Melasma (facial pigmentation). DermNet NZ http://www.dermnetnz.org/colour/melasma.

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DermNet NZ
Facts about the skin from DermNet New Zealand Trust.

Melasma

What is melasma?

Melasma is a chronic skin disorder that results in symmetrical, blotchy, brownish facial pigmentation. It can lead
to considerable embarrassment and distress.

This form of facial pigmentation is sometimes called chloasma, but as this means green skin, the term melasma
(brown skin) is preferred.

Melasma / chloasma

More images of melasma ...

Who gets melasma?

Melasma is more common in women than in men; only 1-in-4 to 1-in-20 affected individuals are male, depending
on the population studied. It generally starts between the age of 20 and 40 years, but it can begin in childhood or
not until middle age.

Melasma is more common in people that tan well or have naturally brown skin (Fitzpatrick skin types 3 and 4)
compared with those who have fair skin (skin types 1 and 2) or black skin (skin types 5 or 6).

What causes melasma?

The cause of melasma is complex. The pigmentation is due to overproduction of melanin by the pigment cells,
melanocytes, which is taken up by the keratinocytes (epidermal melanosis) and/or deposited in the dermis
(dermal melanosis, melanophages). There is a genetic predisposition to melasma, with at least one-third of
patients reporting other family members to be affected. In most people melasma is a chronic disorder.

Known triggers for melasma include:

Sun exposure and sun damagethis is the most important avoidable risk factor
Pregnancyin affected women, the pigment often fades a few months after delivery
Hormone treatmentsoral contraceptive pills containing oestrogen and/or progesterone, hormone

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replacement, intrauterine devices and implants are a factor in about a quarter of affected women
Certain medications (including new targeted therapies for cancer), scented or deodorant soaps, toiletries and
cosmeticsthese may cause a phototoxic reaction that triggers melasma, which may then persist long term
Hypothyroidism (low levels of circulating thyroid hormone)

Melasma commonly arises in healthy, non-pregnant adults. Lifelong sun exposure causes deposition of pigment
within the dermis and this often persists longterm. Exposure to ultraviolet radiation (UVR) deepens the
pigmentation because it activates the melanocytes to produce more melanin.

Research is attempting to pinpoint the roles of stem cell, neural, vascular and local hormonal factors in promoting
melanocyte activation.

What are the clinical features of melasma?

Melasma presents as macules (freckle-like spots) and larger flat brown patches.These are found on both sides of
the face and have an irregular border. There are several distinct patterns.

Centrofacial pattern: forehead, cheeks, nose and upper lips

Malar pattern: cheeks and nose
Lateral cheek pattern
Mandibular pattern: jawline
Reddened or inflamed forms of melasma (also called erythrosis pigmentosa faciei)
Poikiloderma of Civatte: reddened, photoaging changes seen on the sides of the neck, mostly affecting
patients older than 50 years
Brachial type of melasma affecting shoulders and upper arms (also called acquired brachial cutaneous
dyschromatosis).

Melasma is sometimes separated into epidermal (skin surface), dermal (deeper) and mixed types. A Wood lamp
that emits black light (UVA1) may be used to identify the depth of the pigment.

Type of melasma Clinical features

Epidermal
Well-defined border
Dark brown colour
Appears more obvious under black light
Responds well to treatment

Dermal
Ill-defined border
Light brown or bluish in colour
Unchanged under black light
Responds poorly to treatment

Mixed
The most common type
Combination of bluish, light and dark brown patches
Mixed pattern seen under black light
Partial improvement with treatment

How is melasma diagnosed?

The characteristic appearance of melasma means diagnosis is usually straightforward and made clinically. Other
disorders that may be considered instead of melasma or as well as melasma include:

Postinflammatory pigmentation
Solar lentigines and other forms of lentigo

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Drug-induced pigmentation, e.g. due to minocycline or nonsteroidal antiinflammatory drugs

Lichen planus
Naevus of Ota and naevus of Hori
Guttate hypomelanosis, in which pale spots are prominent

Occasionally, skin biopsy may be performed to make or confirm the diagnosis of melasma. Histology varies with
the type of melasma. But some degree of each of the following features is usually found.

Melanin deposited in basal and suprabasal keratinocytes

Highly dendritic (branched) deeply pigmented melanocytes
Melanin in the dermis within melanophages
Solar elastosis and elastic fibre fragmentation

The extent and severity of melasma can be described using the Melasma Area and Severity Index (MASI).

What is the treatment of melasma?

Melasma can be very slow to respond to treatment, especially if it has been present for a long time. Treatment
may result in irritant contact dermatitis in patients with sensitive skin, and this can result in post-inflammatory
pigmentation.

Generally a combination of the following measures is helpful.

General measures

Discontinue hormonal contraception.

Year-round life-long sun protection. Use broad-spectrum very high protection factor (SPF 50+) sunscreen
applied to the whole face every day. It should be reapplied every 2 hours if outdoors during the summer
months. Alternatively or as well, use a make-up that contains sunscreen. Wear a broad-brimmed hat.
Use a mild cleanser, and if the skin is dry, a light moisturiser.
Cosmetic camouflage (make-up) is invaluable to disguise the pigment.

Topical therapy

Tyrosinase inhibitors are the mainstay of treatment. The aim is to prevent new pigment formation by inhibiting
formation of melanin by the melanocytes.

