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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 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).
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 (dermalmelanosis, 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:
Melasma can be very slow to respond to treatment, especially if it has been present for a long time.
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.
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 caution—over-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.
Tyrosinase inhibitors are the mainstay of treatment. The aim is to prevent new pigment formation by inhibiting formation of melanin by the melanocytes.
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.