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33 year old woman developed brown patches on her cheeks, upper lip and forehead after a day river inner-tube riding. She did not wear sunscreen. Her only medicines were birth control pills she started 2 months prior and a vitamin D supplement.

What’s your diagnosis?

Melasma case

Diagnosis: Melasma

Melasma is a condition where one develops dark brown and gray patches, most notably on the forehead, upper lip, nose, and cheeks. It may also occur on the forearms and neck. I consider melasma to be a very rapid, uneven suntan. Melasma can be extremely difficult to treat.

Who is most likely to experience melasma?

Melasma occurs in both men and women, although ninety percent of melasma cases occur in women. This condition that commonly occurs after pregnancy or after the use of birth-control pills, prescribed hormones, or on rare occasion, other medications.

What causes melasma?

Melasma is caused by a combination of genetics, hormones, and sun exposure. The cells in the skin that produce color are called melanocytes. For some unknown reason, melanocytes residing in the forehead, cheeks, upper lip, and sometimes forearms can become sensitized by hormones (again at times triggered by pregnancy and birth control pills) or certain medications. When this occurs, exposure of these areas to the sun causes a rapid production of melanin, the substance that darkens the skin. Melanin acts like an umbrella to protect the skin from additional sun exposure/damage. “Chloasma” is the old term for the dark patches that occur after pregnancy, and some call it “the mask of pregnancy.” The term melasma is now most commonly used. Melasma most notably appears on the forehead, upper lip, nose, and cheeks.

How is melasma diagnosed?

Melasma is easily diagnosed with pregnancy, medication history, timing of appearance, and location. There is a very rare type of birthmark that can look like melasma, and in cases where melasma is completely resistant to treatment, a biopsy may be needed to explore other potential diagnoses.

Can melasma be prevented?

Knowing one’s family history, predisposition for the condition, and as always, implementing good sun protection are essential to preventing melasma. I recommend a sunscreen that is broad-spectrum with a UV and SPF rating of 30. Sunscreens must be applied 30 minutes before going out in the sun and then reapplied every hour and more frequently if either perspiring or swimming.

How is melasma treated?

Melasma is notoriously difficult to treat. I use topical medicines either independently or in combination including hydroquinone, retinols, Kojic acid, and vitamin C. In addition to these measures, alpha-hydroxy acid chemical peels, deep melanage peels, and the use of the Pixel laser can also be helpful. Sometimes based on a patient’s genetics, the cells that produce color – melanocytes – reside deep in the skin. The medicines and lasers that are used to treat melasma can only penetrate so far and may not reach deeply enough for good treatment results. In about a quarter of all cases, even with our very best efforts, we cannot successfully treat melasma to the patient’s satisfaction. Also, it is important to note that even if we are successful in treating melasma, without meticulous sun protection it can return.

Action steps for anyone with melasma.

Patients must realize that this condition is best viewed as a chronic medical condition that needs a lifetime of attention or it will return or get worse. I recommend patients start with over-the-counter options. If these don’t work, see a board-certified dermatologist for other, stronger topical treatments and/or combination laser treatments with peels. Most importantly, if melasma is successfully treated, appropriate sunscreen must be used meticulously for a lifetime to prevent its recurrence.

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