Natural options for management of melasma, a review

Mpofana Nomakhosi and Abrahamse Heidi

Laser Research Centre, Faculty of Health Sciences, University of Johannesburg,
Doornfontein, South Africa
ARTICLE HISTORY
Received 2 March 2017 Accepted 6 January 2018
KEYWORDS
Melasma; hyperpigmentation; natural ingredients; darker skin types; pigmentation
disorders

ABSTRACT
A blemish free, even-toned skin is universally associated with healthy skin. This
reasoning makes people desire to have a flawless skin. Melanin is a naturally
occurring pigment in humans. This pigment is responsible for skin, hair, and eye
color, therefore determines our race and phenotypic appearance. On darker skin
types, it is common that melanin production processes malfunctions. These
malfunctions often lead to overproduction and secretion of melanin. As a result,
unwanted pigmentary problems such melasma occur. Due to unknown etiology and
its recurrence in nature, melasma is challenging to treat. The current available
melasma treatment options often produce undesired side effects and suboptimum
results. First-line topical treatments usually involve hydroquinone or topical
steroids. Apart from the irritant reactions, this treatment mode is not suitable for all
skin types. Skin care specialists are in search of an effective long-term cosmetics
and cosmeceuticals to address hypermelanosis problems. Understanding of
naturally occurring depigmenting agents provides an opportunity for more effective
ways to manage melasma in all skin types. This review considers the benefits of
naturally occurring ingredients which could help address skin pigmentation
problems and broaden the choice for skin-lightening treatments.

Introduction
A blemish free, even skin tone is desirable by everybody. Flawless skin is
considered a universal indication of beauty and healthy skin(1). Melanin, a naturally
occurring pigment in humans, is responsible for skin, hair, and eye color, there-fore
(2)
determines our race and phenotypic appearance . It plays a vital protection role
 (3,4)
from cytotoxic ultraviolet (UV) radiation and oxidative stress . Melanin is
produced from the melanosomes and transferred from melanocytes to keratinocytes
(2,5,6)
. Melanin production is controlled by the expression and activity of a copper
containing enzyme, tyrosinase (7). Tyrosinase is a vital enzyme involved in melanin
synthesis. Tyrosinase regulates the catalytic pro-cesses of hydrolysis of tyrosine to
L-DOPA as well as oxida-tion of DOPA to DOPA quinine (2,7–9). When this process
is malfunctioning, it often leads to overproduction of mela-nin. Over secretion of
melanin causes unwanted skin pro-blems such as post-inflammatory melanoderma,
hyperpigmentation, and melasma (4).
Melasma is a common, acquired hypermelanosis (Table 1) of the face, which
affects both sexes with a noticeable frequency in women (10–13). It is more common
in people of darker skin phototypes due to high melanin content in these skin types
(14,15)
. There seems to be an increased interest among people with skin of color
requesting effective skin care treatments, this brings about great demand to
investigate effective treatment modalities suitable for these skin types as the current
literature is not sufficient. (16–20).
Melasma is characterized by light-to-dark brown symmetrical, homogeneous,
(21)
irregular patches or macules . Although its etiology is not clearly understood,
sun exposure, hormones, preg-nancy, use of phototoxic drugs, genetic influences,
use of cos-metics, and anticonvulsant drugs are among the predisposing factors
(12,13)
. Melasma is reported to have a significant negative impact on many women.
Tremendous emotional stress and psy-chological distress are chronic emotions
brought about by mel-asma (22–25).
According to statistical data, The American Academy of Dermatology estimates
that melasma affects 5–6 million women in the United States (26). Research shows
that pig-mentation disorders are the third (8, 8%) largest group of skin disorders in
dermatology practices. In Brazil, pigmentary dis-orders are the second largest (11,
6%) complaint in women (27). In South Africa, there is paucity of data in statistics.
As a developing country with its diversity similar to America, the statistics may
suggest similar patterns in South Africa.
