Melasma: What Is It and What Are Its Symptoms?
Melasma is a common pigmentation disorder that affects the skin, primarily on the face. It is characterized by dark, irregular patches of skin that can vary in color from brown to grayish-brown. Melasma is more common in women than men, and tends to affect individuals with darker skin types more frequently.
The symptoms of melasma include the appearance of dark, irregular patches of skin on the face, particularly on the cheeks, forehead, nose, and upper lip. These patches may vary in size and shape and can be symmetrical or asymmetrical. Melasma is generally not painful or itchy but can cause significant cosmetic concern.
What Causes Melasma?
The pigment pathway, also known as the melanogenesis pathway, is the process by which skin color is produced in the body. This process is primarily facilitated by a type of skin cell known as a melanocyte, which produces melanin, the primary pigment responsible for skin, hair, and eye color. Here's a simplified version of how this process typically works:
The melanogenesis pathway begins with an amino acid known as tyrosine.
An enzyme known as tyrosinase, which is present in melanocytes, catalyzes the conversion of tyrosine into DOPA (dihydroxyphenylalanine) and then into DOPAquinone.
Further chemical reactions lead to the production of two types of melanin - eumelanin (brown/black pigment) and pheomelanin (yellow/red pigment). The balance of these melanins in the skin determines the color of the skin.
In people who have melasma, this pigment pathway is disrupted, leading to brown to gray-brown patches on the face. Though the exact causes of melasma are unclear, it's thought to occur when melanocytes produce too much melanin in certain areas of the skin.
The exact cause of melasma is not fully understood, but it is believed to be related to a combination of factors that can trigger or aggravate it. These include hormonal changes, sun exposure, genetics, oxidative stress, lipid metabolism, and impaired barrier function.
Hormonal changes: Melasma is often associated with hormonal changes, particularly estrogen and progesterone. This is why melasma is common during pregnancy (often called the "mask of pregnancy") or in women taking birth control pills or undergoing hormone replacement therapy (HRT).
Sun exposure can also trigger melasma, particularly in individuals with lighter skin types. UV light from the sun can cause damage to skin cells by inducing the production of reactive oxygen species (ROS) and stimulating melanogenesis. Melasma can also be exacerbated by visible light at a wavelength of 415 nm. This is why melasma often worsens in the summer and improves in the winter.
Genetics and family history also play a role in the development of melasma. Studies have shown that individuals with a family history of the condition are more likely to develop it themselves.
Gender and ethnicity. Melasma is more common in women than men, particularly during pregnancy or while taking birth control pills. It is also more common in individuals with darker skin types, such as those of Hispanic, Asian, or African descent.
Skin irritation, including irritation from certain skincare products, can also make the condition worse as skin injury or irritation causes the skin to produce more melanin as a defense mechanism.
Other risk factors that can contribute to the development of melasma include oxidative stress, lipid metabolism, impaired barrier function, a history of sun exposure or skin damage, and certain medications.
Researchers are still trying to understand more about the underlying molecular mechanisms that lead to the overproduction of melanin in melasma. Studies suggest that it might involve the activation of certain signaling pathways in melanocytes that enhance tyrosinase activity and melanin production.
Current treatments for melasma aim to reduce the production of melanin by inhibiting tyrosinase and other enzymes involved in the pigment pathway. These treatments include topical medications like hydroquinone, azelaic acid, and kojic acid, chemical peels, laser treatment, and protection from sun exposure.
Understanding the underlying causes of melasma and who is at risk can help individuals take steps to prevent or manage the condition effectively.
Melasma and Pregnancy
The development of melasma is extremely common during pregnancy, and highlights the role that hormones play in its development. Melasma affects 50-70% of pregnant women. This type of melasma is known as "chloasma" or "pregnancy mask," and is believed to be related to hormonal changes that occur during pregnancy that make the skin more sensitive to the sun, increasing the risk of sun damage and exacerbating melasma.
While treatment options for melasma will be discussed at length below, it is worth mentioning here that many of the treatment options for melasma, such as hydroquinone and retinoids, are not recommended for use during pregnancy due to potential risks to the developing fetus. Treatments that are safe for use during pregnancy include azelaic acid and glycolic acid, among others.
It is important to consult with a healthcare professional before starting any treatment during pregnancy. Pregnant women can also refer to the recommended lifestyle changes for managing melasma below.
Lifestyle Changes to Manage Melasma
In addition to medical treatments and pregnancy-specific management strategies, there are several lifestyle changes that individuals with melasma can make to help manage the condition. These include:
Wearing sunscreen. Sun exposure can trigger the production of excess melanin in the skin, leading to the development of melasma. Wearing sunscreen with at least SPF 30 and avoiding sun exposure during peak hours can help to prevent further pigmentation.
Wearing protective clothing. Wearing a wide-brimmed hat and clothing that covers the arms and legs can help to protect the skin from sun damage and prevent further pigmentation.
Avoiding hot showers. Hot water can worsen melasma by activating melanocytes, or pigment-producing cells in the skin.
