MELASMA

Melasma is a chronic skin disorder that results in symmetrical, brownish patches on the face, mainly affecting the cheeks, nose, forehead and upper lip area.
It is a very common condition affecting the middle aged people. It usually occurs between the age of 20 and 40 years. Melasma is more common in females than males.
It can lead to considerable embarrassment and distress.

What causes melasma?

The cause of melasma is complex.

There is evidence of strong genetic predisposition to melasma. One in every three people report a positive family history.

Melasma commonly arises in healthy adults. Chronic sun exposure causes increased deposition of melanin within the dermis, which persists long-term. Exposure to ultraviolet radiation (UVR) worsens the pigmentation because it activates the melanocytes to produce more melanin.

The various factors triggering melasma include:

Sun exposure and sun damage

Pregnancy

Hormone treatments — oral contraceptive pills containing oestrogen and progesterone, hormone replacement, intrauterine devices and implants

Certain medications, scented soaps and cosmetics may cause a phototoxic reaction that can precipitate melasma

Hypothyroidism

How does melasma look like?

Melasma presents as irregular, light to dark brown coloured patches present on both sides of the face.
The most common area to be affected includes the malar area (cheeks), followed by the nose, forehead and upper lip.
It might be also associated with prominent vessels in the background.

How can I get rid of melasma?

Melasma is usually very slow to respond to treatment, especially if it has been present since a long duration.
Generally a combination of various treatment modalities is required to get the best results.
The therapeutic options include:

  1. Topical creams containing one or more depigmenting agents like hydroquinone, azelaic acid, kojic acid, arbutin, liquorice extract, resveratrol
  2. Topical and oral anti-oxidants, i.e., vitamin A, C, and E, glutathione, coenzyme Q10.
  3. Topical tretinoin
  4. Topical and oral tranexamic acid
  5. Alpha hydroxy acids (AHAs) like glycolic acid, lactic acid, mandelic acid, in the form of creams or face washes.
  6. Chemical peeling
  7. Photofacial
  8. Microneedling
  9. Face PRP
  10. Q-switched laser
  11. Fractional lasers
What is the best treatment for melasma?

Melasma is a very difficult to treat condition. Single therapy is rarely helpful in getting rid of melasma.
A combination of different therapeutic options including topical depigmenting agents, with oral tranexamic acid and anti-oxidants with a series of chemical peels and micro-needling have given great results in my clinical practice.

How effective is laser treatment in melasma treatment?

Fractional and Q-switched lasers are the most commonly used lasers in the management of melasma. But, laser treatment is associated with lots of heat generation in the skin manifesting as redness, which increases the risk of post-inflammatory hyperpigmentation. This can make your melasma patch look worse!
Hence, lasers are usually not the first choice of treatment for melasma in coloured skin people.
On the contrary, the other physical modalities like chemical peeling, micro needling, face PRP and even photo facial, are safe as well as very effective in improving the pigmentation of melasma.

What is the role of sunscreens?

Sunscreen plays a very vital role in melasma management. As we all know that UV exposure precipitates as well as exacerbates melasma, so you can understand the importance of using sunscreen in this case.

What is the best sunscreen that should be used?

It is advisable to use a broad spectrum sunscreen, preferably a sun block that gives protection against UVA, UVB, as well as visible rays. The SPF should be at least 30+.
Recently, there are many studies indicating the role of infrared (IR) rays in worsening of melasma pigmentation, so one should use a sunscreen which also has some anti-oxidants like vitamin A, and E, to get that additional protection against IR rays.

Mere usage of sunscreen is not enough!
To avail maximum benefits of a sunscreen, you should know how to use it.

Following are the correct methods of using a sunscreen:

  1. Apply the sunscreen on all the exposed areas of the body not protected by clothing
  2. Apply a generous amount evenly
  3. Sunscreen should be applied daily, 365 days a year, even when you stay indoor or its cloudy or rainy
  4. Apply it at least 15 minutes before stepping out of the house
  5. Re-apply every 2 hours, especially after immersion in water or excessive sweating
  6. Additionally, make use of other physical methods of photo protection, like avoid going out between 11 am to 3 pm, using broad brimmed hat, covering the face with a scarf, and staying under the shade as much as possible.
Are the results of melasma treatment permanent?

Results take time, and the above measures are rarely entirely successful.
The chances of recurrence is present if proper sun protection is not taken, or if there occurs any hormonal imbalances. Continuous research is going on to discover newer topical and oral agents for effective treatment in the future.

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