Classification of melasma
Four clinical patterns (Figure 1) of hypermelanosis are cited in patients with
(12,28)
melasma . These include, but are not limited to, a centrofacial, malar, and
(10,26)
mandibular pattern. Melasma is not involved in the mucous membranes .
Centrofacial is the most common pattern of melasma. This pattern involves the
cheeks, forehead, upper lip, nose and chin. The malar pattern involves the cheeks
and nose. The mandibular pattern involves lesions that occur over the ramus of the
mandible.
Table 1. Causes of acquired hypermelanosis (41).
Exogenous sources
Cosmetics
Photosensitizing agents (bergamot oil)
Drugs (Isotretinoin, tetracycline, Methotrexate, griseofulvin, sulphonamides)
UV exposure (melasma, solar lentigo, freckles)
Skin disorders and conditions
Melasma
Linea fusca
Poikeloderma of civatte
Erythromelanosis follicularis
Riehl’s malanosis
Post inflammatory hyperpigmentation
Other causes
Pregnancy
Hemochromatosis
Liver disease
Addison’s disease
Pituitary tumor

Table 2. Frequency of facial features affected by melasma (adapted from Ref. (29)).
Topographies Percentage
Mandibular 18
Temporal 24
Glabella 25
Mentonian 29
Parotid 30
Nasal 40
Supralabial 51
Zygomatic 84
Originally published in Handel AC, Lima PB, Tonolli VM, Miot LDB, Miot
HA. Risk factors for facial melasma in women: a case-control study. Br J
Dermatol. 2014 © British Association of Dermatologists. Reproduced by
permission of British Association of Dermatologists. Permission to reuse must
be obtained from the rightsholder.

Studies conducted in Brazil on the incidence of topogra-phies (Table 2) concur

that the facial area was the most affected; melasma was more noticeable on
forehead, upper lip, zygoma, nose, chin, and parotid regions (26,28,29). Other areas of
the body such as forearms and neck may also be involved with melasma (7).
Melasma is further classified according to the time it takes to resolve when
treated. It is classified as either transient or persistent (10,30). Transient type is when
melasma retracts within a year of termination of stimulus, e.g., post-pregnancy.
Persistent melasma is seen when melasma persists more than a year after the
stimulus has been removed (12,31).
Melasma is classified into four different histological types according to its depth
(10,32)
in the skin . When melanin is distributed in the epidermis, it is illuminated
more intense under the Wood’s lamp, a common tool for the diagnosis of melasma.
This type is referred to as the epidermal type and is the most common. Dermal
melasma is not as intense under Wood’s lamp and melanin is distributed in the
dermis. In mixed type melasma, Wood’s lamp gives some interrupted intense
illumination on some areas while others remain unchanged. On very dark
individuals, Wood’s lamp cannot illuminate melasma due to the skin color acting
as a compet-ing chromophore. This type of melasma is classified as the intermediate
melasma (10,30).
Histopathological studies have suggested a hyper func-tional effect on
melanocytes (32–34). When compared to normal skin, the involved skin shows
larger melanocytes which are extremely discolored with very noticeable dendrites
and increased synthesis of eumelanin. Epidermal melanocytes were noticed to be
filled with more mitochondria, Golgi apparatus, and rough endoplasmic reticulum.
Ribosomes also reflected increased melanocytic activity (34). Electronic
microscopy studies revealed almost a similar finding to his-tology.
Microscopically, there were more keratinocytes, mela-nocytes, and dendrites when
compared to the uninvolved skin (33).
South Africa is a country of multiple ethnicity and origin, covering a wide range
of darker skin types (35). Melasma is found more frequently and noticeable on
Fitzpatrick skin types III–VI (darker skin phototypes) (14,15). Most interven-tion
procedures (topical treatments, lasers and light, chemical peels) have been used but
with undesired side effects and suboptimal results on darker skin types (3,16). The
darker skin types tend to be sensitive to treatment interventions. Side effects like
ochronosis when using hydroquinone (HQ), skin irritations to glycolic acid peels
are common reported unde-sired effects. Darker skin types are more prone to post-
inflam-matory hyperpigmentation and have a greater chance of relapse (14,36,37).
