Facial melasma

Skin pigmentation disorders are common problems that patients often consult dermatologists about. It is especially unpleasant 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 kind of pathology is this, and is it possible to get rid of it? [ 1 ]

Melasma is always noticeable. Unsightly spots on the face - from light beige to dark brown - have clear boundaries, no peeling, no changes in skin structure, etc. In winter, the spots become slightly lighter, but in summer they become especially obvious. 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. To prevent the skin from darkening, many women in Central Asia still wear special umbrellas to protect themselves from the sun. This fashion for fair 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 as "for the sun".

Over the years, fashion has changed, and tanning has become popular. However, it is still believed that beautiful skin should have an even and healthy tone, without spots or other foreign elements. [ 3 ]

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

It is believed that the appearance of melasma is most likely in people aged 35-40 years, although such 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 is not so optimistic: getting rid of the problem requires a lot of effort and patience.

Treatment of melasma is usually carried out by a dermatologist-cosmetologist. However, the patient must additionally consult with a gynecologist, endocrinologist, gastroenterologist.

Causes melasma

Melasma in the form of intensely colored spots on the face can be caused by pathology or have a hereditary etiology.

Melanin is a pigment substance that provides the color of the skin and iris. Excessive accumulation and deposition of this substance causes hyperpigmentation. The main causes of this process can be called:

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

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

Medicines that increase skin sensitivity to solar radiation and contribute to the development of melasma:

• nonsteroidal 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 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 hydrochloride, Ebastine);
• topical anti-acne medications (Adapalene, Retinoic acid, benzoyl peroxide, Isotretinoin).

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

Risk factors

The pigment substance is produced 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 shades);
• pheomelanin (gives a reddish color);
• leukomelanin (neutral color).

Although 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 regulation of pigment cells still leave many questions for specialists. Scientists assume that the basis for the development of melasma lies in hereditary predisposition, which makes itself known under the influence of certain 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 can be called:

• 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 related to the ratio of sex hormones. Less often, melasma is a consequence of metabolic disorders, improper functioning of the liver, thyroid and pancreas, and intestines. There is also evidence of the negative impact of incorrectly selected cosmetics or improperly performed procedures.

Pathogenesis

Human skin tone varies, and this is due to many factors:

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

Melanin production 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 exchange link – dioxyphenylalanine. Then, through subsequent processes, this link is converted into melanin. [ 8 ]

The mechanism of melanin formation is called melanogenesis. It is caused by the presence of tyrosine, singlet oxygen, zinc and copper ions.

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

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

The regulatory mechanisms of melanocyte function are currently not sufficiently studied. However, all specialists are confident that ultraviolet radiation is almost always a stimulator 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 periodically changes, depending on the phase of the monthly cycle, as well as during pregnancy, while taking contraceptives, or with the onset of menopause. All these periods can contribute to excessive accumulation of melanin. Experts have calculated that every third woman taking oral contraceptives has a problem with hyperpigmentation. [ 10 ]

The processes of melanogenesis are influenced not only by sex hormones, but also by hormones of the adrenal glands and thyroid gland.

Symptoms melasma

Melasma is classified as an acquired disorder of a benign nature. Pigmentation of the skin has a local limitation - most often, spots are located only in the facial and neck area, without spreading further to the body. However, in some cases, foci are also found on the décolleté and upper limbs.

Manifestations of melasma look like uneven spots of varying quantity and size. Their color varies from light brown to absolutely dark, almost black. The spots have clear boundaries and are localized mainly on exposed skin.

The mucous membrane (lips, eyes) is usually not affected. No peeling or changes in tissue structure are observed.

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

The first signs often become noticeable towards the end of spring or the beginning of summer. A slight darkening appears, which many patients mistake for skin contamination. However, this “contamination” cannot be washed off: over time, its borders become clearly visible, and it becomes clear that this spot 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 their unsightly appearance. [ 11 ]

Forms

Conventionally, melasma is divided into several types based on clinical manifestations, histological features, as well as the course of the pathology.

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

• malar melasma (spots are located mainly on the cheeks and nose);
• centrofacial melasma (spots are located in the forehead, upper lip, chin area, near the nose;
• mandibular melasma (spots are found on the mandibular arch).