Eating a healthy diet and staying hydrated. Eating a diet rich in antioxidants, such as fruits and vegetables, can help to promote healthy skin and prevent further pigmentation.
Managing stress. Stress can exacerbate melasma by triggering hormonal changes in the body. Practice stress-reducing techniques, such as meditation or yoga, to manage stress.
Ingredients To Look For In Your Skincare Products
Hydroquinone, a topical skin-lightening agent used in treating hyperpigmentation disorders like melasma, inhibits melanin production and is effective at concentrations of 2-4%. However, its long-term use can lead to skin irritation, rebound hyperpigmentation, and a rare condition called exogenous ochronosis, which causes blue-black skin pigmentation. Despite its effectiveness, concerns about its potential carcinogenicity based on animal studies have led to restrictions in some countries. Paradoxically, hydroquinone can also exacerbate pigmentation due to its cytotoxic effects on melanocytes, the pigment-producing cells. Some patients treated with hydroquinone have reported increased skin darkening, suggesting the need for supervised use of this treatment.
I’ll cover hydroquinone in greater detail in a separate blog. Stay tuned.
Tranexamic acid, a synthetic derivative of the amino acid lysine, has shown potential in treating melasma. In recent years, topical and oral forms of TXA have also been studied for their effectiveness in treating melasma. Though its exact mechanism is unclear, TXA is believed to work by inhibiting melanin synthesis, showcasing anti-inflammatory effects, and obstructing angiogenesis (new blood vessel formation). These properties can reduce hyperpigmentation, control inflammation - a known melasma trigger, and suppress increased vascularity often seen in melasma-affected areas.
Retinoids, which include tretinoin, are vitamin A derivatives that work by increasing the turnover rate of skin cells. They stimulate the production of new skin cells and promote the exfoliation of older, pigmented skin cells. By removing these melanin-containing cells, tretinoin can help reduce the appearance of hyperpigmentation associated with melasma.,
Tretinoin can also help regulate the production of melanin in the skin, leading to a more even skin tone and improve the penetration of other topical treatments, making it a common combination therapy for melasma. Tretinoin can however, also cause skin irritation and dryness, particularly during the initial stages of treatment and it is important to introduce it into your skincare routine slowly, ideally starting with products such as our Retin-oil Serum, that are formulated with milder retinoids like retinyl palmitate.
Natural Extracts: Licorice Root Extract, Bearberry Extract and Mulberry Extract
Licorice root extract contains glabridin, which has been shown to have anti-inflammatory and antioxidant properties. It also inhibits tyrosinase, a key enzyme involved in melanin production. Several studies have evaluated the effectiveness of glabridin for melasma and found it to be effective, including a clinical trial that indicated that 2.5% G. glabra cream was effective as treatment for melasma in a 28-day course with minimal side effects
Bearberry extract contains arbutin, which is a natural derivative of hydroquinone. Arbutin inhibits tyrosinase and reduces melanin production. Several studies have found that arbutin is effective in reducing hyperpigmentation in patients with melasma.
Mulberry extract contains kojic acid, which inhibits tyrosinase and reduces melanin production. A study found that a topical cream containing 1% kojic acid and 2% ascorbic acid improved hyperpigmentation in patients with melasma after 12 weeks of use.
Ingredients that fight hyperpigmentation typically work best in combination. We’ve used bearberry and mulberry extract alongside vitamin C, niacinamide and alpha arbutin in our Serum Vitamin C, Niacinamide, Alpha Arbutin, which we’ve formulated especially for skin types prone to pigmentation and melasma.
Alpha arbutin is a naturally occurring compound that is often used as a skin lightening agent in cosmetics and skincare products. It works by inhibiting the activity of tyrosinase, and several studies have backed up its effectiveness, as already mentioned in the paragraph on bearberry extract.
Topical steroids, such as hydrocortisone, have anti-inflammatory properties and can be used to treat melasma by reducing inflammation and irritation that can worsen hyperpigmentation. Steroids also inhibit the production of melanin in the skin, which helps reduce the appearance of hyperpigmentation. But - and this is extremely important to note - long-term steroid use has serious side-effects and is not encouraged. Even when used in the short-term, steroids should only be used under the guidance of a healthcare professional.
I personally prefer not using them at all since most skin conditions have no permanent cure and require ongoing management making it a better idea to use ingredients and products that are safe for long-term use.
Azelaic acid is a naturally occurring acid that is used to treat a variety of skin conditions, including hyperpigmentation and melasma, due to its ability to inhibit tyrosinase. Azelaic acid also has anti-inflammatory properties, which can help alleviate the redness and inflammation often associated with skin disorders, antioxidant properties that can help protect skin from damage caused by free radicals and other environmental stressors.
Azelaic acid is topically applied and is available in both prescription and over-the-counter formulations. Azelaic acid is generally well-tolerated by most people. However, it can cause some side effects, such as redness, itching, and dryness. These side effects are usually mild and go away on their own.
