Melasma is one of the most common causes of facial pigmentation. But not all pigment is melasma. It is often misdiagnosed and is often treated incorrectly. As Melbourne dermatologists who specialise in pigmentary disorders, Dr. Michelle Rodrigues from Chroma Dermatology will bust myths and give you the facts on melasma in this blog. Read on to learn more.

What is melasma?

Melasma is a chronic and relapsing condition of hyperpigmentation and it can seriously affect quality of life. Melasma appears as light brown or even dark brown patches on the skin. It is seen on areas such as the forehead, cheeks and even the upper lip and the chin.

Who is likely to get melasma?

People that are more likely to be affected are patients that are female, patients who have had lots of outdoor exposure and those with darker skin types (skin of colour). Melasma is said in some research papers, to be one of the most common causes for people with skin of colour to visit a dermatologist. As a dermatologist in Melbourne, I see and treat hundreds of patients with melasma each year. Usually, patients are between the ages of 30 and 60.

Why does melasma occur?

This is a million dollar question and is a complex one to answer! The complexity of melasma is still being discovered through research that we and others around the world are doing right now.

Historically, it was thought that melasma was predominantly hormonal and that women, especially those on the oral contraceptive pill, were at risk of developing it. It was even called ‘hormonal pigmentation’ or ‘mask of pregnancy’ in years gone by. The reality is that patients can get it when they have had none of these exposures and have none of these risk factors. Even men can get melasma.

At this stage, it is believed to be due to a combination of both genetic factors, ultraviolet light, visible light, and heat exposure, as well as hormonal and vascular influences. It is really quite complex.

What is chloasma?

Chloasma is exactly the same as melasma. It is just another word to describe the same condition.

How do you diagnose melasma?

Melasma is usually a clinical diagnosis but rarely, a skin biopsy is needed to differentiate it from other conditions. A wood’s lamp can be helpful in determining the depth of the pigment. I often find now, with the experience I have gathered, I can often tell where the pigment is sitting without the use of the woods lamp and I also can recognise when the melasma has been incorrectly treated with a laser or IPL device. I must say, there are many times when patients come to Chroma Dermatology for treatment of their melasma…only to find, they actually have another pigmentary disorder and have been incorrectly diagnosed.

There is one condition that looks remarkably similar to melasma. It is called exogenous ochronosis. This is a condition that may be caused by application of topical creams. Prolonged use of high concentrations of hydroquinone mixed with other ingredients like resorcinol and other heavy metals can be a cause of this. It is notoriously hard to treat but picosecond lasers can be used (with special settings) to try to remove some of the darkening on the skin.

What are some common causes of hyperpigmentation other than melasma?

Post- inflammatory hyperpigmentation is a common cause of hyperpigmentation on the face. It can result from something as simple as pimples or irritation from a cosmetic cream or makeup that can cause redness and itch and it then turns into a brown spot afterwards or smudgy brown areas.

Another example of a common cause of hyperpigmentation is combined freckles and Hori’s neavus. This is most common in those with Chinese skin (Asian skin types). They can occur in the same area and appear very similar to melasma and can co-exist with it.

Freckles are also a common cause of hyperpigmentation and are very common in those with skin types 1 and 2. It can be prevented to a degree with good sun protection but genetics do play a role. They can be treated with creams and various laser technologies.

Is melasma something you treat often at Chroma Dermatology? And what are some things that we should know about melasma?

Over the past 11 years as a consultant, I have treated a lot of melasma. In fact, we treat so much melasma that I have developed an intimate understanding of what melasma looks like in certain age groups, ethnic backgrounds and after certain treatments. Because we are also seeing patients referred to us by other dermatologists, we see a broad range of mild melasma right through to the most difficult and severe cases of melasma. We also have conducted several research projects in melasma and have published those findings in medical journals which hopefully provides small but important advances in our understanding of this condition.

For a long time, melasma has been labelled as a problem caused by pregnancy, but there is so much more to melasma than just hormones. Other factors include; genetic predisposition, ultraviolet light A, ultra-violet light B, visible light in those with skin of colour, heat exposure, blood vessel activation and occupational and social behaviours too. Medications and hormones can potentially make things worse also, but we know that melasma occurs in males and people who have never had oestrogen! So there is a lot more to learn about this condition for sure.

What are some of the management options for patients with melasma?

The most important thing to remember is photoprotection (sun protection) and it is absolutely critical to make sure that patients are wearing sunscreen daily. Visible light protection is also very important, especially for those with skin of colour. Iron oxide containing sunscreens are thus important in this skin type.

There are an abundance of topical lotions and potions at the moment that claim to cure melasma. I am yet to see a cure. The gold standard topical cream is still hydroquinone and it can be purchased over the counter in a concentration of 2%. Higher concentrations can be obtained with the prescription, but it really shouldn’t be used for more than a few months at a time without dermatology supervision. Prolonged use can cause skin irritation and rarely allergy. It is best used under the guidance of a dermatologist who understands pigment problems and treats a lot of melasma.

In addition to this, there are potentially skin- directed therapies like certain chemical peels, laser and energy-based devices that have been reported for melasma. It is important to know that microneedling can make melasma worse! And it is important to know that laser and device therapies can also irreversibly worsen this condition so knowing which subtypes of melasma can be treated, which device to use and the settings that should be used are all critical in determining success of treatment.

Want to know more about melasma from dermatologists in Melbourne who specialise in melasma?

Tune in for Part 2. Coming soon..

For more information on melasma check out our other blogs on laser treatment in melasma and melasma diagnosis and pathogenesis

The information contained in this blog post is intended as a guide only and should not substitute seeking medical attention. Please see your healthcare provider for more information on suitability of products, treatments or procedures.