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Melasma is a chronic skin disorder that results in symmetrical blotchy, brownish facial pigment. Melasma is more common in women and generally starts between the ages of 20-40 years but can begin as early as childhood and as late as middle age.

It is more common in people who tan well or have naturally brown skin compared with those who have fair skin types. Melasma is caused by the overproduction of melanin by pigment cells called melanocytes. There is a genetic predisposition to melasma with at least 1/3 of people reporting affected family members.

Known Triggers of Melasma:

  • Sun exposure and sun damage – this is the most important avoidable risk factor
  • Pregnancy – in affected women the pigment often fades a few months after delivery
  • Hormone treatments – oral contraceptive pills containing oestrogen and progesterone, hormone replacement therapy, and other hormal contraceptive devices
  • Certain medications, scented or deodorant soaps and cosmetics may cause a phototoxic reaction reaction that triggers melasma
  • An underactive thyroid

Features:

  • Brown freckle-like spots and larger flat brown patches found on both sides of the face and have an irregular border
  • There are several distinct patterns:
    • Centrofacial affecting the forehead, cheeks nose and upper lip
    • Malar affecting the cheeks and nose
    • Lateral cheek pattern
    • Mandibular pattern affecting the jawline
    • Reddened or inflamed pattern known as erythrosis pigmentosa faciei
    • Poikiloderma of Civatte appearing as reddened, photoaging changes on the sides of the neck, mostly affecting patients older than 50 years
    • Melasma is sometimes separated into epidermal, dermal and mixed types. Examination using a Wood lamp can be used to identify the depth of pigment

Epidermal melasma

  • Well defined border
  • Dark brown colour
  • Appears more obvious under black light (Wood lamp)
  • Responds well to treatment

Dermal melasma

  • Ill-defined border
  • Light brown or bluish
  • Unchanged under black light (Wood lamp)
  • Responds poorly to treatment

Mixed melasma

  • The most common type
  • Combination of bluish, light and dark brown patches
  • Partial improvement with treatment

Treatment of Melasma

General measures

  • Discontinue hormonal contraception
  • High SPF sunscreen and wide-brimmed hat
  • Use a light cleanser and if the skin is dry a light moisturiser
  • Cosmetic camouflage (make up) to disguise the pigment

Topical Therapy

Tyrosinase inhibitors are the mainstay of treatment with the aim of preventing new pigment formation by blocking the formation of melanin by the melanocytes:

  • Hydroquinone 2-4% as a cream or lotion
  • Azelaic Acid as a cream, lotion or gel
  • Kojic acid
  • Vitamin C
  • Topical corticosteroids such as hydrocortisone can be used and in combination with the other topical agents as above
  • Tranexamic acid can be applied as a cream

There are compounded topical preparations available that use a number of topical agents, as above, in combination.

Oral Treatments

  • Low dose oral tranexamic acid has been reported to be effective and safe in the treatment of melmasma

Laser

  • Laser can be used to remove pigment, Q-switch Nd-YAG lasers being the most suitable. Several treatments may be required and pre-treatment with a tyrosinase inhibitor is advised