Skin Consultation
Melasma isn’t just a pregnancy thing, it can happen to any woman. And it’s all because of our hormones
27 June 2024
Melasma is often called a “pregnancy mask” because the veil of dark blotchy patches on the face seems to appear when you’re expecting a baby. But melasma doesn’t just occur in pregnant women – the skin condition can appear at any stage of life, including before pregnancy and during menopause.
The ratio of melasma in women versus men is 9:1, and the American Academy of Dermatology says the average age of onset is between 20 and 40 years.
People with deeper skin tones, such as those of Southeast-Asian and South Asian descent, are more prone to developing melasma. Melasma is a complex skin condition. It’s not only influenced by UV exposure and lifestyle factors, but also by genetic and hormonal factors, including medical conditions like thyroid disorder. For some, it can be persistent.
MELASMA IS DIFFICULT TO DIAGNOSE
It is described that melasma is dark, blotchy patches with irregular borders on both sides of the face. The patches are commonly found on the forehead, cheeks and nose.
There is no diagnostic test for melasma. Instead, diagnosis relies predominantly on the doctor recognising it based on medical guidelines, said Dr S K Tan, founder and medical director of IDS Clinic, an aesthetic clinic. The problem is that even with such “textbook” guidelines, melasma isn’t that easy to diagnose.
It is commonly misdiagnosed or overlooked because it can co-exist and/or overlap with other common types of hyperpigmentation, such as post-inflammatory hyperpigmentation, age spots or freckles.
Sometimes, the melasma patches have regular and defined borders, or appear only on one side of the face, which can resemble other forms of pigmentation, said Dr Tan.
HORMONES PLAY A BIG PART IN MELASMA
Hormonal changes play a significant role in the occurence – and recurrence – of melasma.
Hormonal fluctuations in oestrogen and progesterone, notably during pregnancy, can serve as a catalyst for melasma development, stimulating melanin production and resulting in emergence of dark patches on the skin. Melanin is the pigment that gives you your skin tone, as well as your hair and eye colour.
In fact, research has found that elevated levels of oestrogen have been linked to increased skin pigmentation. And because oestrogen is constantly in flux throughout a woman’s life, the chances of melasma recurring is high.
It’s the reason why women who have had melasma before should continue to prioritise sun protection to manage the condition effectively and minimise the risk of recurrence.
Since hormones are involved, being on hormonal contraceptives in your reproductive years, and going on hormonal replacement therapy (HRT) during menopause, or even being treated for medical conditions like thyroid disorder can increase one’s susceptibility to melasma.
In HRT, oestrogen and progesterone may stimulate the melanocytes (melanin-producing cells in the skin), leading to an increase in melanin production and triggering melasma.
The good news: When hormone levels normalise, such as after a woman gives birth or when she stops taking birth control pills, melanin production would then be reduced. Dr Lee said that this would eventually lead to a gradual fading of melasma patches.
METICULOUS SUN PROTECTION
You might not be able to do much about fluctuating hormones but you can still do your part to minimise your risk of melasma.
While UV damage may not be the sole cause of melasma, sun exposure is “the most modifiable risk factor”. That means following strict sun-protection rules – diligent and meticulous application of a broad-spectrum sunscreen of at least SPF30 daily to protect against UVA and UVB rays.
In addition to choosing a sunscreen with physical blockers like titanium dioxide or zinc oxide, it is also advised opting for one with iron oxide, which can block visible light.
You should also avoid prolonged, strong sun exposure, seeking shade where possible and not being outdoors between 10am and 3pm.
MELASMA IS PERSISTENT AND POSSIBLY PERMANENT
There is no definitive cure for melasma and for many, the relapse rate is very high.
A possible reason behind the high recurrence is permanent UV damage to the melanocytes, said Dr Tan. The skin is generally able to repair UV damage on a daily basis but cumulative UV exposure causes the melanocytes to fall short in the repair process, leading to irreparable changes.
Some studies have indicated that this results in hyperactivity of the skin cells, leading to hyperpigmentation occurring again and again.
“UV damage to certain layers of the skin can also allow pigmentation to ‘drop’ or migrate to the deeper layers of the skin, making certain treatments less effective or even unsuccessful,” Dr Tan added.
When combating melasma recurrence, a holistic solution is key, said Dr Tan. In-clinic treatments may include fractional laser (a type of resurfacing laser used to reduce hyperpigmentation and stimulate collagen production), Intense Pulsed Light therapy, chemical peels and even prescription oral medication like tranexamic acid.
The location of the pigmentation – whether epidermal (on the skin surface), dermal (deeper layers within the skin) or both – can affect the treatment plan and prognosis. Generally, epidermal melasma shows better responsiveness to treatment than dermal melasma.
AT-HOME CARE FOR MELASMA
For homecare, in addition to sunscreen, the doctors recommend using hydroquinone, a skin-lightening agent known for its effectiveness in reducing hyperpigmentation.
“It is the ‘gold standard’ by which other skin-lightening ingredients are judged,” said Dr Tan.
Hydroquinone works by blocking the enzyme tyrosinase, which the skin needs to make melanin. However, due to its potency and potential side effects, it requires a doctor’s prescription.
Hydroquinone at higher concentrations can trigger skin irritation and inflammation, which can lead to post-inflammatory hyperpigmentation – a result of skin inflammation or when skin is injured.
For over-the-counter options, consider tyrosinase inhibitors such as vitamin C, arbutin, kojic acid and azelaic acid. The latter is particularly beneficial in preventing melasma recurrence, especially for dermal melasma.
While melasma can’t be completely eradicated, studies have shown that it can be controlled.
The most important thing is to seek prompt and early treatment with a medical professional once you notice pigmentation beginning to develop, to prevent the issue from worsening.
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