I’ll cover azelaic acid in greater detail in a separate blog. Stay tuned.
Kojic acid is a naturally occurring compound that has been used for centuries in traditional Japanese medicine. It is a derivative of fungi and is produced during the fermentation of foods like soy sauce. Kojic acid has a number of beneficial properties for the skin, including skin lightening, and anti-inflammatory properties. It works to lighten the skin and reduce hyperpigmentation by inhibiting the production of free tyrosinase, the amino acid precursor for melanin.
Kojic acid is generally safe and well-tolerated by most people, but can cause some side effects, like redness, itching, and dryness. These side effects are usually mild and go away on their own. It is available in a variety of OTC and prescription products. OTC products typically contain 1% to 2% kojic acid, while prescription products can contain up to 4%.
Vitamin C is a powerful antioxidant that can help to brighten the skin and reduce the appearance of melasma. It also works by inhibiting tyrosinase activity and promoting collagen production. Vitamin C should be used in a concentration of 10-20% and applied once or twice daily to the affected areas of the skin.
I’ve already talked about vitamin C at length in a separate blog. You can read it here.
Niacinamide, also known as vitamin B3, is a water-soluble vitamin that has been found to be effective in treating various skin conditions, including melasma. Niacinamide has been shown to inhibit the transfer of melanosomes (pigment-containing organelles) from melanocytes (pigment-producing cells) to keratinocytes (skin cells) in the epidermis, thereby reducing the amount of melanin in the skin.
Niacinamide also has anti-inflammatory properties, which can help to reduce the redness and inflammation associated with melasma. Niacinamide also has several other benefits for the skin that you can learn about here.
Sunscreen and sun avoidance are crucial for managing melasma. Sun exposure is a major trigger for the development and exacerbation of melasma. UV radiation can induce reactive oxygen species (ROS) and stimulate melanogenesis, leading to increased pigmentation.
Sunscreen should be applied daily, even on cloudy days and even if you plan to spend your day indoors. Sun avoidance is also important, especially during peak hours when the sun's rays are strongest - usually between 10 am and 4 pm. Hats, sunglasses, and protective clothing can also help to reduce sun exposure.
Recommended Skincare Routine For Melasma
In addition to medical treatments and lifestyle changes, establishing a proper skincare routine can help manage melasma and prevent further pigmentation. Here’s a recommended skincare routine for individuals with melasma:
Use a gentle cleanser, such as our Hydrating Gentle Daily Cleanser, to remove dirt, oil, and makeup from the skin. Harsh cleansers can irritate the skin and worsen melasma. Alternatively, skip the morning cleanse altogether and simply rinse your face with water instead.
Moisturize with Crème B3-B5-E. This contains niacinamide, which as already discussed, is an excellent ingredient for combatting hyperpigmentation, and evening out the skin tone.
Follow up with a thick layer of broad-spectrum SPF with at least SPF 30. Apply this even if you’re going to spend the entire day indoors and reapply it every few hours to maintain high levels of protection. UV radiation is a well-known pigmentation trigger and this is the most important step for individuals prone to pigmentation.
Wash your face with the Hydrating Gentle Daily Cleanser. 2-3 times a week use the Resurfacing Face Wash instead to gently exfoliate the skin. Exfoliation helps remove dead skin cells and promotes skin cell turnover leading to a more even skin tone and texture.
Follow up with Serum Vitamin C, Niacinamide, Alpha Arbutin.
Moisturize with Crème B3-B5-E.
Other Melasma Treatments (for when skincare isn’t enough)
In some cases, melasma may resolve on its own without treatment, particularly if it is related to pregnancy or hormonal changes. In many cases however, in-office treatments are needed to improve the appearance of the skin and prevent further pigmentation. Treatment options - beyond the skincare active ingredients just discussed - include:
Oral tranexamic acid
Chemical peels: These involve the application of a chemical solution to the skin, which causes the top layer of skin to peel off, revealing smoother, brighter skin underneath.
Microdermabrasion: This involves the use of a special device to exfoliate the top layer of skin and promote the growth of new skin cells.
Laser therapy: This involves the use of a specialized laser to target and break down excess melanin in the skin.
You can discuss these with your dermatologist to see which one might be right for you. It is important to note however, that melasma can unfortunately, be a persistent condition, and it may take several months or even years of treatment to achieve significant improvement in the appearance of the skin.
In conclusion, melasma is a common condition characterized by patches of hyperpigmentation on the skin, typically on the face. While the exact cause of melasma is not fully understood, hormonal changes, sun exposure, and genetics are all believed to play a role. Treatment options for melasma include topical creams and lotions, chemical peels, microdermabrasion, and laser therapy, among others. Some of these treatments however, are not recommended for use during pregnancy due to potential risks to the developing fetus. Lifestyle changes, such as wearing sunscreen, protective clothing, and managing stress, can also help to manage melasma and prevent further pigmentation. Unfortunately however, melasma can often be persistent and it can take months of consistent effort to see results.
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