Hydroquinone 24% as cream or lotion, applied accurately to pigmented areas at night for 24 months. This
may cause contact dermatitis (stinging and redness) in 25% of patients. It should not be used in higher
concentration or for prolonged courses as it has been associated with ochronosis (a bluish grey discolouration
similar to that seen in alkaptonuria).
Azelaic acid cream, lotion or gel can be applied twice daily long term, and is safe in pregnancy. This may also
sting.
Kojic acid or kojic acid dipalmitate is often included in formulations, as it binds copper, required by L-DOPA (a
cofactor of tyrosinase). Kojic acid can cause irritant contact dermatitis and less commonly, allergic contact
dermatitis.
Ascorbic acid (vitamin C) also acts through copper to inhibit pigment production. It is well tolerated but highly
unstable, so is usually combined with other agents.
Methimazole (antithyroid drug) cream has been reported to reduce melanin synthesis and pigmentation in
hydroquinone-resistant melasma.
New agents under investigation include zinc sulfate mequinol, arbutin and deoxyarbutin (from berries),
licorice extract, rucinol, resveratrol, 4-hydroxy-anisole, 2,5-dimethyl-4-hydroxy-3(2H)-furanone and/or
N-acetyl glucosamine

Other active compounds used for melasma include:

Topical corticosteroids such as hydrocortisone. These work quickly to fade the colour and reduce the likelihood
of contact dermatitis caused by other agents. Potent topical steroids are best avoided due to their potential to
cause adverse effects.

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Soybean extract, which is thought to reduce the transfer of pigment from melanocytes to skin cells
(keratinocytes) and to inhibit receptors.
Tranexamic acid, a lysine analogue that inhibits plasmin and is usually used orally to stop bleeding. It reduces
production of prostaglandins, the precursors of tyrosine. Tranexamic acid has been used experimentally for
melasma as a cream or injected into the skin (mesotherapy), showing some benefit. It may cause allergy or
irritation.

Superficial or epidermal pigment can be peeled off. Peeling can also allow tyrosinase inhibitors to penetrate more
effectively. These must be done carefully as peels may also induce post-inflammatory pigmentation.

Topical alpha hydroxyacids including glycolic acid and lactic acid, as creams or as repeated superficial
chemical peels, remove the surface skin and their low pH inhibits the activity of tyrosinase.
Topical retinoids, such as tretinoin (a prescription medicine) are effective. Tretinoin can be hard to tolerate
and sometimes causes contact dermatitis. Do not use during pregnancy.
Salicylic acid, a common peeling ingredient in skin creams, can also be used for chemical peels, but it is not
very effective in melasma.

The most successful formulation has been a combination of hydroquinone, tretinoin, and moderate potency topical
steroid. This has been found to result in improvement or clearance in up to 6080% of those treated. Many other
combinations of topical agents are in common use, as they are more effective than any one alone. However, these
products are often expensive.

Oral treatment of melasma

Oral medications for melasma are under investigation, including tranexamic acid and glutathione. None can be
recommended at this time.

Devices used to treat melasma

The ideal treatment for melasma would destroy the pigment, while leaving the cells alone. Unfortunately, this is
hard to achieve. Machines can be used to remove epidermal pigmentation but with cautionover-treatment may
cause postinflammatory pigmentation. Patients should be pretreated with a tyrosinase inhibitor (see above).

Fractional lasers, Q-switched Nd:YAG lasers and intense pulsed light (IPL) appear to be the most suitable options.
Several treatments may be necessary and post-inflammatory hyperpigmentation may complicate recovery.

Carbon dioxide or erbium:YAG resurfacing lasers, pigment lasers (Q-switched ruby and Alexandrite devices) and
mechanical dermabrasion and microdermabrasion should be used with caution in the treatment of melasma.

What is the outcome of treatment of melasma?

Results take time and the above measures are rarely completely successful.

Unfortunately, even in those that get a good result from treatment, pigmentation may reappear on exposure to
summer sun and/or because of hormonal factors. New topical and oral agents are being studied and offer hope for
effective treatments in the future.

Related information

References:

Vaneeta M. Sheth, Amit G. Pandya. Melasma: A comprehensive update Part I:Journal of the American Academy of
DermatologyVolume 65, Issue 4, October 2011, Pages 689697
Vaneeta M. Sheth, Amit G. Pandya. Melasma: A comprehensive update Part II Journal of the American Academy of
Dermatology, Volume 65, Issue 4, October 2011, Pages 699-714
Gupta AK, Gover MD, Nouri K, Taylor S. The treatment of melasma: A review of clinical trials. J Am Acad Dermatol
2006;55:1048-65. Medline.

DermNetNZ:

Bleaching creams

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Melasma (facial pigmentation). DermNet NZ http://www.dermnetnz.org/colour/melasma.html

Skin problems in pregnancy

Sensitive skin

Other websites:

Melasma Medscape Reference

Melasma British Association of Dermatologists
Patient information: Melasma (The Basics) UpToDate (for subscribers)
Melasma: Tips to Make It Less Noticeable video, American Academy of Dermatology
Melasma: Tips for managing American Academy of Dermatology

Books:

See the DermNet NZ bookstore

Author: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Updated September 2014.

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