Dr Neenu Koul
Melasma is a common, acquired, characteristic pattern of marginated, symmetric, light-to-dark brown facial hyperpigmentation, involving sun-exposed areas. It causes cosmetic disfigurement with considerable psychological impact.
Sites of Predilection: Cheeks, forehead, upper lip, nose and chin and sometimes,
neck as well. It is commoner in women than in men (9:1) Rare before puberty, occurring most commonly in women of reproductive age. Melasma is classified into
* Epidermal type
* Dermal type
* Mixed or epidermo-dermal type
* Indeterminate type
Causative factors in women : Although the exact cause of melasma remains unknown, multiple factors seem to be contributing to its aetiopathogenesis in women. Hormonal factors are considered one of the most important causative factors. Other factors include genetic factors, sunlight, cosmetics,thyroid dysfunction,, pregnancy, oral contraception, phototoxic and anti-seizure drugs.
Causative factors in men: Melasma in men is definitely less common than in women, The main causative factors among the male patients appeared to be sun-exposure and family history.
Treatment of Melasma
* Removal of aggravating factors
* Vigorous photoprotection: is essential, because photodarkening can occur with just a couple of hours of sun exposure.
* Life style modification: avoiding peak hours of sunlight (in tropics, between 11 AM – 4 PM), using shady side for activities
* Sunscreens: Opaque sunscreens containing zinc oxide, 10% (and SPF of 30) have dual benefit of camouflaging
* Lightening agents:
* Hydroquinone (HQ), used alone or in combination, is the gold standard for the treatment of melasma
*Azelaic acid
*Kojic acid
*Retinoids
*Topical steroids
*Glycolic acid
*Liquorice derivatives
*Niacinamide/ Arbutin/ Ascorbic acid/ Mequinol;
Combination treatment
The most extensively studied and widely used combination with HQ is with Retinoids and Corticosteroids- the “triple combination.”
Physical therapies
*Chemical peels: Medium depth peels should be performed with great caution, especially in dark skinned patients and deep peels are not recommended for Indian skin
*Laser therapy: Lasers may, however, be used in selected resistant cases, after proper counselling.A combination of pulsed CO 2 laser (to remove epidermal pigment) and alexandrite laser (to remove dermal pigment) gives a better result.
*Dermabrasion
It is best to defer treatment primarily because melasma frequently disappears after delivery. Even if treated, it is resistant to treatment, due to persistent hormonal trigger. During pregnancy it is best just to advocate frequent application of a broad spectrum sun screen.
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