Although medium depth peels, e.g., tri-chloroacetic acid, are recommended for
management of mel-asma, they should be used with caution as there is a risk of
developing hypertrophic scarring and unwanted permanent depigmentation
(17,36,37). Use of deep peels is completely prohibited as they are not suitable for
darker skin types (36,37). Treatment interventions such as laser, although
recommended in literature for melasma treatment, are not suitable for darker skin
types (14,36–38).

Figure 1. Fitzpatrick skin phototype V with total face involvement melasma. (a)
Female full face melasma involvement. (b) Male pattern melasma involving upper
mentonian lesions, mandibular, zygomatic, temporal, and frontal (researchers’
collection).
Diagnostic tools
Analysis of melasma is essential as it informs the treatment choice. There are few
instruments that are used for melasma analysis. These include Wood’s lamp,
dermoscopy, reflec-tance confocal microscopy, colimetry, mexametry, Melasma
Area and Severity Index, and histology. Wood’s lamp exam-ination is the most
common melasma grading tool in which the skin is examined while exposed to the
black light emitted by Wood’s lamp. This diagnostic tool was invented by a
Caltimore physicist, Robert W. Wood, in 1903. Black light is invisible to the naked
eye because it is in the UV spectrum with a wavelength just shorter than the color
violet. The Wood’s lamp glows violet in a dark environment because it also emits
some light in the violet part of the electromagnetic spectrum. A traditional Wood’s
lamp is a low-output mer-cury arc covered by a Wood filter (barium silicate and
9% nickel oxide) and emits wavelength 320–450 nm (peak 365 nm). Wood’s lamp
highlights the difference in pigmen-tation between affected and normally skin.
Intensely seen pigmentation under this lamp responds better to topical treatment
(39,40).
Treatment of melasma
Current modalities
Treatment of melasma is challenging to treat due to its recur-rence nature. Current
treatments of melasma include applica-tion of sunscreen, use of topical HQ alone
or in combination with tretinoin, and or a corticosteroid (7,10,13,41). Superficial
chemical peels and laser therapy are also common treatments (21). HQ is
considered the gold standard among the topical treatments of melasma; however,
its use is associated with many undesirable side effects. Skin irritations,
cytotoxicity, mutagenicity of melanocytes, contact dermatitis, and exogen-ous
ochronosis in ethnic phototypes are amongst reported side effects (42). Natural
plant extracts have also been used in the treatment of melasma (Table 3).
Naturally occurring remedies for melasma treatment
The goal of treating melasma is to reduce hypermelanosis without causing
hypopigmentation or irritation on the sur-rounding skin. There are many modalities
available on the market; however, the side effects associated with them are
significant. Naturally occurring depigmenting ingredients, e.g., kojic acid, vitamin
C, soybean, licorice, arbutin, mequi-nol, niacinamide, glucosamine, aloesin,
mulberry, hesperidin, ginseng, azelaic acid, umbelliferone (UMB), and grape seed,
are presented in this study (Table 3).
Vitamin C (ascorbic acid)
Vitamin C is extracted from green leafy vegetables and citrus fruits. It is a water
soluble vitamin with potent functions (42). It has the ability to reduce dopaquinone
to DOPA, therefore acting as an antioxidant found in large quantities in human skin
(3,10,43–45). Vitamin C has an added benefit of photo protective effects by
preventing absorption of both UVA and UVB harmful radiation as well as
promotion of collagen synthesis (46).
