Melasma is a common skin problem manifesting as symmetric hyperpigmentation on the forehead, cheeks, and chin. Women and individuals with darker skin types are more often affected.

Cause

Ultraviolet radiation (UVL) is a major factor, but visible light, hormonal influences, and genetics also play causal roles.

Emerging concepts include:

• UVL stimulates melanin synthesis by increasing reactive oxygen species and plasmin activity in keratinocytes.
• Increased melanocyte-stimulating hormone.
• Stimulation of cell signalling pathways stem cell factor and endothelial growth factor.

Triggers

Melasma worsens in the summer with increased UVL exposure. Pregnancy and oral contraceptives are recognised triggers, but such hormonal influences are not always evident.

Treatment

Finding effective treatments is often an exhausting process for patients, as there are a multitude of cosmeceuticals claiming skin-lightening properties with little or no scientific validation of efficacy.

Consult a dermatologist who has expertise in managing skin disorders and will be able to develop a treatment plan appropriate for you. This will minimise the financial and emotional costs otherwise incurred without professional guidance.

Melasma Essentials

1. Photoprotection—Regular use of UV and visible light broad-spectrum sunscreen, sun avoidance, and a broad-brimmed hat are fundamental. Iron oxides, which produce the tint in BB creams, protect against visible light.
2. Skin care using a gentle cleanser and moisturiser.
3. Skin-lightening agents. Hydroquinone inhibits melanin production and is the most effective available skin-lightening chemical. However, hydroquinone (and other lightening agents) may cause irritant dermatitis, which can be managed by less frequent applications or by switching to another product.

4% hydroquinone combined with tretinoin (retinoic acid) and a mild corticosteroid is more effective than monotherapies. In Australia, this combination requires a prescription and must be formulated by a qualified compounding pharmacist.

1. Cosmeceuticals, including vitamin C, kojic acid, niacinamide, and azelaic acid, are less effective than hydroquinone but are options for patients who cannot use hydroquinone. They are also used for maintenance therapy.
2. Oral tranexamic acid (TA), though not TGA-approved for treating skin conditions, reduces melanin production and is an effective treatment for melasma. TA is a plasmin inhibitor and promotes blood clotting but does not increase thromboembolic disease (TE) in patients without risk factors for TE.
3. Chemical peels, lasers and other devices can be considered when topical therapies fail but must be used cautiously (particularly in darker skin)

Conclusion

Melasma is a challenging disorder that can be treated with photoprotection and skin-lightening agents. Success requires a long-term commitment as response to treatment may be partial and recurrences frequent. If you are struggling with facial pigmentation, consider consulting one of the dermatologists at Sky Blue Dermatology. We understand the complex challenges patients face with chloasma and are passionate about helping patients find solutions based on scientific evidence and our real-world experience.