What is it?
The melasma, also known as chloasma or pregnancy mask, is a very common condition characterized by a hypermelanosis of the skin. It consists of the appearance of generally irregular dark, bilateral, symmetrical spots (maculae) in areas exposed to the sun such as the face (forehead, mustache and cheeks), neck and forearms. They usually last for years and usually increase the coloration during the summer months due to sun exposure.
Who does it affect?
It mainly affects the middle-aged female (90% of the cases) and especially of dark skin. In men receiving estrogen therapy for prostate cancer, the occurrence is higher, although it is not very common (10%).
The only symptom of melasma is a change in the color of the skin causing an unsightly effect and in some cases may provoke pruritus.
The appearance of this lesion can be caused by the following factors:
- Genetic factor
- Hormonal factors (pregnancy, oral contraceptives, menopause)
- Excessive sun exposure
- Reaction medications or cosmetics
Depending on whether they become chronic we can differentiate between:
- Transient melasma: disappears after a year after stopping the hormonal stimuli (pregnancy, contraceptives)
- Persistent melasma: mainly those caused by an extreme sun exposure. They are characterized by not disappearing.
Depending on the depth we can differentiate between:
- Epidermal or superficial melasma: affects the upper layer of the skin, it’s of brown color and has well defined edges.
- Dermal or deep melasma: affects the deeper level of the dermis and is characterized by blue-gray spots.
- Mixed melasma: is a combination of the melasmas discussed above. It has a grayish brown color.
Before prescribing the treatment it is very important to inform the patient that it’s an effective but very slow process and that there is a possibility that the melasma reappears after its elimination. For this reason it’s very important to carry out maintenance, if there is no contraindication, stop using contraceptives and use SPF50 sunscreens as prevention.
According to the type of melasma, one treatment or another will be performed. Through the Wood lamp is determined the depth of the melasma and consequently the treatment.
The treatments can be:
- Depigmenting drugs
- Chemical peeling
- Laser treatment
In the most favorable scenario, with the absence of contraceptives and without forecast of pregnancy immediately, the most effective treatment is based on the combination of non-ablative fractionated laser (3-4 sessions / year) with topical depigmenting products in the form of creams or lotions. It should be clearly explained that combined use is the key to success in this condition. If we treat the melasma with laser only we will obtain few results. If we apply only depigmenting creams we will get a partial clarification or no result.
About the depigmenting products, the ideal is to use the Hydroquinone 2-5% in a discontinuous way, to combine treatment stages with rest stages. It’s the most effective whitening product, although it can’t be applied to pregnant women or women who want to become pregnant, and in some women it causes irritations and redness, which may force them to leave it.
In cases of intolerance to hydroquinone, is prescribed the arbutin as a precursor to hydroquinone, but it must be known that it is not as effective.
Together with Hydroquinone is used the kojic acid that has a beneficial effect and increases the results of Hydroquinone. Adding Retinoic Acid or Glycolic Acid increases the penetration effect of Hydroquinone. It can have the disadvantage, according the skins in which it’s used, of increase also the irritation. If the skin tolerates these combinations of Hydroquinone + Kojic Acid + Retinoic Acid or Glycolic Acid, satisfactory results come before. A corticoid or other anti-inflammatory is usually introduced to minimize predictable skin irritation.
Of the laser must know that only the non-ablative fractionated laser, preferably Erbium, is suitable. The other lasers used as Q switched of Neodymium or Alexandrite or IPL, not only do not solve the melasma but can make it worse.