Facial melasma

Skin pigmentation disorders are common problems with which patients often refer to dermatologists. It is especially frustrating when unattractive spots appear on the face: this cosmetic problem is called melasma. The disease is benign, but it causes a lot of psycho-emotional discomfort to its owners. What is this pathology, and is it possible to get rid of it? [1]

Melasma is always visible. Unsightly spots on the face - from light beige to dark brown - are distinguished by clear boundaries, without peeling, changes in the skin structure, etc. In winter, the spots brighten a little, but in summer they become especially pronounced. Sometimes people have only one or two spots, but often the face is completely covered with them. [2]

Epidemiology

A fair face and clear skin have always been considered the first indicators of beauty. So that the skin does not darken, many women in Central Asia still wear special umbrellas to protect them from the sun. A similar fashion for light skin originated in India and Turkey, and the first protective umbrella appeared in the 17th century in France: it was called "parasol", which literally translates "for the sun".

Fashion has changed over the years, and tanning has gained popularity. However, it is still believed that beautiful skin should have an even and healthy tone, without spots and other extraneous elements. [3]

According to statistics, every fifth person on the planet has various kinds of pigment spots like melasma - and the problem occurs in women about twice as often as in men, and older people more often than in young people. In most cases, the "culprit" is an excessive passion for tanning, or regular work (stay) in the open air, under the scorching sun.

It is believed that the appearance of melasma is most likely in people aged 35-40 years, although similar hyperpigmentation is often found in young girls and boys.

There are cases when melasma spots disappeared on their own. But more often than not, the situation becomes less optimistic: getting rid of the problem requires a lot of effort and patience.

Melasma is usually treated by a dermatologist-cosmetologist. However, the patient must additionally consult with a gynecologist, endocrinologist, gastroenterologist.

Causes melasma

Melasma in the form of intense color spots on the face can be caused by pathology, or have a hereditary etiology.

Melanin is a pigment substance that provides the shade of the skin, the eye iris. Excessive accumulation and deposition of this substance causes hyperpigmentation. The main reasons for this process are:

• exposure to sunlight (approximately every second case of melasma) associated with prolonged exposure to the open sun, frequent visits to the solarium;
• during pregnancy, hormonal imbalance associated with ovarian dysfunction, hepatic dysfunction, thyroid malfunction, taking contraceptive medications and hormones;
• inflammatory reactions on the skin;
• diseases of the digestive system, metabolic disorders, hyper and hypovitaminosis.

Other likely causes of melasma include chemicals and medications that can increase the skin's sensitivity to ultraviolet light. This is especially common in individuals with a hereditary predisposition to hyperpigmentation. [4]

Medicines that increase skin sensitivity to sunlight and promote the development of melasma:

• non-steroidal anti-inflammatory drugs and analgesics (Diclofenac, Ibuprofen, Indomethacin, Piroxicam, Naproxen);
• antibacterial drugs (Gentamicin, Azithromycin, Tetracycline, Erythromycin, Doxycycline);
• diuretics (Furosemide, Hydrochlorothiazide, Acetazolamide, Chlorthalidone, Amiloride);
• drugs that affect the work of the cardiovascular system (Amiodarone, Simvastatin, Minoxidil, Carvedilol, Losartan);
• oral contraceptives, hormonal drugs (Gestodene, Estradiol);
• antidepressants (Doxepin, Fluoxetine, Venlafaxine, Paroxetine, Amitriptyline, etc.);
• sedatives, barbiturates (Phenobarbital, Diazepam, Alprazolam);
• antiallergic agents (Cetirizine, Astemizole, Diphenhydramine hydrochloric acid, Ebastin);
• local drugs for acne (Adapalen, Retinoic acid, benzoyl peroxide, Isotretinoin).

It is important to note that the question of the cause of the occurrence of melasma has not been sufficiently studied to date. In this regard, it is often not possible to clearly establish a causal relationship between the appearance of this problem and any violation in the body. However, each of the above causes can be considered a contributing factor to the development of melasma. [5]

Risk factors

The production of pigment substance occurs in melanocytes - epidermal cells. There are several variants of this substance, the predominant amount of which determines the shade of the skin and hair:

• eumelanin (provides brown and black tint);
• pheomelanin (gives a reddish color);
• leukomelanin (neutral color).