Literature provides evidence of the instability of vitamin C in the form of a
solution. Many studies have concurred that it is quick to oxidize and decomposes
in solution (3,45). Vitamin C obtained from fruits and vegetables has limited
stability and permeability; this may result in unwanted skin irritations and allergy
(47). Ascorbate esters such as magne-sium ascorbyl-2-phosphate are always added
to any Vitamin C solution to stabilize it (1,3,10,45).
Recent literature demonstrates that the success of topical vitamin C is based on
combination therapy. Vitamin C has been combined with iontophoresis (43,46,48),
with mesother-apy (47), with laser Q-Switched ND:YAG laser (49), or frac-tional
Q-Switched Ruby Laser (50). Due to its limited permeability being a charged
molecule, combination therapies are aimed to assist vitamin C penetration ensuring
better efficacy (47). Clinical trials investigating efficacy of vitamin C with
iontophoresis (43) or comparing it with HQ (51) have both revealed excellent
results with minimal tolerable side effects (Table 3).
Solano et al. (3) acknowledge vitamin C as an excellent antioxidant due to its
ability to reduce back o-dopaquinone to dopa, thereby inhibiting melanin formation.
Smit et al. (6) suggest that vitamin C is a popular depigmenting agent cur-rently
used in most skin whitening formulations. Draelos (1) echoes the same effects of
vitamin C in the inhibition of melanin production, however contends that it is a poor
light-ening product when used alone; better results are achieved when combined
with licorice extracts. Bandyopadhyay (10) and Rendon and Gavira (41) suggest
that vitamin C is effec-tive when used with MAP cream.
Kojic acid
Kojic acid is a naturally occurring hydrophilic fungus deriva-tive, which acts as a
tyrosinase inhibitor and an antioxidant (52). It is best combined with corticosteroids
to reduce irrita-tion (10,41). It is commonly used in Asia and Japan with
concentrations between 1% and 4%. Application of kojic acid creams is usually
twice a day (41,53).
In recent studies, efficacy of topical kojic acid on melasma has been investigated
by comparing it with HQ (54), used as monotherapy comparing it with its separate
different combi-nations (52). On both studies, no side effects were observed and
results suggested its action as a possible tyrosinase inhibitor. Results achieved on
both studies suggested that kojic acid has limited efficacy when used as
monotherapy, being a hydrophilic molecule, encounters greater resistance by the
cutaneous barrier; however, combination therapies have resulted in significant skin-
lightening effects (Table 3).
Soybean
Stimulation of collagen synthesis, protection against photodamage induced by
UVB, antioxidant, anti-inflammatory, and moisturizing effects are among other
properties of soybean (55). Natural soybeans contain two serine protease inhibitors,
Bowman–Birk inhibitor and the soybean trypsin. The two proteases act by
interfering with the protease activated receptor 2 pathway (keratinocyte
phagocytosis of melanosomes and melanosome transfer). The therapeutic effect of
this process is the pigment lightening effect (1,41).
In an in vivo study (Table 3), Yucatan dark-skinned swine were treated with
soybean and soya milk paste for a period of 9 weeks (56). Histopathology of the
sites treated showed that both soybean and soya milk reduced melanin deposits into
the epidermis through phagocytosis of melanosomes, which resulted in reduced
color; additionally, both soybean and soya milk extract demonstrated the ability to
prevent suninduced pigmentation (56). It is interesting to note that these results
were achieved without an additional vehicle to exert their depigmenting properties.
This is an added advantage as the thick stratum corneum is the primary barrier to
transdermal treatments (57).
Licorice
Licorice extract has the ability to inhibit tyrosinase activity through its principal
active compound glabridin which results in the suppression of melagonesis (4).
Liquiritin and isoliquirtin are other two popular active agents of licorice, both act
as melanin disperser or removal of epidermal melanin (58,59).
