Melasma is brown facial pigmentation, almost exclusively in females, in a symmetrical distribution on the cheeks, above the eyebrows, above the lip and at the jawline from a combination of hormones and sun exposure. It is often more obvious in low light settings, such as at sunset. Melasma, also called the "mask of pregnancy," is caused by a combination of hormones, predominantly estrogen from pregnancy or birth control, and sun exposure. Once it starts, melasma tends to reoccur very easily with minimal amounts of sun exposure, even if the hormonal trigger is removed. I divide melasma into two types: "relatively easy" and "hard." The difference is dependent on how deep in the skin the pigmentation is found, and whether both the hormonal stimulation and sun exposure can be reduced. Deeper pigment is harder to improve
Cause of Melasma
- Pregnancy hormones
- Birth Control Pills
- Hormone Replacement Therapy
- Your own hormones
- Sun Exposure—a major cause of melasma.
- Ethnic background—medium or darker skin tones are more prone to melasma.
Things That Make Melasma Worse
Medications which increase sun sensitivity—especially Doxycycline, Minocycline and some blood pressure/diuretics.
Heat—exposure to heat such as working in a hot environment
Trauma or irritation of the skin—washcloths, facial cleansing/makeup brushes, exfoliants, medicated creams.
Choices for Melasma Treatment
Melasma treatment involves both removing the triggers, and using creams and procedures to reduce existing pigment. Daily, year round, broad spectrum sun protection and avoidance of sun exposure is absolutely essential. Reducing hormonal triggers is often a challenge as pregnancy eventually ends, but often the need for birth control continues. Even if the hormonal trigger is removed, the melasma remains "turned on" and even tiny amounts of sunlight cause it to reoccur. Treatment at home with prescription skin bleaches, retinoid creams, and sunscreen, combined with in-office chemical peels or microdermabrasion is tried first. "Easy" melasma usually responds fairly well to this treatment. For more resistant cases, Intense Pulsed Light, laser, and deeper chemical peels under the supervision of a dermatologist experienced in treatment of pigment, are considered. Results are varied, and these procedures may actually make pigment worse.
Reduce Hormonal Influence— if possible
Sun Protection—absolutely essential to use a high SPF broad spectrum sunscreen every day, year round, reapplied every 2 hours during sun exposure. Sun exposure must be minimized. Wear hats and plan outdoor activities morning and evening. Dr. Cook recommends our DCL Super Sheer SPF 50 Sunscreen.
Prescription Bleach— Hydroquinone (HQ), however some brands are not available at present, and we will substitute as needed.
Botanical Lighteners to Reduce and Calm Pigment—Dr. Cook recommends our Antioxidant Skin Lightener.
Shed Pigment and Increase Penetration of Medications and Lighteners— Prescription Retin-A, Refissa or Tazorac or OTC Retinol and our Antioxidant Enzyme Peel, Correcting Serum or Intensive Correcting Serum may be recommended.
Chemical Peel Alternating With SilkPeel— every 2 weeks to remove pigment.
It Takes Time to See Results with Melasma Treatment
For some period of time after it is controlled, up to several years, there is always a tendency for it to reoccur. Response to treatment varies based on depth of pigment (deeper pigment is harder to remove) and if factors causing it can be reduced. After pregnancy it may fade spontaneously. Some cases are very stubborn
Possible Side Effects of Melasma Treatment
HQ Skin Bleaches— may cause skin irritation, nail discoloration, temporary lightening of normal skin.
Retin-A, Refissa or Tazorac— may cause irritation.
Chemical Peels— there may be some peeling or crusting for a few days after treatment. If treatment is too aggressive, pigment may actually darken.
Things to Remember About Melasma Treatment
Birth Control Pills or Hormone Replacement Therapy and other Sun Sensitizing Medications—changing or discontinuing them are medical decisions which must be made in consultation with your prescribing physician.
Prescription Skin Bleaches— Triluma cream is used 2 months on, 2 months off. All others are used 4 months on, 2 months off. If you use them continually they stop working and can actually cause pigment darkening. During the off period of time, you should continue your botanical lightener, other recommended products, and sunscreen.