Despite the fact that melasma is characterized by the appearance of predominantly dark brown spots, their shade depends on the ratio of the amount of one or another type of pigment substance. [6]

The process of melanin production and the regulation of the work of pigment cells still leave many questions for specialists. Scientists suggest that the basis for the development of melasma lies in a hereditary predisposition, which makes itself felt under the influence of some provoking factors. It is a proven fact that the main factor is solar radiation, which contributes to an increase in the number of free radicals that cause damage to the DNA of pigment cells and accelerate the distribution of pigment. In addition, ultraviolet radiation itself is also capable of damaging cellular DNA.

Thus, the main provoking factors are:

• excess ultraviolet radiation;
• changes in hormonal balance (for various reasons: pregnancy, menopause, treatment with hormonal drugs, hormone-producing tumor processes, etc.);
• inflammatory diseases affecting the skin. [7]

Changes in hormonal levels are mainly associated with the ratio of sex hormones. Somewhat less often, melasma becomes a consequence of metabolic disorders, malfunctioning of the liver, thyroid and pancreas, and intestines. There is also evidence of the negative impact of improperly selected cosmetics or illiterate procedures.

Pathogenesis

Human skin tone can be different, and this is due to many factors:

• the amount and degree of pigment distribution;
• the thickness of the epidermal layer;
• the state of the stratum corneum;
• saturation and quality of the vascular network;
• properties of melanin-containing cell structures;
• the content of melanin in melanosomes and the quality of its divergence in epidermal cells.

The production of melanin occurs in specific structures of melanocytes, namely in melanosomes, by converting the amino acid substance tyrosine. Under the influence of enzymes such as DOPA oxidase and tyrosinase, tyrosine is transformed into an intermediate metabolic unit, dioxyphenylalanine. Further, through subsequent processes, this link is converted into melanin. [8]

The mechanism by which melanin is formed is called melanogenesis. It is due to the presence of tyrosine, singlet oxygen, zinc and copper ions.

There are more than a thousand melanocytes per 1 cm² of skin. Moreover, in dark-skinned people, this number is only slightly higher than in fair-skinned people. But their melanin is formed much more actively, which is explained by genetic characteristics.

Currently, scientists are already confidently talking about a free-radical theory of regulating the formation of melanocytes. This theory suggests that damage to the mitochondrial DNA zones occurs with a deficiency of antioxidants, which entails a breakdown in melanin production. [9]

The regulatory mechanisms of melanocyte function are currently not well understood. However, all experts are sure that ultraviolet radiation is almost always a stimulant of such processes. The state of the nervous system also has some influence.

There are two main regulatory directions:

• through the hypothalamus and the anterior pituitary gland, with the release of MSH, a hormone that stimulates the production of melanin;
• through the pineal gland, which inhibits the production of melanin.

The condition of the skin largely depends on the hormonal background in the body - and, above all, on the balance of sex hormones. In women, this balance changes periodically, depending on the phase of the monthly cycle, as well as during pregnancy, while taking contraceptive drugs, or with the onset of menopause. All of these periods can contribute to the excessive accumulation of melanin. Experts estimate that every third woman taking oral contraceptives has a problem with hyperpigmentation. [10]

Melanogenesis processes are influenced not only by sex hormones, but also by adrenal and thyroid hormones.

Symptoms melasma

Melasma is classified as an acquired disorder of a benign nature. Pigmentation of the skin has a local limitation - most often the spots are located only in the facial and cervical area, not spreading further to the body. However, in some cases, lesions are also found on the décolleté and upper extremities.

Manifestations in melasma have the form of unequal spots of varying number and size. Their color ranges from light brownish to completely dark, almost black. The spots are distinguished by clear boundaries, localized mainly on open skin.

The mucous membrane (lips, eyes) is usually not affected. There is no peeling or changes in tissue structure.

In summer, the spots become noticeably darker, brightening in winter.

The first signs often become visible towards the end of spring or early summer. A slight darkening appears, which many patients mistake for skin pollution. Nevertheless, this “pollution” is not washed off by anything: over time, its boundaries are clearly manifested, and it becomes clear that this stain is nothing more than melasma. The lesions acquire a brownish color, can be located separately or merge with other lesions. They do not hurt, do not itch, do not cause any other discomfort. The only problem is the unsightly appearance. [11]

Forms

Conventionally, melasma is divided into several types, based on clinical manifestations, histological features, and also on the pathology course.

