Melasma
Disease Overview
Melasma is a skin condition caused by hyperactive melanocytes which increase their production and accumulation of melanin in the epidermis. Appearing as gray-brown patches of skin predominantly on the face, these patches can also develop on the forearms and neck.1
The disease primarily affects women during their childbearing years, with men representing less than 10% of patients.2,3
Although its etiology is unknown, UV light, pregnancy, thyroid disturbances, and medications (i.e. oral contraceptives and anti-epileptics) have all been implicated in its pathogenesis.4 Melasma is a chronic disorder that may last for decades.3 Furthermore, there appears to be a genetic and ethnic component, as it often runs in families, and the prevalence is increased in individuals of Fitzpatrick type skin IV–VI.5,6
Epidemiology
The true incidence of melasma is unknown, however, it is a very common occurrence. It is estimated that facial melasma affects over 5 million people in the US.4
Almost 90% of affected patients are women. Melasma commonly occurs in women who are pregnant or using oral contraceptives or hormone replacement therapy; also, it can often be seen in women without a predisposing factor. The disease may affect any racial group or skin type but is more commonly found in darker skinned individuals, such as Hispanics, Asians, and other racial groups.3,5,6
Clinical Burden of Disease
Such evident incongruous pigmentation is detrimental to patients’ psychological well-being. In fact, patients report adverse consequences in their social life, recreational activities, and emotional well-being as a result of melasma.7 Disfiguring facial lesions can lead to decreased social functioning, lowered production at work or school, and reduced self-esteem. Fortunately, with proper treatment, their psychological profile improves. This can help them feel less embarrassed and more attractive and make fewer efforts to conceal their skin.8
Current Treatment Paradigm for the Management of Melasma
Melasma is challenging to treat and its course is often marked with recurrences. Since sunlight is a causative factor, sunscreens (with both ultraviolet A (UVA) and ultraviolet B (UVB) protection) and avoidance of sun exposure play a primary role in the treatment of melasma.1
There is no standard therapy for melasma. Although several treatment guidelines and algorithms have been proposed, they are, in most cases, based on expert consensus rather than on evidence from robust, large, randomized studies.9 In most cases, a multimodality approach is required, incorporating photoprotection, skin lighteners, exfoliants, antioxidants, and resurfacing procedures, based on the patient's characteristics and clinical presentation.1,10,11
1. Lapeere H, Boone B, De Schepper S, et al. Chapter 75: Hypomelanoses and hypermelanoses. In: Fitzpatrick’s Dermatology in General Medicine, 8th ed. New York, NY: McGraw-Hill Education, 2017.
2. Vázquez M, Maldonado H, Benmamán C, Sánchez JL. 1. Melasma in men. A clinical and histologic study. Int J Dermatol. 1988;27(1):25-27.
3. Handel AC, Miot LDB, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014;89(5):771-782. doi:10.1590/abd1806-4841.20143063
4. Grimes PE. Melasma. Etiologic and therapeutic considerations. Arch Dermatol. 1995;131(12):1453-1457.
5. Taylor SC. Epidemiology of skin diseases in people of color. Cutis. 2003;71(4):271-275.
6. Halder RM, Nootheti PK. Ethnic skin disorders overview. J Am Acad Dermatol. 2003;48(6):S143-S148.
7. Balkrishnan R, McMichael AJ, Camacho FT, et al. Development and validation of a health-related quality of life instrument for women with melasma. Br J Dermatol. 2003;149:572-577.
8. Balkrishnan R, Kelly AP, McMichael A, Torok H. Improved quality of life with effective treatment of facial melasma: The PIGMENT trial. J Drugs Dermatol. 2004;3(4):377-381.
9. Shankar K, Godse K, Aurangabadkar S, et al. Evidence-based treatment for melasma: expert opinion and a review. Dermatol Ther (Heidelb). 2014;4(2):165-186. doi:10.1007/s13555-014-0064
10. Chien A, Voorhees J, Kang S. Chapter 217: Topical Retinoids. In: Fitzpatrick’s Dermatology in General Medicine, 8th ed. New York, NY: McGraw-Hill Education, 2017.
11. Grimes PE, Ijaz S, Nashawati R, Kwak D. New oral and topical approaches for the treatment of melasma. Int J Womens Dermatol. 2018;5(1):30-36. doi:10.1016/j.ijwd.2018.09.004