Embedded Files
Melasma is a chronic, acquired, relapsing hyperpigmentation disorder presenting as symmetrical brown–grey patches, primarily on sun-exposed areas of the face. It is particularly prevalent in individuals with darker skin tones due to higher baseline melanin activity.
What will the patient tell you? (History)
What will the patient tell you? (History)
Melasma usually affects women (though men can be affected) between the ages of 20 and 40. It is most common in Fitzpatrick skin types III–V.
Key Features:
Patients report the gradual onset of symmetrical patches of darker pigmentation, most often on the forehead, cheeks, nose, and upper lip (centrofacial pattern).
Course:
It has a chronic course, with patches worsening upon exposure to sunlight, heat, pregnancy, and hormonal influences (like combined oral contraceptives or HRT). Recurrence is high despite partial improvement with strict sun protection.
Risk Factors:
UV and Visible Light Exposure (the major driver).
Hormonal Influences (Pregnancy, hormonal birth control/HRT).
Genetic Predisposition (up to 50–60% report a family history).
Higher melanin reactivity makes these individuals more susceptible to melasma. Also, any irritation from harsh products or procedures easily triggers post-inflammatory hyperpigmentation (PIH), which can worsen the melasma.
Image Sourced From Derm Net
Image Sourced From Skin Sight
Image Sourced From Nottingham Skin of Colour
What will it look like? (Examination)
Melasma presents as bilateral, symmetrical, light- to dark-brown or grey-brown macules/patches with irregular but well-demarcated borders. They are typically asymptomatic and non-scaly.
Common Patterns:
Centrofacial: Forehead, cheeks, nose, upper lip (most common).
Malar: Cheeks and nose.
Mandibular: Jawline/chin.
Types:
Melasma is classified by the depth of pigment: Epidermal (darker brown, better response to treatment), Dermal (light brown–blue-grey, ill-defined, poorer response), or Mixed (most common).
Assessment:
Clinical examination is primary, sometimes supplemented by a Wood’s lamp or dermoscopy.
Crucial Note for Darker Skin Tones
The colour often appears as a deep brown or slate-grey. Clinicians must look for signs of exogenous ochronosis (blue-black patches) if there is a history of prolonged or inappropriate use of high-concentration hydroquinone or potent steroids.
How can you help? (Treatment)
The key goals are to fade existing pigment, prevent new pigment, and avoid harm. Treatment is long-term, requires maintenance, and must be gentle due to the risk of treatment-induced PIH and scarring.
General Measures (Essential First-Line):
Strict, Daily Photoprotection: Use broad-spectrum SPF 30–50+ that covers UVA, UVB, and visible light. Mineral/tinted formulas with iron oxide, zinc oxide, or titanium dioxide are preferred, especially in darker skin tones. Reapply frequently.
Barrier-Friendly Skincare: Use gentle, non-fragranced products. Avoid harsh scrubs or aggressive actives that cause irritation and trigger PIH.
Review Hormonal Triggers: Consider alternatives to hormonal contraception/HRT.
Topical Therapy: (Start low and slow, often used in combination)
Triple Combination Cream (TCC): Hydroquinone + tretinoin + mild topical steroid (often used for 3–6 months under specialist supervision).
Other Agents (for monotherapy or maintenance): Azelaic acid (20%) is highly effective and generally safer for darker skin tones. Other options include Kojic acid, cysteamine, topical tranexamic acid, and Vitamin C.
Guidance for Darker Skin Tones: Introduce actives slowly (2–3 times/week) and use gentle formulations (creams preferred over gels).
Systemic & Procedural Options (Second/Third-Line):
Oral Tranexamic Acid: Effective for moderate/severe melasma, but requires specialist prescription and monitoring for thromboembolic risk.
Chemical Peels: Only superficial peels (e.g., low-strength glycolic, lactic) should be used. In darker skin, they must be conservative, spaced, and dermatologist-led to avoid PIH.
Laser/Light Devices: Only for resistant cases and must be performed by experts familiar with darker phototypes using cautious settings, as misuse can easily worsen melasma or cause PIH.
Google Sites
Report abuse