According to clinical symptoms, the following types of disease are distinguished:

• painting melasma (spots are located mainly on the cheeks and nose);
• central melasma (spots are located in the frontal, upper lip, chin region, near the nose;
• melasma is mandibular (spots are found on the mandibular arch).

According to the characteristics of the clinical course, the pathology is divided into the following options:

• melasma passing (spots are temporary and disappear on their own after the end of the influence of the provoking factor);
• persistent melasma (manifestations of the disease do not disappear, but only periodically darken and brighten).

According to histological characteristics, the following types of disease are distinguished:

• epidermal melasma (the content of melanin increases in the epidermal layer);
• dermal melasma (melanin content increases in both the superficial and deep dermis, which is manifested by dark brown spots that do not change when examined with a Wood lamp);
• mixed melasma (dermal-epidermal, with different deep localization of spots).

Doctors note that the epidermal variant of pathology is the easiest to treat, and the dermal and mixed type is the most difficult.

Melasma Addison

When people talk about Addison's specific melasma, they mean hypocorticism, or chronic insufficient function of the adrenal cortex. The disease can develop against the background of any lesion of the adrenal cortex or pituitary gland, in which there is a decrease in the production of cortisol or aldosterone. In the overwhelming majority of cases (about 80%), an autoimmune reaction acts as a provoking mechanism. Tuberculosis becomes somewhat less common. Even less often, pathology is caused by fungal lesions, tumor processes, syphilis, AIDS, adrenal hemorrhage.

Symptoms of Addison's melasma develop gradually over several years. The patient notes chronic fatigue, loss of appetite, irritability. Since the disease is accompanied by increased excretion of salt from the body, the sick person begins to use it in large volumes. On open areas of the skin (not only on the face, but also on the arms, legs), age spots appear - this symptom may be one of the first.

The diagnosis of such a pathology is quite complicated, as well as further treatment, which involves hormone replacement therapy. These drugs are usually taken for life. [12]

Complications and consequences

Melasma is in many cases safe, creating only aesthetic discomfort. However, the risk of developing serious complications is still present: we are talking about a malignant tumor process - melanoma. This tumor can appear at any age, in patients of any gender. The appearance of a problem can be determined by the following characteristic symptoms:

• the contour of the melasma spot loses clarity, becomes blurred;
• the spot grows rapidly, suddenly darkens, or becomes reddish;
• the tone becomes uneven;
• redness of the nearest layer of the epidermis is noted.

Another frequent, but indirect consequence of melasma is psychological discomfort, leading to apathy, depressive states. Female patients are especially susceptible to this complication. [13]

Diagnostics melasma

In the process of diagnosing melasma, it is extremely important to inspect pathological foci using a Wood filter lamp. We are talking about a diagnostic device popular among dermatologists that makes it easy to determine the type of disease, distinguish dermatoses, fungal lesions and other skin problems. [14]

Dermatoscopic and siascopic examination helps to assess the extent and depth of melanin accumulations. This is necessary in order to correctly determine the further treatment tactics.[15]

If there are suspicions that diseases of the digestive tract and endocrine system are involved in the development of melasma, then the doctor may prescribe other diagnostic procedures:

• coprogram, definition of dysbiosis;
• biochemical liver function tests;
• gastroscopy;
• ultrasound examination of the liver and abdominal organs;
• gynecological examination for women.

In rare cases, a biopsy of a small skin particle is additionally prescribed. As a rule, this study is appropriate if a malignant process is suspected. It is also possible to conduct a general blood test, immunological studies.

Differential diagnosis

Melasma should be distinguished from diseases such as lentigo, Becker's nevus, cutaneous lymphoma, pseudoleucoderma with pityriasis versicolor, drug-induced melasma, pellagra, and Riel's melanosis. Differential diagnosis is performed only by a specialist, a dermatologist, since it often becomes problematic to distinguish one pathology from another. He also finds out the type of melasma and, if possible, determines the cause of the disorder.

Differentiation involves the use of a digital dermatoscope and a special Wood lamp, a diagnostic device capable of emitting ultraviolet light in the long-wavelength spectrum.

Sometimes it is necessary to distinguish melasma from chloasma: these are, in fact, two equivalent concepts. Chloasma is a type of melasma and often occurs in women during pregnancy.