Based on the clinical course characteristics, the pathology is divided into the following variants:

• transient melasma (the spots are temporary and disappear on their own after exposure to the provoking factor has ended);
• persistent melasma (symptoms of the disease do not disappear, but only periodically darken and lighten).

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

• epidermal melasma (the melanin content increases in the epidermal layer);
• dermal melasma (the melanin content increases in both the superficial and deep layers of the dermis, which manifests itself as dark brown spots that do not change when examined with a Wood's lamp);
• mixed melasma (dermal-epidermal, with different depth localization of spots).

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

Melasma Addison

When they talk about specific Addison's 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 vast majority of cases (about 80%), the provoking mechanism is an autoimmune reaction. Less often, tuberculosis becomes a trigger factor. Even less often, the pathology is caused by fungal infections, tumor processes, syphilis, AIDS, adrenal hemorrhages.

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

Diagnosis of such pathology is quite complicated, as is further treatment, which involves hormone replacement therapy. Taking such drugs is usually lifelong. [ 12 ]

Complications and consequences

Melasma is safe in many cases, creating discomfort only in an aesthetic sense. 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 the problem can be determined by the following characteristic symptoms:

• the outline of the melasma spot loses clarity and becomes blurred;
• the spot rapidly increases in size, 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 and depressive states. Female patients are especially susceptible to this complication. [ 13 ]

Diagnostics melasma

In the process of diagnosing melasma, it is extremely important to examine the pathological lesions using a Wood's filter lamp. This is a diagnostic device popular among dermatologists, which allows you to easily determine the type of disease, distinguish between dermatoses, fungal lesions and other skin problems. [ 14 ]

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

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

• coprogram, determination of dysbacteriosis;
• biochemical liver 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 and immunological studies.

Differential diagnosis

Melasma should be distinguished from such diseases as lentigo, Becker's nevus, cutaneous lymphoma, pseudoleukoderma in pityriasis versicolor, drug-induced melasma, pellagra, Riehl's melanosis. Differential diagnostics is performed only by a specialist, a dermatologist, since it often becomes problematic to distinguish one pathology from another. He also determines 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's lamp - a diagnostic device capable of emitting ultraviolet light in the long-wave spectrum.

Sometimes it is necessary to distinguish melasma from chloasma: these are essentially two equivalent concepts. Chloasma is one of the varieties of melasma and often occurs in women during pregnancy.

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

Treatment melasma

The treatment plan 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 treatment options simultaneously. [ 16 ]

1. If melasma occurs while taking hormonal drugs, then they are discontinued, 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), and apply them to the skin of the face and neck regularly, regardless of the time of year.
4. Refuse to use aggressive topical acne medications.
5. Review the cosmetics you use and consult with specialists. The presence of retinoids, alpha hydroxy acids, beta hydroxy acids (AHA, BHA) in such products is undesirable.
6. Maintains the skin's natural moisture, preventing dehydration, which disrupts its natural protection.
7. Additionally, special cosmetics are used that inhibit the process of melanin production, for example:
   1. hydroquinone (not recommended during pregnancy and lactation);
   2. kojic, azelaic acid;
   3. topical corticosteroids;
   4. topical retinoids (not recommended during pregnancy).
8. Various exfoliating procedures are used (chemical peeling, microdermabrasion, laser peeling, fractional renewal, various combination techniques - for example, superficial erbium laser peeling with fractional erbium renewal).
9. They practice pigment-destroying procedures, in particular photorejuvenation (not suitable for deep-seated pigment accumulations).
10. Proanthocyanidin preparations are taken orally.

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

Procedure	Action	Key points
Peeling procedures	Exfoliate the surface layer of the skin, removing pigmented areas.	They help to eliminate only superficial spots characteristic of epidermal melasma.
Laser and photorejuvenation	They destroy the pigment with a directed laser beam or color pulse.	Effective even for deep melanin deposits. However, the effect does not last long: the spot partially or completely recovers within a few months.
Mesotherapy	It involves performing shallow injections to destroy the pigment and suppress the activity of pigment cells.	The procedure is moderately effective, but successfully copes with the task in combination with peeling procedures.
Cosmetic whitening	Involves external use of drugs with a mesotherapeutic effect.	The effect appears only after several months of regular use of the products (usually from six months to a year). The most effective of them 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 at once, since specialists have proven the ineffectiveness of monotherapy. [ 17 ]

How to remove melasma?

