Several years ago, a dermatologist colleague and beloved friend sent me a patient. He is a remarkable surgeon and has a waiting list as long as the Mississippi, so he has had to send out his general dermatology cases. I humbly accepted his referral.
I still remember it because of how he described her condition. He told me it was "melasmoid" but not melasma, though until she met him she felt she had this condition. He was, of course, spot on in his assessment.
Funny thing about skin- it's all patterns. I keep waiting for some advanced pattern recognition technology to come along like manifest destiny and claim dermatology as its own. The imperialism of artificial intelligence. So far, though, it can't hold a hand or decide how to manage a complication. And it can't see "melasmoid" from melasma.
These tiny differences, subtle but appreciable distinctions are paramount in dermatology. If you can't see them, you can't do this job well. So we have to learn them.
Melasma is a common disorder of pigmentation that predominantly affects women, though also affects men and transgender individuals. It characteristically involves the face but it can involve other parts of the body such as the forearms. Though it can affect any race, women with darker skin seem to be disproportionately affected.
Melasma appears as symmetric patches of dark pigmentation with irregular borders.
If you look closely, the pattern of dyspigmentation is "reticulate" or netted, so to speak. Look closely.
Do you see it?
Melasma is a fascinating condition because we still don't have a full understanding of why it happens. We know that if you biopsy the skin of melasma, you'll find upregulation of melanocytes and melanosomes (their precursors), mast cells, sun damage, c-kit/kit ligand and vascular endothelial growth factor. Exposure to sunlight, oral contraceptives and pregnancy are known to exacerbate the condition, but the true etiology is uncertain. It's thought that certain "inducers" like sunlight tend to turn on the cells that make our pigment, known as "melanocytes" and they work in overdrive.
UV isn't the only inducer. Certain medications including phenytoin seem to precipitate melasma, and it can be brought on it seems too by autoimmune thyroid disease (don't forget to screen for this).
We used to use a Wood's light for this (read: UV light) because certain types of melasma seem to be more stubborn, and we think of these as being deeper in the skin. Theoretically, you could see this with a Wood's lamp. But the utility of this has come into question, and truthfully I don't really even know if it matters because this condition is just so stubborn anyway.
But there are a few things to know about melasma. Like so many things in dermatology, the condition itself has a pattern.
1. It can happen on the central face which is the most common, affecting the nose, lips, cheeks, forehead, but it spares the philtrum of the lip
2. It can happen in a "malar" distribution- cheeks and nose that people describe as "buttterfly".
3. Along the mandibular (jawline) area (which technically should be considered malar since "male" means jaw in Latin.
In any event, the most important treatment is to stay out of the sun. Make your playtimes for beautiful sunset evenings and avoid peak UV hours.
Beyond that there are a host of things that can be done for this condition, but you should always remember that I said this condition is stubborn. Be upfront about that.
Okay, well, there are a few notable treatments for melasma, but this condition is frankly recalcitrant. Lasers, chemical peels, energy devices and a host of topicals have been used to combat it because it can re and many of them have their roots in plant based therapies.
Of course, botanicals to the rescue, like always. Plants bringin it in for the win once again.
Don't you just want to sit on this windowsill with a good book and a hot cup of tea and pretend you don't hear anything else? Is that just me?
Brighteners such as kojic acid, azelaic acid, licorice root, Vitamin C all do their share to combat melasma and all are plant based therapies. Kojic acid can be an allergen. Azelaic acid comes from a cereal grain or rice fermentation. Vitamin C, and licorice, well, you know...
Other well known topical treatments are hydroquinone and retinoids, often used in combination and sometimes with a topical steroid.
Hydroquinone works by blocking this enzyme known as tyrosinase, which is the enzyme we need to make melanin. Cool stuff, but sadly it is absorbed and it can also lead to a condition known as acquired ochronosis where the skin paradoxically turns darker like the brown "ochre" pigment in clay. I'll talk more about these in another post.
Recently there was something that dermatologists are calling a "game changer" in the treatment of melasma. I'm holding back my enthusiasm on this one still, but I'll tell you about it. It's called tranexamic acid and it is a by mouth medication that substantially reduces the appearance of melasma while the person remains on the medicine. But it has a host of reasons not to use it. These are a few from my beloved JAAD:
Okay some of them don't apply, like having used hydroquinone within three months or regular use of tanning parlors (the horror!). But you'll agree, the list is loooong....
You might think why would you ever want to be on one of this medicine? Well, you might if you had that stubborn melasma, because tranexamic acid works. It's a game changer, plain and simple. Talk it over with your doctor though because as you can see it is not without its risks, and honestly, after three months of stopping the medication, surprise!, melasma returned. Ugh.
Researchers in many of the studies thought that if they had really focused on topical therapies in addition, they might have quality of life fairly substantially. One study showed that even though TA improved melasma in the intervention group much more than the control, the quality of life didn't differ drastically. It's all about expectations.
But that brings us back to basics. What about those topicals? What about photo protection? Is sunscreen enough?
Funny you should ask...
It turns out that UV protection in conventional sunscreens doesn't seem get the job done well on its own, though in fairness, it doesn't seem like much will.
We really need not only a filter, but a physical block, pun intended to prevent worsening of melasma on the first sunny day of the year. UV causes damage, but also visible light seems to aggravate photodermatoses, and we get both when we are outside. Let's take a good look at the electromagnetic spectrum. This again is from the JAAD. Thank you Dr Lim.
What seemed to be superior in improving melasma were physical sunscreens with tints (usually made from Fe2O3) according to the same paper, whose excellent photo I included below.
Looks like photo protection still shines in melasma (wink).
I tend to use this one on my face and it blends pretty evenly with both my husband's skin and mine, and we are two different skin types. I used to recommend a different one, but they didn't do as well with the EWG rankings recently. For the body, I would recommend something else, and there are many to choose from. I'll do a separate post on those.
For my kids, I use this one, and I love love love the scent.
This article doesn't cover the non-topical forms of photo protection, but I'll get that covered asap.
Take care, reader.
DelRosario E, Pandya A et al. Randomized, placebo-controlled, double-blind study of oral tranexamic acid in the treatment of moderate-to-severe melasma. JAAD VOLUME 78, ISSUE 2, P363-369, FEBRUARY 01, 2018
Geisler A et al. Visible Light Part II. JAAD 2021 https://www.jaad.org/issue/S0190-9622(21)X0004-7
Bolognia J. Dermatology Third Edition. Disorders of Pigmentation
Melasma photo cred: blamonds.co.uk