In a clinical trial studies, topical liquiritin has been compared with a vehicle cream
(58), used as monotherapy on an efficacy study (59,60). The results of all three
studies (Table 3) proved licorice as safe, lightening agent with added anti-
inflammatory benefits (59). Nano technology demonstrated a possibility of loading
large amounts of licorice for enhanced efficacy (60).
Mequinol
Mequinol is used as an alternative to HQ due to fewer properties that lead to
irritation of the skin. Mequinol is the formulation of 0.01% tretinoin and a
penetration enhancer (61). This is a scheduled concentration and, therefore, requires
a prescription. Though its pathway is unclear, mequinol is thought to be a tyrosinase
inhibitor (62). Mequinol has been found to be effective in treating dyspigmentation,
even on darker skin types, without causing any side effect (1). A pilot study
investigated the efficacy of topical 2% mequinol and 0.01% tretinoin for melasma
on men (62). The study demonstrated positive results as complete clearance was
noted in 12 weeks with minimal tolerable side effects (Table 3).
Niacinamide
Niacinamide is the active form of vitamin B3 found in yeasts and root vegetables.
It is an important precursor of nicotinamide adenine dinucleotide and nicotinamide
adenine dinucleotide phosphate (42). A recent clinical trial investigated topical
niacinamide; the study results demonstrated its efficacy in both subjective and
objective measures (63). Additionally, side effects were mild and tolerable (Table
3). Other studies conducted both in in vitro and in humans have found niacinamide
to have inhibitory mechanism on melanosome transfer to keratinocytes (34,64).
Additionally to depigmenting effects, topical niacinamide has antiaging properties
as it decreased collagen oxidation and improved ageing-induced sallowness (65).
Glucosamine
Glucosamine is an amino-monosaccharide which is found in all human tissues.
When an amino acid group is added to glucose, the result is the production of the
sugar. The molecule product is then acetylated to N-acetyl glucosamine (66). N-
acetyl glucosamine has been found to have lightening effects on hypermelanosis
due to its reduction of melanin in the melanocytes by prevention of tyrosinase
glycosylation (51,66). A recent randomized clinical trial (66) indicated that N-
acetyl glucosamine combined with nicotinamide could be a good alternative to HQ
when treating melasma. Results of this study demonstrated efficacy in both
subjective and objective measures (Table 3). Subjects were instructed against direct
sun exposure and daily use of sun protection factor, SPF 15. Combination of
niacinamide and glucosamine has been found to have even better results compared
to use of glucosamine alone (67).
Arbutin
Arbutin is a HQ derivative found in cranberries, pears, wheat, and blueberries (68).
Its mechanism of action is based on inhibition of melanogenesis by binding
tyrosinase without influencing the messenger RNA transcription of tyrosinase (45).
Its efficacy is dependent on its concentration; the higher the concentration, the
better the results. In melasma management, arbutin has been used in combination
with lasers (69) as an ingredient in a hydrogel mask (70) or combined with Ellagic
acid (71). In all these studies, there have been no undesirable side effects. In a
randomized single-blind placebo study (71), 1% topical arbutin brought about a
significant response with no side effects.
In vitro studies have shown improvement in the appearance of hyperpigmentation,
reduction in melanin content in melanocytes as well as reduction in tyrosinase
activity; when compared to HQ, arbutin had demonstrated less toxic effects, making
it a better choice (53). Chawla et al. (72) observed that tyrosinase hydroxylation
and DOPA activity of tyrosinase inhibition effect are dose dependent. This effect
may be due to the chemical structure of dA as de-oxysugars have the ability to
increase skin penetration and binding affinity for tyrosinase (3,72).
Researchers endorse that α arbutin has an enhanced efficacy compared to arbutin
itself and is less toxic when compared to HQ (73,74). Its action is achieved without
affecting the mRNA expression enzymes. This has been demonstrated in cultured
human melanoma cells. Its effects are further demonstrated by its effectiveness of
inhibition of mushroom tyrosinase in vitro (75,76).
