Education Center
What Is Melasma
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At a Glance
Melasma is a common skin condition characterized by brown to gray-brown patches of hyperpigmentation typically affecting the cheeks, bridges of the nose, forehead & upper lip. While the face is the most common area, sometimes the arms, shoulders & upper back are affected.
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Who Does it Affect
Melasma is most common in women & individuals with medium to darker skin tones. 10-15% of cases occur in men.
What Causes Melasma
Hyperpigmented patches of the cheek
The infamous melanocyte
Etiology
At the soul of melasma lies the melanocyte, the site of excess pigment production. Melasma is a complex disorder of hyperpigmentation caused by the interplay of a genetic predisposition, ultraviolet & visible light triggers, as well as hormonal influences. 30-50% of individuals with the condition have affected family members. It is most common in regions of the world with high sun exposure. It may be triggered by oral contraceptives, pregnancy & hormone replacement therapy.
Features of Melasma
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Biopsy Features of Melasma
Biopsies from the affected brown patches compared to normal skin show increased melanin in the epidermis & dermis, large hypertrophic melanocytes & damage to the basement membrane.
Other cells that are affected in the dermis include mast cells, fibroblasts & endothelial cells. In some cases, blood vessels are increased. There is evidence of collagen & elastic tissue damage.
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A Phenotype of Photodamage
Multiple cytokines & growth factors contribute to the increased melanin production & damage observed in the epidermis & dermis. Cytokines & growth factors produced that drive these changes include alpha-MSH, endothelin-1, prostaglandin, stem cell factor, hepatocyte growth factor, & fibroblast growth factor. Melasma is considered a unique phenotype of photodamage because of its clinical appearance & unique features of the condition occurring in the epidermis & dermis. These features are indeed closely related to the changes observed in chronic exposure to ultraviolet visible light & heat.
Treatment
Common Therapies
Melasma is a chronic disorder of hyperpigmentation. While there are no cures, current treatments can indeed be effective. However, relapses are almost universal. Sustained remission of the disease remains an ongoing & frustrating challenge. Our institute is committed to expanding clinical care & research to find a cure. The current foundation for treating melasma is photoprotection & topical lighteners. For increasingly challenging cases, oral antioxidants, tranexamic acid & a spectrum of procedures are utilized. These procedures include chemical peels, lasers & light sources, microneedling & platelet-rich plasma.
PHOTOPROTECTION: Should include an SPF 50+ plus UVA and visible light protection (iron oxide formulations are recommended). In addition, shade, wide-brim hats, while avoiding peak UV hours are recommended.
TOPICAL AGENTS: These agents represent the first line therapy for melasma treatment. They include the gold standard hydroquinone formulations, tretinoin and low potency topical corticosteroids. Non-hydroquinone lighteners include azelaic acid, kojic acid, and niacinamide. Newer lighteners are cysteamine, thiamadol, malassezin, metformin and 2-mercaptonicotinoyl glycine.
ORAL THERAPIES: Tranexamic acid, which acts by inhibiting plasmin and vascular changes, has emerged for treatment of recalcitrant cases. It does require monitoring for thromboembolic phenomenon. Polypodium leucotomos is utilized as a photoprotective and antioxidant adjunct.
-Chemical Peels include glycolic acid, salicylic acid, lactic acid, Jessner’s and trichloracetic acid. Peels should be utilized with care and caution to avoid side effects, including postinflammatory hyperpigmentation.
PROCEDURAL APPROACHES:
-Lasers and Light Based Therapies can be used as second and third line approaches for individuals with recalcitrant and/or moderate-to-severe disease. They include the fractional non-ablative lasers, low-fluence Q-switched Nd: YAG lasers, picosecond lasers, and microneedling with radio frequency. Lasers and light based therapies should be used with care and caution to avoid postinflammatory hyperpigmentation.