causes the melanin to be deposited within the deeper layer of the skin. Ultraviolet (UV) light from the sun sparks melanocytes to produce more and more melanin and deepens the pigmentation. Clinical studies reveal that one typically develops melasma in the summer months, when the sun is most intense. 

Hormones play a big part, this is why birth control pills, hormone replacement medicine, intrauterine devices and implants can also trigger melasma. These factors account for the melasma in about a quarter of affected women. In up to 20% of patients with melasma, popping contraceptive pills has been implicated as the cause of this disorder. Some medical conditions that affect hormone levels may also cause melasma.

Genetics plays a role too. In many studies, up to 70% of patients reported having close relatives who were similarly affected. The incidence of melasma also rises in patients with thyroid disease.

Some skin care products, like cosmetics, may irritate the skin and worsen melasma. One should avoid waxing because this procedure may cause the skin to be inflamed and make melasma severe.

An ounce of prevention

Since sun exposure triggers melasma, sun protection is a must. This means wearing sunscreen every day, even on cloudy days, and reapplying the sunscreen every two to four hours. Choose a sunscreen that offers broad-spectrum protection, a sun protection factor (SPF) of 30 or more, and zinc oxide and/or titanium dioxide to physically limit harmful sun’s rays on your skin.

Your sunscreen must block UVA as well as UVB. UVA rays is associated with cancer and UVB rays are linked to wrinkling, aging, cancer, and discoloration.

If you have melasma now, the first step in reversing sun damage is preventing further damage. The usual recommendation is to apply sunscreen 20 minutes prior to going outside and wear a wide-brimmed hat and sunglasses, especially between 10 am to 3 pm. Heat and friction worsens the condition so avoid saunas and facial scrubs.

Managing Melasma

Melasma is tricky and stubborn. It is one of the harder types of hyperpigmentation to correct because it is tied to hormones and can go in deeper layers of the skin, which are harder to reach with topicals.

To date, there is no cure for melasma. But its appearance can be improved so there is no need to hide behind thick coverage make-up. Melasma can fade on its own, often when the trigger is stopped, such as in giving birth or when oral contraceptive is stopped.

Some people, however, have melasma for years, or even a lifetime. So how do you treat it? Your skin care physician may give you creams, lotions or gels that you can slather on. They have active ingredients that work by lightening the skin. These include hydroquinone, tretinoin, steroids, azelaic acid, kojic acid and tranexamic acid. Studies say that a minimum of three months use is needed for a good response.

Other clinic procedures are chemical peels and microdermabrasion. These improve melasma by removing the outermost cells of the skin that contain the excess pigment. Lasers, such as intense-pulsed light (IPL) and fractional lasers are suitable options but tend to be more expensive.

In all of these treatments, the effects are gradual and a strict avoidance of sunlight is required. Patients should always consult a skin care physician and avoid trying any at-home remedies or over-the-counter medicines. These treatments often involve scrubbing and may have chemicals that can aggravate the skin and make the condition worse. Remember, not all brown patches on your skin are melasma. In this instance, beauty is only skin-deep.


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