Melasma

What is melasma and what does it look like?

Melasma is a common skin disorder. Loosely translated, the word means “black spot.” If you have melasma you’re probably experiencing light brown, dark brown and/or blue-gray patches on your skin. They can appear as flat patches or freckle-like spots. Commonly affected areas include your face, including the cheeks, upper lip and forehead, as well as the forearms. Melasma is sometimes called the “mask of pregnancy” because it frequently affects pregnant women. Melasma typically darkens and lightens over time, often getting worse in the summer and better in the winter.

Another, less common name for melasma, is chloasma. Although this disorder is completely harmless, it understandably makes some people feel self-conscious.

Where does melasma most commonly occur?

Melasma appears most commonly on your cheeks, nose, chin, above the upper lip and the forehead. It sometimes affects your arms, neck and back. In fact, melasma can affect any part of your skin that is exposed to sunlight. That’s why most people with melasma notice that their symptoms worsen during the summer months.

How common is melasma?

Melasma is a very common skin disorder, especially among pregnant women. 15% to 50% of pregnant women get it. Between 1.5% and 33% of the population may get melasma and it happens more often during a woman’s reproductive years, and rarely happens during puberty. It usually starts between 20 and 40 years of age.

Who is at risk of melasma?

Fairer-skinned people are less likely to be affected by melasma than those with darker brown skin or those who tan well. Women are more likely to get melasma than men: about 10% of those who get melasma are men, 90% women. Pregnant women get melasma more often than anyone else. You’re also at risk if you take oral contraceptives and hormones.

What happens in the skin?

Your skin is made up of three layers. The outer layer is the epidermis, the middle is the dermis, and the deepest layer is the subcutis. It’s an organ – the largest organ – and it makes up about one-seventh of your body weight. Your skin is your barricade. It protects your bones, muscles, organs and everything else from the cold, from germs, sunshine, moisture, toxic substances, injury and more. It also helps regulate your body temperature, prevent hydration and feel sensations like the warmth of the stove, the fur on your dog’s belly and the pressure of someone else’s hand holding yours.

Your epidermis contains cells called melanocytes that store and produce a dark color (pigment) known as melanin. In response to light, heat, or ultraviolet radiation or by hormonal stimulation, the melanocytes produce more melanin, and that’s why your skin darkens.

Why do women get melasma when they’re pregnant?

Pregnant women have increased levels of the hormones estrogen and progesterone. These hormones are thought to contribute to your melasma. The darker color usually fades after pregnancy.

What are the types of melasma?

There are three types of melasma and they have to do with the depth of the pigment. A Wood’s lamp that emits black light may be used to determine the depth of the pigment. The three types are:

1. Epidermal: Epidermal melasma has a dark brown color, a well-defined border, appears obvious under black light and sometimes responds well to treatment.
2. Dermal: Dermal melasma has a light brown or bluish color, a blurry border, appears no differently under black light and doesn’t respond well to treatment.
3. Mixed melasma: Mixed melasma, which is the most common of the three, has both bluish and brown patches, shows a mixed pattern under black light and shows some response to treatment.

Is melasma cancerous?

Melasma is not cancerous, a sign of cancer, or a skin condition that “turns into” cancer. However, there are skin cancers that may mimic melasma, so seeing your dermatologist is often recommended to confirm the correct diagnosis.

Is melasma permanent?

Melasma is a typically chronic disorder. This means that it’s long-lasting (three months or more). Some people have melasma for years or their entire lives. Other people may have melasma for just a short time, such as during pregnancy.

Is melasma painful?

Melasma is harmless. It’s not painful, itchy, or uncomfortable in any way.

What causes melasma?

There are two main causes of melasma: radiation, whether ultraviolet, visible light, or infrared (heat) light; and hormones.