Aloesin
Aloesin is a compound which is derived from aloe extracts. In an in vitro study
conducted by Jones et al. (77), aloesin proved to have the ability of inhibiting
melanin production from mushroom and murine sources. Choi et al. (78)
investigated aloesin pigmentary inhibition effects on UV-induced pigmentation on
human skin. The study involved topical application of aloesin on the human forearm
that has been exposed to UV radiation four times daily for 15 days. Aloesin was
found to have suppressed pigmentation by 34%. This result suggested that aloesin
could be used for hypermelanosis which is due to UV radiation. Melasma could
also benefit as the literature has cited sun exposure to stimulate the formation of
melasma. There is dearth of data regarding its efficacy on melasma.
Mulberry extract
Mulberry extract is a Morus alba L. derivative plant from Moraceae family. The
root bark has been found to have skin depigmenting effects due to its inhibitory
action of dopa oxidase activity of tyrosinase and its superoxide scavenging activity
(53). An in vitro investigative study looked at the effects of compounds found in
dried mulberry leaves on melanin biosynthesis (79). The result of this study was
significant as cultured melan-a cells responded positively. It was discovered that
dried mulberry leaves have an inhibitory effect on tyrosinase action and on melanin
formation in melan-a cells (79). A randomized clinical trial investigated 75%
topical mulberry oil compared to a placebo in the treatment on melasma (80).
Results demonstrated that mulberry was a safe and effective lightening agent with
added antioxidant benefits with mild side effects such as itching (Table 3).
Hesperidin
Hesperidin is a bioflavonoid which is fund mostly in peels and membranes of citrus
fruits (81); it known for its anti-inflammatory and antioxidant effects (82). In vitro
studies conducted have demonstrated good result when treating hypermelanosis due
to its ability to inhibit melanin without causing cytotoxicity (82,83). A recent
efficacy in vitro demonstrated hesperidin to decrease tyrosinase activity with added
antioxidant and skin barrier strengthening effects (84). Other benefits of hesperidin
are antiaging; it protects against UVA-induced fibroblast damage as well as
protection of collagen damage induced by oxidation (85).
Ginseng
For thousands of years, ginseng has been traditionally used eastern Asia due to its
versatility to treat various diseases such as hypertension, liver and kidney
dysfunction, diabetes mellitus, and wound healing (86). Red ginseng and white
ginseng are the two traditional preparations of ginseng having a ginsenosides as the
most important constituent of ginseng (87). White ginseng comes from peeled,
dried ginseng root while the red ginseng is produced by steaming fresh ginseng root
and then drying it to acceptable moisture content, red ginseng is more potent than
the white ginseng (86). In vitro and observational studies investigated its
melanogenic effect demonstrated that ginseng reduced melanin content, tyrosinase
activity as well as perception of UVB-induced ROS (21,88,89). Efficacy of oral
ginseng has been investigated in a clinical study (88). Both subjective and objective
measurements showed significant improvement at completion of the study (Table
3). In the study, mild side effects were controlled as soon as ginseng was stopped.
Azelaic acid
Azelaic acid is a nine carbon, naturally occurring, nontoxic saturated non-phenolic
dicarboxyl acid. Original use of azelaic acid was on the treatment of acne (53). Due
to effects on tyrosinase, it has been used to treat hypermelanosis of the skin (90,91).
Azelaic acid works on the mitochondrial enzymes resulting in direct cytotoxic
effect towards melanocytes; it also inhibits DNA synthesis. It also has an effect on
reduction of free radicals production (53). Studies done in Indo-Malay-Hispanic
studies discovered that 20% concentration of azelaic acid is equivalent to those of
2% HQ (90). Baliña and Graupe (91) indicate a similar efficacy for 20% azelaic
acid compared to 4% HQ, both in terms of lesion size reduction, pigmentary
intensity, and overall response. Azelaic acid is well tolerated with minimal side
effects such as a burning sensation, mild erythema, pruritis, cutaneous irritations,
and scaling (90,91). There is dearth of data pertaining recent studies in azelaic acid
on melasma; this topic requires more studies.
