MelasmaCraig Kraffert, MD
Melasma, or chloasma, is a skin condition in which brown patches develop primarily on the cheekbones, forehead and upper lip. Melasma is also often seen on the nose, chin, lower cheeks and lateral neck. The dark patches typically have distinct edges with pigmentation being deposited in one or more layers of the skin. Melasma may be confined to the outer layer of skin, the epidermis, or it may be present solely in the inner layer of skin, the dermis. Generally, however, it is present to a greater or lesser degree in both outer layers of skin.
Causes of Melasma
The tendency to develop melasma is genetically predetermined. Most of the genetic factors that contribute to this tendency are not fully identified, but it is clear that people who have inherited baseline skin color in the light olive to dark olive range have increased susceptibility.
Melasma has been referred to as the “mask of pregnancy” because it often develops during pregnancy. Oral contraceptives can also trigger melasma. It can be seen in association with menopause, hormonal imbalance, certain medications and ovarian disorders. Because of its almost exclusive development in women, it is thought that estrogen contributes to the formation of melasma in predisposed people. However, estrogen is not essential to the development of melasma as men may be affected.
One key factor that appears essential to the development of melasma in predisposed persons is sun exposure. Both ultraviolet A (UVA) and ultraviolet B (UVB) rays from sunlight or tanning beds can trigger malasma.
Treatment of Melasma
Treatment of melasma is challenging. Long-term success is dependent upon strict avoidance of sun exposure on melasma-prone skin. Even one day of unprotected sun exposure can disrupt months of meticulous treatment. Effective broad-spectrum sun protection, sun avoidance and sun shielding clothing are essential for optimal management of melasma.
In addition to sunlight avoidance, topical therapy is required for best results in melasma management. The FDA has only approved one product, Tri-Luma, for melasma treatment. This product, however, has had a rocky road at the FDA with a three- or four-year absence from the market.
Tri-Luma provides the most consistent and rapid results in the care of moderate to severe melasma with good results frequently seen within eight weeks. Tri-Luma contains hydroquinone (a common synthetic skin lightening ingredient), fluocinolone acetonide (a topical steroid) and tretinoin (the vitamin A derivative found in Retin-A®). Despite having a topical steroid, Tri-Luma is frequently irritating as a result of the irritancy of tretinoin and hydroquinone as well as sodium metabisulfite, a preservative.
Use of Tri-Luma is also somewhat concerning because it contains a fluorinated steroid which can theoretically cause atrophy of facial skin over time. Certain studies suggest that inclusion of tretinoin prevents skin atrophy from steroids, but this claim is physiologically suspect. In addition, Tri-Luma contains paraben preservatives and, despite having two very unstable molecules (tretinoin and hydroquinone), is packaged in an open (non-airless) tube. The brown residue that typically develops at the tube opening is a result of active ingredient oxidation.
Besides Tri-Luma, other prescription lightening products containing hydroquinone are available. These products work much slower than Tri-Luma and most contain sulfite preservatives. None of these other options is FDA approved to treat melasma. Compounding pharmacies will often prepare custom formulations with over 4% hydroquinone but these products are typically very unstable and inelegant.
Alternative Treatments for Melasma
The lack of universally safe and effective treatments has stimulated the search for alternative ways to influence melasma. While sun protection and avoidance are essential, skin care products with concentrated natural brightening ingredients are becoming increasingly popular. These products typically brighten skin more gently and slowly than hydroquinone-containing products.
In certain cultures, skin brightening has been a social ideal for generations. Korea has long focused on skin brightening and implementation of hybrid natural/high-tech formulations. Amarte Cosmetics, for example, has several products with brightening properties and is expected to release a complete line of concentrated brightening products including a state-of-the-art sunscreen later this year.
Melasma is very difficult to treat. It can be emotionally and psychologically troubling and may create a negative impact on quality of life. The good news is that the options for melasma treatment are expanding and becoming increasingly effective.