Ultraviolet and infrared radiation from the sun are key in making melasma worse. Other possible causes of melasma include:

• Antiseizure medications: Drugs that prevent you from having seizures may be a cause of melasma. An example of an antiseizure medication is Clobazam (Onfi®).
• Contraceptive therapy (birth control): Melasma has been observed in individuals who use oral contraceptive pills that contain estrogen and progesterone.
• Estrogen/Diethylstilbestrol: Diethylstilbestrol is a synthetic (man-made) form of the hormone estrogen. It’s often used in treatments for prostate cancer. Again, there’s a pattern between increased estrogen and melasma.
• Genetics: About 33% to 50% of people with melasma have reported that someone else in the family has it. The majority of identical twins both have melasma.
• Hypothyroidism: A condition where your thyroid is underactive.
• LED Screens: Melasma may be caused by the LED lights from your television, laptop, cell phone and tablet.
• Pregnancy: It is unclear why “the mask of pregnancy” happens to pregnant women. However, experts theorize that the increased levels of estrogen, progesterone and the melanocyte-stimulating hormones during the third trimester of pregnancy play a role.
• Hormones: Hormones like estrogen and progesterone may play a role in some people. Postmenopausal women are sometimes given progesterone, and have been observed developing melasma. If you aren’t pregnant, you likely have elevated levels of estrogen receptors found in your melasma lesions.
• Makeup (cosmetics): Some cosmetics can cause what’s called a phototoxic reaction.
• Phototoxic drugs (medicines that make you sensitive to sunlight): These include some antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), diuretics, retinoids, hypoglycaemics, antipsychotics, targeted therapies and some other drugs.
• Skin care products: A product that irritates your skin in general will likely make your melasma worse.
• Soaps: Some scented soaps are thought to cause or worse melasma.
• Tanning beds: The UV light produced by tanning beds damages your skin just as bad as the UV light from the sun, and sometimes worse.

What are the signs of melasma?

Melasma causes light brown, dark brown, and/or bluish patches or freckle-like spots on your skin. Sometimes the patches can become red or inflamed. Melasma appears in six locations or a combination of locations on your skin:

1. Brachial: The melasma appears on your shoulders and upper arms.
2. Centrofacial: The melasma appears on your forehead, cheeks, nose and upper lip.
3. Lateral cheek pattern: The melasma appears on both cheeks.
4. Malar: The melasma appears on your cheeks and nose.
5. Mandibular: The melasma appears on the jawline.
6. Neck: In people age 50 or older, melasma can appear on all sides of the neck.

Your healthcare provider will decide for sure if you have melasma or another type of skin disorder.

Do certain foods affect melasma?

At this time no foods or drinks are known by experts to directly cause, magically cure or worsen melasma. However, to keep your skin healthy in general, try a skin-healthy diet of foods rich in Vitamin D:

• Almond milk.
• Eggs.
• Meat.
• Milk.
• Mushrooms.
• Oily fish.
• Orange juice.
• Yogurt.

If I have melasma, does that mean I’ll get thyroid disease?

Those with melasma are more likely to have a thyroid disease. Your healthcare provider may test your thyroid.

Your dermatologist or other healthcare provider will examine your skin to diagnose melasma. They’ll use a Wood’s lamp (a black light) to see changes in the color of your skin. You might have your thyroid checked because there does seem to be an association between thyroid disease and melasma.

Melasma can sometimes be mistaken for another skin condition. To tell the difference between skin conditions, your healthcare provider may perform a biopsy, which is where a small piece of your skin is removed and examined. A biopsy is quick, safe procedure routinely performed during a normal visit to your healthcare provider’s office. Skin conditions commonly confused with melasma include:

• Actinic lichen planus and lichen planus.
• Drug-induced pigmentation.
• Guttate hypomelanosis.
• Hydroquinone-induced exogenous ochronosis.
• Lentigo (age spots).
• Nevus of Hori.
• Nevus of Ota.
• Postinflammatory pigmentation.

If you have melasma, the results of the biopsy will typically reveal the following:

• Dendritic (branched) pigmented melanocytes.
• Melanin in the basal and suprabasal keratinocytes.
• Melanin in the dermis within melanophages.
• Solar elastosis and elastic fiber fragmentation.

The severity of your melasma can be measured by using the Melasma Area and Severity Index (MASI). Your healthcare provider may administer the test.

What questions might my healthcare provider ask to diagnose melasma?

• When did see the discoloration in your skin?
• Where are the discolorations located on your body?
• Is there a history of melasma in your family?
• Are you pregnant?
• What soaps do you use?
• What cosmetics/makeup do you use?
• Do you have any other skin disorders?
• Are you interested in prescriptions that may improve your melasma?
• Are you interested in procedures that may improve your melasma?

Can melasma be raised on the skin?

