What are the other Names for this Condition? (Also known as/Synonyms)

• Chloasma
• Mask of Pregnancy

What is Melasma? (Definition/Background Information)

• Melasma is a benign skin condition that results in hyperpigmentation (darker skin) patches, most commonly on the face. Exposure to sunlight is an important risk factor for the condition
• Melasma more often develops in young women; it is also common during pregnancy, thus termed “Mask of Pregnancy”. Nevertheless, this painless condition is not known to adversely affect pregnancy in any manner
• Based on skin involvement, Melasma is categorized as:
  • Epidermal Melasma: These are dark brown in color, have well-differentiated borders, and respond well to treatment
  • Dermal Melasma: These are light brown to blue-grey in color, have poorly-differentiated borders, and do not respond well to treatment
  • Mixed Melasma: It is the most common form of Melasma and is a combination of the dermal and epidermal type. The response of this type to treatment may be described as fair

Who gets Melasma? (Age and Sex Distribution)

• Melasma is observed in young and middle-aged adults in the 20 to 40 years’ age group
• Both men and women are at risk for the condition, but a higher incidence is noted in women
• Most of the affected individuals have natural brown skin; also, those with skin that tan easily have a higher risk for Melasma
• Individuals of all racial and ethnic background can be affected

What are the Risk Factors for Melasma? (Predisposing Factors)

The following risk factors have been identified for Melasma:

• Positive family history of the condition - it is reported that 3 in 5 individuals have family members with Melasma
• Pregnancy: According to experts, the condition is observed in 50-70% of pregnant women (due to hormonal factors
• Exposure to sunlight
• Individuals with brown skin and skin that is more susceptible to tanning have a greater risk. Those with fair skin or dark (black) skin are not easily affected
• Use of oral (hormonal) contraceptives and hormone replacement therapy
• Women with thyroid gland disorders such as hypothyroidism and hyperthyroidism
• Use of certain medications, including cancer therapy
• Use of certain cosmetics that may result in a phototoxic reaction on skin

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Melasma? (Etiology)

The cause of Melasma is not well-understood; it is believed to develop from a complex set of factors.

• Advancing age, exposure to ultraviolet rays (sunlight), and hormonal factors in genetically susceptible individuals may trigger a phototoxic reaction
• This may result in melanocytic abnormalities causing an overproduction of the pigment melanin (thus leading to hyperpigmentation)

Melasma is non-contagious and it cannot be transmitted from one individual to another.

What are the Signs and Symptoms of Melasma?

The signs and symptoms of Melasma may vary among individuals and depends on whether it is the dermal, epidermal, or mixed type. The skin condition may be mild or severe. The signs and symptoms may include:

• Presence of light or dark brown (or blue-grey) discoloration on the face
• Certain distinct patterns are noted on different parts of the face; the areas of involvement may be scattered as islands or appear continuous
• The forehead, cheeks, nose, chin, and lips present hyperpigmented skin in nearly 80% of the cases
• Some patches can be red brown and appear inflamed
• In most individuals, a large part of the face is affected
• Other than the face, Melasma may form on the arms and shoulders (sun-exposed parts of the body)

There is no sensation of pain, itchiness, or irritation observed.

How is Melasma Diagnosed?

A diagnosis of Melasma may involve the following:

• A thorough medical history assessment and complete physical examination
• Assessment of the signs and symptoms
• Dermoscopy: It is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
• Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation
• Skin biopsy: A skin biopsy is performed and sent to a laboratory for a pathological examination. The pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis

Note: In most cases, a skin biopsy is not required to diagnose Melasma.

A differential diagnosis to eliminate other conditions may be considered, before arriving at a definitive diagnosis. These may include:

• Acquired dermal macular hyperpigmentation
• Drug-induced hyperpigmentation
• Nevus of Hori
• Nevus of Ito
• Nevus of Ota
• Post-inflammatory hyperpigmentation
• Solar lentigo

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Melasma?

The complications of Melasma may include:

• Cosmetic issues resulting in emotional stress in most individuals
• Recurrence of the skin pigment changes such as in subsequent pregnancies
• Poor treatment response and worsening of the condition with treatment

How is Melasma Treated?

It is very important to note that Melasma in pregnancy should be carefully evaluated by a qualified healthcare provider, before starting and/or performing any treatment. This is because the treatment may have the potential to affect the developing fetus and the guidance of a healthcare expert is crucial.

The treatment is usually undertaken based on the type of Melasma and the specific set of skin signs and symptoms noted; however, the treatment is often challenging and difficult. The treatment measures may include:

• Avoidance of outdoor light and tanning beds
• Daily use of broad-spectrum sunscreens
• Use of sun protection with hats, sunglasses, and clothing
• Discontinuation of oral and intradermal hormones
• Combination cream with hydroquinone, retinoid, and mild topical steroid
• Use of other pigment-inhibiting creams containing hydroquinone, azelaic acid, or kojic acid
• Use of chemical peels with glycolic acid, laser therapy, and intense pulsed light therapy may be considered; but, there is a risk of aggravating the condition

How can Melasma be Prevented?

Currently, there are no known methods to prevent the occurrence of Melasma. However, one may lower one’s risk for the skin condition by considering the following factors:

• Treating any underlying conditions early and adequately
• Use sunscreens and wide-brimmed hats to ensure protect from sunlight
• Check with the healthcare provider before taking any oral contraceptives
• A careful and periodic monitoring of the pregnancy is advised and recommended
• Inform your physician if you are allergic to certain medications

Individuals may use other cosmetic “masking” creams to hide the darkened skin on the face and neck.

What is the Prognosis of Melasma? (Outcomes/Resolutions)

The long-term prognosis for Melasma is usually good, in a vast majority of cases.

• However, in many, the response to treatment is inadequate, and the condition may take a long duration to improve
• Melasma is also known to recur on sun exposure and in the presence of other predisposing factors
• Following pregnancy, the skin discoloration is known to reduce significantly over many months

Additional and Relevant Useful Information for Melasma:

• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken avoid strong soaps and chemicals that could potentially worsen the condition
• The presence of dirt on the body is not a causative factor for the condition. However, it helps to be clean and hygienic, which may help the condition from getting worse