What is Melasma?
Melasma is a common skin condition where symmetrical brown patches appear mostly on the face of women of Asian descent. Multiple factors are believed to be implicated in the formation of this common hyperpigmentation disorder. Melasma, formerly known as Cholasma, the mask of pregnancy is often seen right after childbirth.
How Common Is Melasma?
The general prevalence of melasma is about 1%, however this rate increases according to geographical location, ethnic group and amount of UV exposure. The age of onset is usually from 20-30 years of age, and it is not uncommon for many women to present with melasma later in life.
Although women making up overwhelmingly 90% of the cases of melasma, it can affect men with significant impact on their quality of life.
What causes Melasma?
Melasma is due to the overproduction of melanin (skin pigment) that can be triggered off by a hosts of factors. The 3 main factors contributing to melasma includes UV light, genetics and hormonal influences.
UV light is thought to induce reative oxygen species that stimulates melanin synthesis. Recent studies have also shown that visible light can also induce hyperpigmentation. It is of no surprise then that individuals with melasma often notice their pigmentation being exacerbated by light exposure.
A genetic predisposition to melasma is involved in about 50% of cases. This is especially so with inidividuals with darker skin types. The genes contributing to melasma may not only be involved in regulating pigmentation, but also inflammatory, hormonal and vascular responses.
Hormones play an important role in melasma. While melasma affects women in much greater proportion to men, it is often triggered by pregnancy, oral contraceptive pills and hormomal therapies.
What Does Melasma Look Like?
Melasma tends to present as flat symmetrical hyperpigmented patches. It is found mainly on the central portion of the face, cheeks and jawline. It is not common for melasma to extend to extra-facial areas such as the chest and limbs. The edges of melasma are often irregular.
In our experience, many individuals may have a mixture of hyperpigmentation and other dermatological conditions in addition to melasma. These may include freckles, solar lentigenes, seborrheoic keratoses and skin tags.
What Are The Different Types Of Melasma?
Melasma may affect all layers of the skin. When pigmentation affects only the upper outer layer of the skin, it is known as epidermal melasma. When the pigments are lodged more deeply into the dermis, it is then known as dermal melasma. Mixed melasma has both epidermal and dermal components. It is important to differentiate the different types of melasma during your consultation as it will give a guide to the best treatment option.
- Epidermal melasma
- Dermal melasma
- Mixed melasma
How Is Melasma Diagnosed?
Melasma is diagnosed based on the history, distribution and clinical examination of your skin.
A Wood’s lamp is used to examine the distribution and severity of the condition. This serves as a guide to determine how deep the melasma is, and the presence of other pigmented skin conditions, such as freckles and sun spots.
The Melasma Area and Severity Index (MASI) can be used to assess the severity and extent of your melasma. This measure of assessment takes into account the area involved, darkness and homogeneity of the areas. The higher the score, the more severe the symptoms. However this remains a subjective assessment tool, and serial clinical photography remains a practical way to assess response to treatment.
Of course, while we have tools to assess the physical symptoms, we must not underestimate the psychological impact of the skin condition. Often in Asian cultures, individuals may feel self conscious, embarrassed and feel the condition to be ‘unsightly’.
How can I reduce my Melasma?
Although Melasma is considered a chronic pigmentary skin condition, there are steps that you can take to reduce the worsening of your symptoms.
- Elimate trigger factors such as direct sun exposure, sunbeds and sun tanning.
- Sun protection: Melasma is very sun sensitive. Use a Sunblock of at least SPF 30-50 and PA+++ regularly
- Cosmetic Camouflage
You will be able to find more resources here.
When it comes to the treatment on melasma, no single treatment modality will yield the best results. A combination approach taking into account the severity of the melasma, the type of melasma and your skin type will better improve the appearance of your melasma.
Melasma treatments include:
- Topicals lightening agents
- Oral medications e.g. tranexamic aicd
- Chemical Peels
- Energy based devices and Lasers
Topical Therapy for Melasma
Combination topical therapy that reduces melanin production, increases skin cell turnover and reduces the inflammatory component is superior to monotherapy. During consultation, Dr Ng will advise on the type of topical treatment that is suitable for your skin.
The first line treatment of Melasma involves using a triple combination of products, which contains Hydroquinone, Tretinoin and a steroid. Hydroquinone is a skin lightening agent that reduces melanin synthesis by inhibiting the enzyme involved in the process. The tretinoin (a retinoid, or Vitamin A based cream) enhances melanin elimination by increasing cell turnover and reducing melanocytic activity. The steroid cream, which is mild in potency aims to reduce inflammation. This triple combination regime is reported to improve Melasma symptoms in 60-80% of individuals treated, and visible improvement is noticeable at 8 weeks.
Other Topical formulations thought to be beneficial may include:
- Azelaic acid
- Kojic acid
- Tranexamic acid
- Ascorbic acid (Vitamin C)
Laser Melasma Treatment
For more than a decade, various laser systems have been used in their attempt to treat melasma. Various studies and methods of lasering have not shown which laser system to be the most optimal in the treatment for melasma. This is not surprising as the cause of melasma is multifactorial, and targeting only the pigmentation component is not ideal.
Lasers work by the principle of selective thermolysis. Ablative laser systems such as the CO2 and Er:YAG laser which mainly target water within the skin are deemed too harsh with resultant increased incidences of post-inflammatory hyperpigmentation.
On the other hand, non-ablative lasers such as the Q-Switched and Pico-second laser selectively target the melanin and is safer in individuals with darker skin type. Studies have shown that gentle non-ablative laser treatments with topical lightening creams gives better results compared to monotherapy. However, lasers are not without their side effects.
Melasma can still recur despite laser treatment, may result in post-inflammatory hyperpigmentation (dark spots) and mottled hypopigmentation (white spots). From experience, Dr Ng believes that while laser as a treatment can be offered, laser treatments must not be relied on solely to treat melasma, their use must be judicious.
Our Approach to Melasma Treatment
Melasma remains a challenging condition to treat because it can be frustrating and can adversely impact on one’s quality of life. With the current body of knowledge and experience, a combination approach taking into account the type of melasma, the severity of melasma and your skin type is customized to each individual.
During consultation and examination, Dr Ng will advise you on the best treatment options to help reduce the appearance of melasma safely and effectively.
- Ogbechie-Godec, O.A., Elbuluk, N. Melasma: an Up-to-Date Comprehensive Review. Dermatol Ther (Heidelb) 7, 305–318 (2017). https://doi.org/10.1007/s13555-017-0194-1
- Lee MC, Lin YF, Hu S, Huang YL, Chang SL, Cheng CY, et al. A split-face study: comparison of picosecond alexandrite laser and Q-switched Nd:YAG laser in the treatment of melasma in Asians. Lasers Med Sci 2018;33:1733-8.
- Choi, Y.-J., Nam, J.-H., Kim, J.Y., Min, J.H., Park, K.Y., Ko, E.J., Kim, B.J. and Kim, W.-S. (2017), Efficacy and safety of a novel picosecond laser using combination of 1 064 and 595 nm on patients with melasma: A prospective, randomized, multicenter, split-face, 2% hydroquinone cream-controlled clinical trial. Lasers Surg. Med., 49: 899-907. https://doi.org/10.1002/lsm.22735