Melasma is usually flat. See your healthcare provider if you have concerns about another type of skin disorder.

Can melasma appear overnight?

No. Melasma appears slowly over a period of weeks or months.

Are freckles melasma?

Spots of melasma can sometimes be mistaken for freckles but they are not the same skin condition.

Are age spots/sun spots/liver spots melasma?

They can look similar! But, melasma patches are almost always larger than what we call age spots, sun spots, or liver spots. Ask your healthcare provider if you’re concerned about another condition.

Is there a cure for melasma?

Melasma is hard to treat. To determine a treatment plan, your healthcare provider will have to first figure out what’s possibly causing the melasma. Is it sunlight? Your birth control? Genetics? Your soap? Too much screen time?

Depending on the person, melasma may go away on its own, it may be permanent, or it may respond to treatment within a few months. Most cases of melasma will fade away with time and especially with good protection from sunlight and other sources of light.

Unfortunately, there is no definitive treatment that will automatically make melasma disappear. At this time there is no way to remove dermal pigment.

If you have melasma, be sure to avoid:

• Hormone treatments, specifically ones that involve estrogen.
• Birth control, specifically oral contraceptive pills that contain estrogen and progesterone.
• LED light from your television, laptop, cell phone and tablet.
• Makeup you find irritating to your skin.
• Medications that may cause or worsen melasma.
• Scented soaps.
• Skin care products that irritate your skin.
• Tanning beds.
• Waxing, which can aggravate the melasma.

Do I need to see a dermatologist for melasma?

Yes. A dermatologist will be able to perform treatments that your usual healthcare provider may not be able to.

Can melasma go away on its own?

Yes, it’s possible that your melasma will go away on its own within a few months. However, it is not likely to go away while you’re pregnant or taking hormone contraceptives. Take preventative steps like avoiding sunlight to keep your melasma from getting worse or, if it does fade away, to keep it from coming back. Melasma can return.

How is melasma treated? What medicines help?

The first thing you need to do to treat your melasma is to make sure that it doesn’t get any worse. Do this by avoiding the sun, tanning beds, LED screens, irritating soaps and birth control that includes hormones. If you are exposed to the sun, be sure to wear sunscreen with iron oxides and a SPF of 30-50 applied every two hours, as well as a wide-brimmed hat. These steps may prevent your melasma from getting worse.

The second path to take is topical medications. Topical therapy using tyrosinase inhibitors prevents new pigment formations by stopping the formation of melanin (the dark color). Examples of tyrosinase inhibitors and other types of helpful agents include:

• Azelaic acid: This cream, lotion or gel is applied twice a day. It’s safe for pregnant women to use.
• Cysteamine: A small study of 50 people found cysteamine cream to be more effective than a placebo.
• Hydrocortisone (a topical corticosteroid): Hydrocortisone helps fade the color caused by melasma. It can also lessen the likelihood of dermatitis that may be caused by other agents.
• Hydroquinone: This medication is applied as a cream or lotion. It goes directly onto the melasma patches at night for two to four months.
• Methimazole: Methimazole is an antithyroid cream or an oral tablet. It’s known to help melasma that resists hydroquinone.
• Soybean extract: Soybean extract is thought to reduce the transfer of color from the melanocytes to the skin cells.
• Topical alpha hydroxyacid: Epidermal pigments can be peeled off. This cream or chemical peel removes surface skin.
• Tranexamic acid: This is a cream or injection, or an oral medication.
• Tretinoin: This prescription is a topical retinoid. It’s effective, but can cause dermatitis and should not be used during pregnancy.

The combination of hydroquinone, tretinoin and a moderate topical steroid has had the best effect on melasma.

Other agents that are being studied to improve melasma include:

• Absorbic acid (vitamin C).
• Arbutin.
• Deoxyarbutin.
• Glutathione.
• Kojic acid or kojic acid dipalmitate.
• Licorice extract.
• Mequinol.
• Resveratrol.
• Runicol.
• Zinc sulfate.

Are there complications/side effects of the medications?

Dermatitis is a side effect of hydroquinone and tretinoin. Azelaic cream, lotion, or gel can sting. Always be on the lookout for any allergic reactions. Report all side effects to your healthcare provider. It might be appropriate for you to use a different medication to avoid the side effects.

