MELASMA

Pigmentation disorders are the third most frequent complaint in dermatological problems and it predominantly occurs in patients between the age of 30 and 40 years. Melasma, represents one of the pigmentation disorders. It is an acquired disorder of melanogenesis leading to hyperpigmentation. Melasma presented in symmetrical brown to grey-black macules or patches. It is mostly seen on the face but rarely seen on extra-facial area such as the neck, chest and upper limb. Melasma commonly described in three clinical patterns which are centro-facial (65%) with patches on the frontal, nasal dorsum, cheekbones and chin areas; malar (20%) and mandibular (15%). Melasma is more prevalent in women as compared to men. It typically develops in between age of 20 to 40 years.

CAUSES OF MELASMA

Although the exact cause of melasma is unknown, several factors are associated with its development and worsening. The most commonly reported risk factors are genetic predisposition, ultraviolet radiation exposure, hormonal influences, psychosocial stress and cosmetics.

1. Genetic component is the most important risk factor for melasma. About 50% of patients diagnosed with melasma has family history running down and this happened particularly in those with darker skin types (Skin Fitzpatrick III-VI). Patient tend to developed melasma earlier and present with longer duration of symptoms in among those who has family history of melasma.

2. Hormonal changes. Sex hormones like oestrogen and progesterone are involved in skin pigmentation regulation. There is a relationship between melasma and hormonal activities based on the highly reported cases of melasma which occurs after the period of adolescence, during pregnancy, or while using oral contraceptives/hormone replacement therapy and in patients with underlying endocrine disorders. The prevalence of melasma decreases after menopause and rarely occur before puberty. This relationship supports the fact that women are more frequently to be diagnosed with melasma as compared to male.

3. Chronic Sun Exposure is a prerequisite for the development of melasma. Chronic ultraviolet radiation exposure will activate an inflammatory cascade mainly through the formation of reactive oxygen species and oxidative stress leading to melanogenesis. UV factors are more likely to correspond with centro-facial melasma where the UV focuses more directly.

4. Psychosocial stress also has been reported as a trigger factor for melasma formation. High cortisol levels and melanocortin production are seen in those having psychosocial stress, which directly exert the melanogenic activity and further causes melasma. Cosmetic products are not implicated to cause melasma but has been demonstrating a higher prevalence of contact sensitivity towards melasma patients. Cosmetics contact sensitivity and pigmented cosmetics dermatitis should be considered as the etiologic factors when all the other causing factors have been ruled out. Skin care products that cause irritation towards your skin will likely worsen your melasma.

PREVENTION

1. Avoidance of sun exposure
2. Sun Protection. To wear a wide-brimmed hat while outdoors, seeking shade, and applying a broad-spectrum sunscreen every 2-4 hours (SPF 30 or higher, PA +++ and above) throughout the day, even on cloudy days and after swimming or sweating.
3. Avoidance of oral contraceptive pills,hormonal replacement therapy if possible
4. Avoidance of skin care products and make up that irritate your skin.

TREATMENT OPTION

There is no one best treatment for melasma. Often, the most effective treatment combines sun protection with medications that you apply to your skin and sometimes a procedure. They includes:

1. Topical:

• Hydroquinone. Available in a cream, lotion, gel or liquid, this medication works by lightening the skin.Higher strength versions can only be obtained through a doctor’s prescription.
• Tretinoin and corticosteroids. These medications enhance the skin lightening process when added to hydroquinone. Some contain three compounds—hydroquinone, tretinoin and a corticosteroid—which are then called a “triple cream.”
• Other topical medications. Topical therapy using tyrosinase inhibitors prevents new pigment formations by stopping the formation of melanin, these may include  Azelaic acid, Kojic acid,Arbutin,Licorice extract,and etc.

2. Oral:

• Tranexamic acid: In studies, tranexamic acid has been shown to decrease the patches of melasma when other treatments fail to work. It Inhibits plasminogen/plasmin pathway → inhibition of melanin synthesis. Before prescribing this medication, your doctor/dermatologist will talk with you about your health.

3. In-Office Procedures:

• When topical medications don’t do the trick, doctors may use in-office procedures such as Microdermabrasion or Dermabrasion treatment, which slough off the top layers of the skin.
• Chemical Peel: In this procedure, your doctors will put a chemical on your skin that may make it peel. The skin that regenerates should be smoother and more evenly colored.
• Light-Based Procedures/Light Therapy: like intense pulsed light, non-ablative fractionated lasers and low fluence Q-switched lasers.

CONCLUSION

Melasma is a benign skin disorder that has no morbidity. The key reason why some patients seek treatment is aesthetic. Thus, healthcare workers including medical practitioners, dermatologists, and primary care providers should educate the patient on avoiding the sun and discontinuing the trigger medications. Use the treatment and management advice from doctors/dermatologistr. And make sure you’re getting the right treatment by confirming the diagnosis with your healthcare provider.