Like melasma, chloasma is an excess of pigmentation in a limited area of the skin. Experts have not yet decided on the correct use of one or another concept, therefore they are often used as synonyms.

Treatment melasma

The treatment regimen for melasma is always complex, including a number of procedures, recommendations and prescriptions. Since the problem is often difficult to correct, maximum efforts should be made to eliminate it, using several options at the same time. [16]

1. If melasma occurs while taking hormonal drugs, then they should be canceled if possible.
2. Avoid taking medications or products that can increase the sensitivity of the skin to ultraviolet rays.
3. They purchase high-quality external sunscreens with a wide range (UVB + UVA), use them to be applied to the skin of the face and neck regularly, regardless of the season.
4. Refuse to use aggressive external drugs for acne.
5. They review the cosmetics used, consult with specialists. The presence of retinoids, alpha hydroxy acids, beta hydroxy acids (AHA, BHA) in such products is undesirable.
6. Maintains the natural moisture of the skin, avoiding dehydration that compromises the natural defenses.
7. Additionally, they use special cosmetics that inhibit the processes of melanin production, for example:
   1. hydroquinone (not allowed during pregnancy and lactation);
   2. koic, azelaic acid;
   3. topical corticosteroids;
   4. topical retinoid drugs (not possible during pregnancy).
8. Various exfoliating procedures are used (chemical peeling, microdermabrasion, laser peeling, fractional renewal, various combined techniques - for example, surface erbium laser peeling with fractional erbium renewal).
9. Pigment-destroying procedures are practiced - in particular, photorejuvenation (not suitable for deeply located accumulations of pigment).
10. Proanthocyanidins are taken orally.

The main procedures to get rid of the manifestations of melasma are:

Procedure	Act	Highlights
Peeling procedures	Exfoliate the superficial skin layer, removing pigmented areas.	Only superficial spots, characteristic of epidermal melasma, help to eliminate.
Laser and photorejuvenation	Destroy the pigment with a directed laser beam or color pulse.	Effective even with deep-seated melanin accumulations. However, the effect does not last long: the stain is partially or completely restored over several months.
Mesotherapy	It involves shallow injections to destroy pigment and suppress the activity of pigment cells.	The procedure is medium-effective, but it successfully copes with the task in combination with peeling procedures.
Cosmetic whitening	It involves the external use of drugs with a mesotherapeutic effect.	The effect appears only after several months of regular use of funds (more often - from six months to a year). The most potent of these contain hydroquinone, which can cause allergic and inflammatory reactions.

Treatment for melasma is carried out under the supervision of an experienced dermatologist-cosmetologist. As a rule, several treatment options are combined with each other at once, since experts have proven the ineffectiveness of monotherapy. [17]

How to remove melasma?

In mild cases, if the melasma spot is single and superficial, you can try to get rid of it in an alternative way. True, such treatment will be long-term, and no one can guarantee the effect. However, many patients recommend using these remedies:

• Finely chop the parsley, squeeze out the juice and apply it to the stain, for about 25 minutes. Instead of juice, you can use minced parsley - namely, the resulting green gruel. It is applied to the problem area and left for 20-25 minutes. To enhance the effect, a little lemon squeeze can be added to the gruel or juice. The procedure is carried out daily in the evening, before going to bed.
• Make masks from fresh cucumber, daily at night.
• Apply a slice of lemon for a quarter of an hour. After the procedure, the skin is wiped with clean water.
• A mask is made from kefir, sour cottage cheese, milk whey. Every evening, the mask is applied for about 20 minutes, after which it is washed off with warm water and a moisturizer is applied.

Do not use alcohol or alcohol-based solutions on melasma spots. All of the above funds are used in the evening to wash them off with water in the morning. It is impossible to go outside immediately after the procedure - due to a temporary increase in the photosensitivity of the skin.

Medicines

Sometimes melasma goes away on its own - for example, after normalization of hormonal levels. But this does not always happen. Topical products that contain hydroquinone are often used to make stains less visible. Such a component significantly lightens the darkened area, directly affects the enzyme tyrosinase, which plays a major role in the processes of pigment production. Such funds are used as directed by a specialist. However, a single preparation with hydroquinone will not be enough to successfully and permanently get rid of melasma. Specialists will always offer the patient a combination of products and procedures, especially for persistent or multiple stains.