Chemical peels and lasers may cause the surface layers of skin to die, cause post-procedure hyperpigmentation, and cause hypertrophic scars. They can be safely used with topical medications, but only by specialists who have experience treating melasma.

How long will it take the medications to take effect?

It depends on the person and the medication used. Melasma can be slow to respond to treatment. The agents listed above rarely eradicate all of the melasma.

Are there any procedures that can help melasma?

A topical treatment isn’t your only option. There are some procedures that your dermatologist can do to improve your melasma.

• Chemical peel: In this procedure, your dermatologist will put a chemical on your skin that may make it peel. The skin that regenerates should be smoother and more evenly colored.
• Light-based procedures like intense pulsed light, non-ablative fractionated lasers and low fluence Q-switched lasers.

What do I do if I’m pregnant and have melasma?

Your melasma is likely to go away when you’re no longer pregnant. If it doesn’t, pursue treatment options with your healthcare provider. While pregnant, be careful to only use topical and oral treatments that are approved for pregnant women.

What specialist should I see to help with treatment of melasma?

A dermatologist specializes in skin conditions. They can help you with management and treatment of your melasma.

Does makeup cover up melasma?

Yes, but use cosmetics that include sunscreen and pay attention to any that may aggravate your melasma by irritating your skin.

What vitamins can I take to help with melasma?

Vitamin D helps keep your skin healthy in general. Your healthcare provider might test your vitamin D levels to make sure that you’re getting enough of it from high vitamin D foods such as meat, cereals, oily fish and eggs. You could also take a vitamin D supplement. Start at 2,000 International Units (IU) per day.

Will melasma go away if I go off birth control?

If the hormones in your contraception are the cause of your melasma then, yes, it may go away. Typically it takes about three or more months for the melasma to fade.

Will melasma go away after I give birth? What about after breastfeeding?

Melasma will likely fade within three months after you’re no longer pregnant.

Can melasma be prevented?

Regrettably, you can’t avoid genetics, or stop the skin condition when you’re pregnant. But you may be able to avoid the factors listed above which make melasma worse. At this time no medication can completely prevent melasma. However, a skin-friendly diet including adequate amounts of vitamin D is likely to help.

What can I expect if I’ve been diagnosed with melasma?

Melasma is a harmless skin condition. It doesn’t itch or hurt, and it doesn’t become malignant. Expect it to get worse and/or reoccur if you don’t take steps such as avoiding the sun and makeups and soaps that irritate your skin.

How long will I have melasma?

If you have the dermal pigment, it may take longer to fade away than if you have the epidermal pigment. Melasma is typically a chronic disorder. This means that it’s long-lasting (three months or more). Depending on the person, melasma may go away on its own, it may be permanent, or it may respond to treatment. If you take preventative measures and follow any treatments recommended by your healthcare provider, your melasma might disappear.

How do I take care of myself?

Avoid exposure to sunlight without sunscreen. Cut down on screen time in front of your LED screen television, tablet, mobile phone and computer. Choose a method of birth control that doesn’t include hormones. Use the treatment and management advice from your dermatologist or another healthcare provider. And make sure you’re getting the right treatment by confirming the diagnosis with your healthcare provider.

What is it like living with melasma?

Melasma is harmless, physically, but can have an emotional impact. Some people may feel embarrassed to allow others to see their skin condition. Fortunately, melasma typically fades after about three months.

When should I see my healthcare provider about melasma?

To start treatment, see your healthcare provider as soon as possible when you see signs of melasma. The worse it gets, the harder it will be for treatments to work.

What questions should I ask my healthcare provider about melasma?

• Do I have melasma or another type of skin disorder?
• What medications and/or vitamins can I take to help heal my melasma?
• How many hours of sunlight do you recommend I receive?
• Is there a specific sunscreen you recommend?
• Are the soaps I’m using right now aggravating my melasma (come with a list if you need to)?
• What birth control should I use?
• Are any of my current medications causing or worsening my melasma?

A note from Cleveland Clinic

Melasma is common, normal and harmless, but it can be bothersome. This skin disorder can affect your social life if you’re feeling self-conscious about it. But you don’t have to just “live with it.” There are treatment options. There are preventative measures you can take. There are dermatologists who can help you. Ask them questions and voice your concerns.

Always listen to the advice of your healthcare provider and follow your treatment plan carefully.