Umbelliferone
UMB is a phenolic compound of plant origin from the Apiaceae (Umbelliferae)
family such as carrots and coriander (92,93). Due to its ability to absorb UV light
in at several wavelengths (300, 305, 325 nm), this compound is mainly used in sun
protection factors as the key ingredient (92). Other effects include non-toxicity to
the skin, antioxidant, and anti-inflammatory properties (93). The use of this
ingredient in melasma requires more research on its efficacy as there is paucity of
data regarding its effectiveness.
Grape seed extract
Grape seed extract contain an antioxidant proanthocyanidin (94). Oral intake of
grape seed (Table 3) extract for 6 months resulted in lightening effects of melasma
(94). There is however dearth of data regarding its efficacy on topical use.
Limitations of these treatments
Natural therapies have a potential to be used as alternative management for
melasma; however, paucity of data regarding their efficacy and potential side effect
profile needs to be addressed. More controlled clinical trials are lacking to
determine their role. Only a few natural ingredients have been incorporated into
topically applied cosmetics or cosmeceuticals often due to lack of parallel human
studies (10,26,41,42).
Preventative measures
Although its etiology is not clearly understood, sun exposure, hormones,
pregnancy, use of phototoxic drugs, genetic influences, use of cosmetics, and
anticonvulsant drugs are cited among predisposing factors (12,13). UV radiation is
cited as being the main cause of melasma as it induces the increase in melanogenic
activity (12,32). Melasma has been found to reduce during cold winter months and
worsens with hot summer climates. In intertropical regions, melasma incidence
is observed to have an increased tendency (95,96).
Melasma is also thought to be induced by heat. Authors identified nighttime
workers, who are exposed to heat of ovens, e.g., bakers, and professionals exposed
to high intensity of light, e.g., dentists, experience great resistance when treating
melasma. Worsening of the melasma is also reported as being worse after being
exposed to their working condition (97,98).
All these studies suggest that safe sun practice is key to all individuals. If melasma
is common among other family members, children should be taught about safety
sun exposures. Being a female categorizes one as being at risk due to pregnancy
hormones. Use of depigmenting cosmetics as preventative therapy would be proper
when pregnant even before melasma starts to appear. Genetic predisposition has
been noted in melasma studies (26,27). This reasoning suggests that whenever there
is family history, members at risk should try and avoid melasma triggers.
Patient counseling
Melasma is not just a cosmetic concern but rather a medical concern due to its
disfiguring nature. It has been associated with significant negative psychological
and emotional effects. Decrease in social functioning, reduced productivity at work,
and low self-esteem are reported side effects due to melisma (7,22). Tremendous
emotional stress and psychological distress are chronic emotions brought about by
melasma (7,22–25). Grimes (33) indicates that these symptoms lead to unnecessary
stress, ailments, disorders, and often disease.
In Brazil, studies of quality of life on patients suffering from melasma have been
conducted from all geographic regions. It was found that quality of life of these
patients was affected by melasma which was related to emotional well-being, skin
appearance, embarrassment, and frustration. In response to the Melasma Quality of
Life Scale (MelasQol) questionnaire, it was observed that most of the time patients
reported discomfort, expressed feelings of frustration, agreed to being embarrassed
about their skin appearance. Patients further indicated that facial lesions caused
great dissatisfaction, low self-esteem lower productivity at work or school as well
as withdrawal from social life (99,100).
The findings of the studies of quality of life on patients suffering from melasma
suggest that melasma is more than just a cosmetic concern. These MelasQol
findings propose that melasma treatments should not be only clinical-based
treatments but rather also addressed the psychological aspect as well.