In mild cases, if the melasma spot is isolated and superficial, you can try to get rid of it using folk remedies. True, such treatment will be long-term, and no one can guarantee the effect. Nevertheless, many patients recommend using the following 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 parsley minced through a meat grinder - namely, the resulting green gruel. It is applied to the problem area and left for 20-25 minutes. To enhance the effect, you can add a little lemon squeeze to the gruel or juice. The procedure is carried out daily in the evening, before going to bed.
• Make masks from fresh cucumber, every night.
• Apply a piece of lemon for a quarter of an hour. After the procedure, wipe the skin with clean water.
• Make a mask from kefir, sour cottage cheese, and whey. Apply the mask every evening for about 20 minutes, then rinse with warm water and apply a moisturizer.

Do not apply alcohol or alcohol-containing solutions to melasma spots. All of the above products are used in the evening and washed off with water the next morning. You cannot go outside immediately after the procedure due to temporary increased photosensitivity of the skin.

Medicines

Sometimes melasma goes away on its own – for example, after normalizing hormonal levels. But this is not always the case. In order to make the spots less visible, external agents containing hydroquinone are often used. This component significantly lightens the darkened area, directly affects the enzyme substance tyrosinase, which plays a major role in the processes of pigment production. Such agents are used as prescribed by a specialist. However, only one drug with hydroquinone will not be enough for successful and lasting elimination of melasma. Specialists will always offer the patient a combination of agents and procedures, especially for persistent or multiple spots.

In addition to hydroquinone, preparations with azelaic acid, tretinoin, kojic, lactic or glycolic acid are actively used. In complex cases, corticosteroids are prescribed, as well as special procedures - for example, laser and chemical peeling. [ 18 ]

Bleaching Cream Vivant skin care

Obagi Fx C-Therapy Cream

Tretinoin gel	An analogue of Supatret, it has a minimum number of side effects. It renews the upper layer of the skin and can be used for both treatment and prevention of hyperpigmentation. The treatment course is no more than 14 weeks.
Expigment by ORVA	Anti-pigmentation cream made in Turkey, containing 4% hydroquinone. Effective for melasma, freckles, post-acne.
A product containing 2% hydroquinone, as well as kojic acid and retinyl propionate. Particularly recommended for the treatment of age-related melasma.
Melalite forte cream from Abbott Laboratories	The product, containing 4% hydroquinone, reduces pigment synthesis and is suitable for eliminating 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 product is no more than 3-4 months.
White Bio-Hydroquinone Cream by Chantarelle	A whitening agent with hydroquinone, reduces the severity of defects, evens out skin tone, reduces the intensity of hyperpigmented areas caused by hormonal imbalance, chloasma, photoaging.
Low-fat cream, has a light structure. The composition includes vitamins: ascorbic acid and tocopherol. It is recommended to apply in the evening and leave on the skin overnight for a long-term effect. 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 the indicated external preparations:

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

Do not apply the product 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, it is necessary to review 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 moisturizing creams, alternating them with the application of medicinal products.

Prevention

The main method of preventing the development of melasma is considered to be the protection of the skin from ultraviolet radiation. In order to protect the skin of the face 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 recommendations from experts:

• It is not advisable to be exposed to 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 a Panama hat 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 include foods rich in vitamins and microelements - for example, citrus fruits, berries, vegetables, greens. It is advisable to reduce coffee consumption as much as possible, replacing it with freshly squeezed juice, herbal teas or just clean water.
• An active lifestyle is one way to maintain hormonal balance in the body. Even greater benefits can be obtained by doing physical exercise outdoors.
• You should not take medications without consulting a doctor, or prescribe them to yourself. There are a number of medications that can increase pigmentation: if the treatment involves taking such medications, then it is necessary to avoid exposure to sunlight during the treatment course, and wear only closed clothing.
• It is not recommended to visit solariums often, and it is even better to avoid such procedures altogether.
• It is necessary to take daily care of your facial skin and prevent the development of inflammatory processes, which will prevent the appearance of post-inflammatory spots.

Forecast

If you approach the treatment of melasma competently and comprehensively, the prognosis can be called favorable. For a speedy recovery, 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 when it is impossible to determine the origin of melasma, when the doctor's instructions are not followed. Some cases of lack of effect from treatment are also associated with the individual characteristics of the patient's body. However, in most cases the pathology can be cured.

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