In addition to hydroquinone, drugs with azelaic acid, tretinoin, koic, lactic or glycolic acid are actively used. In difficult cases, corticosteroid medications are prescribed, as well as special procedures such as laser and chemical peels. [18]

Tretinoin gel	An analogue of the Supatret remedy, has a minimum number of side effects. Renews the top layer of the skin, can be used for both treatment and prevention of hyperpigmentation. The treatment course is no more than 14 weeks.
EXPIGMENT BY ORVA	Antipigment cream made in Turkey, containing 4% hydroquinone. Effective for melasma, freckles, post-acne.
Bleaching Cream Vivant skin care	A product containing 2% hydroquinone plus kojic acid and retinyl propionate. It is especially recommended for the treatment of age-related melasma.
Melalite forte cream by Abbott Laboratories	The product, containing 4% hydroquinone, reduces pigment synthesis and is suitable for the elimination of melasma of any origin. The cream is applied daily at night, washed off in the morning and a regular day cream with sufficient sun protection is used. The duration of treatment with this remedy is no more than 3-4 months.
White Bio-Hydroquinone Cream by Chantarelle	Whitening agent with hydroquinone, reduces the severity of defects, evens out the tone of the skin, reduces the intensity of hyperpigmented areas provoked by hormonal imbalance, chloasma, photoaging.
Obagi Fx C-Therapy Cream	Low-fat cream, has a light structure. The composition contains vitamins: ascorbic acid and tocopherol. Recommended to apply in the evening and leave on the skin overnight for long-term exposure. It is important not to allow the product to come into contact with the mucous membrane of the eye.

There are contraindications to the use of these external drugs:

• hypersensitivity to any of the components;
• age under 14;
• the period of pregnancy and breastfeeding;
• acute skin inflammations, wounds, burns in the area of application of the product;
• rosacea.

Do not apply products under the eyes or in close proximity to them. It is also undesirable to use the cream near the lips. [19]

One of the main side effects of such drugs is excessive dryness of the skin in the area of application. If this happens, then it is necessary to revise the amount and frequency of use of the product. Some patients note that dryness goes away on its own with regular use of such drugs. Additionally, you can apply moisturizers, alternating with the application of medicinal products.

Prevention

The main method for preventing the development of melasma is considered to be the protection of the skin from ultraviolet radiation. In order to protect the skin from the sun's rays, you need to regularly use special sunscreens with an SPF of 15 or more. Such products should be applied to the skin about half an hour before its contact with the sun, and do not forget to renew the application every 1.5-2.5 hours.

Other expert recommendations:

• It is undesirable to be in direct sunlight in the summer, from 10 am to 3 pm.
• In sunny weather, it is necessary to cover the face area with a cap or panama with a wide visor, and cover other parts of the body with light clothing made from natural fabrics.
• It is important to eat right: the diet should contain foods rich in vitamins and microelements - for example, citruses, berries, vegetables, herbs. It is advisable to reduce your coffee consumption as much as possible by replacing it with freshly squeezed juice, herbal teas, or just plain water.
• An active lifestyle is one of the ways to maintain hormonal balance in the body. An even greater benefit can be gained from exercising outdoors.
• You should not take medicines without consulting a doctor, prescribe them yourself. There are a number of drugs that can enhance pigmentation: if the treatment involves taking such drugs, then it is necessary to avoid exposure to sunlight during the course of the treatment course, to wear only closed clothing.
• It is not recommended to visit solariums often, or even better to refuse such procedures altogether.
• It is necessary to take care of the skin on a daily basis, to prevent the development of inflammatory processes, which will prevent the appearance of post-inflammatory spots.

Forecast

If we approach the treatment of melasma competently and comprehensively, then the prognosis can be called favorable. For a speedy cure, it is very important to find out the cause of the disease and try to eliminate it, and only then proceed to a cosmetic solution to the problem.

Difficulties with treatment may arise if it is impossible to determine the origin of melasma, if the doctor's prescriptions are not followed. Some cases of the lack of effect of treatment are also associated with the individual characteristics of the patient's body. Nevertheless, in most cases, the pathology is curable.

It is worth noting that melasma is removed very slowly. Complete elimination of the problem is possible only in every third patient, since in many cases, even after a stable remission, a relapse of the pathology occurs over time. The reappearance of the spot is most often associated with ultraviolet radiation, or with a sharp change in hormonal balance.