Discussion and conclusion
New, effective, treatment products for melasma are in huge demand. Until melasma
can be treated successfully, and its cause identified, researchers work tireless on
this subject matter. Development of effective bleaching preparations for
hyperpigmented lesions remains a challenge in the cosmetic industry (2,6). This
brings about a necessity for development of effective treatment products with no or
fewer side effects for management of melasma for all skin phototypes.
Although HQ has remained the gold standard in treating hypermelanosis of the skin,
various naturally occurring alternatives are being investigated, due to their lack of
side effects. Alternative melasma management is required for darker skin
phototypes as these skin phototypes are intolerant to use HQ. Prolonged use of HQ
leads to worse pigmentary changes. Besides temporal relief, use of HQ on darker
skin types is not the best choice and should be avoided (10,13).
Plant extracts have a potential to relieve symptoms of skin discoloration with
minimal tolerable side effects. This suggests that naturally occurring ingredients or
plant extracts ingredients could be used successfully in treating melasma even on
darker skin types without risk of aggravating the condition. There have been no
detrimental side effects reported on longterm use of the naturally occurring
ingredients reviewed.
Stability of the depigmenting product choice should play a vital role. Vitamin C
from fruits and vegetables has to be stabilized for it to be effective. This should alert
the patients to familiarize themselves with efficacy of ingredients listed on the
packaging as only proper actives will have a desired effect of the treatment. Most
depigmenting creams and solutions have Vitamin C in the list of their active
ingredients. It is concerning which form of vitamin C is usually used as the
packaging does not always state clearly.
Counseling of patients is of importance during the treatment. Treatment time is an
important factor to consider when dealing with melasma cases. In the researcher’s
experience in skin care practice, patients who suffer from melasma tend to be
impatient and request rapid treatment intervention. Some ingredients such as
liquiritin have proved to be effective in a short period of time (58). Discontinuation
of use of cosmetics which contain perfume is also another important factor that
patients should be aware. Patient compliance is of utmost important for optimum
results when treating melasma.
Lack of proper sun protection practices has remained a challenge. This challenge is
notable especially on darker skin phototypes. They have a misconception that their
skin does not get sun damage; hence, no sun tan is noticed on these skin types. It is
imperative that during therapy, sun exposure is limited. Lack of sun protection
practice reverses the result of the therapy. Photo protection should play an integral
part in the skin care regimen of all individuals. Its importance should not be
underestimated or overlooked. An American study analyzing data dating from 1992
National Health Interview survey regarding sun protection behaviors found that out
of 1583 African-Americans, only minority respondents were aware of sun
protection. The findings suggested that only 3 in 10 adults practiced sun protection,
while in adolescents 69% were sunburnt while less than 40% practiced sun
protection. Parents did not adequately protect their children from the sun and
imitation tanning practices were found to be common among females and young
adults (101). Good sun protection habits are vital for a desired outcome to be
achieved for all skin phototypes.
Current skin pigment analysis tools are not suitable for use on darker skin types. A
universal melasma analysis tool, Wood’s lamp, cannot detect melasma on darker
skin types. Due to high epidermal melanin content in darker skin types acting as a
competing chromophore, it is challenging to contrast melasma from normal skin
(10,30). This necessitates updated skin analysis tools which will enable analysis of
all skin types.
Literature has demonstrated melasma to have negative impact on quality of life (22–
25). It is significant that all studies looking at effectiveness of treating melasma
should also consider measuring the difference on quality of life as well. Studies
cited in this review reported the use of natural therapies in melasma management
and the possibility that naturally occurring depigmenting ingredients offer potential
to expand the choices for treating hypermelanosis and a better choice of effective
antimelanogesis topical treatments when dealing with all skin phototypes inclusive
of the darker skin phototypes as they get affected the most by melasma.
Disclosure statement
The authors indicate no potential conflict of interest.
Funding
This work is based on the research supported by the South African Research Chairs
Initiative of the Department of Science and Technology and National Research
Foundation of South Africa (Grant Number 98337).