Melasma: Understanding Dark Spots on the Face

Melasma is a skin condition in which patches of brown spots appear on the skin. Those patches—also known as hyperpigmentation, a general term for skin discoloration—tend to appear on the cheeks, chin, forehead, nose, and upper lip.

While it can affect anyone, melasma most commonly occurs in people with dark skin tones. It often appears during pregnancy as well. Melasma is so common during pregnancy that it's also known as the "mask of pregnancy."

Although the patches may cause concern, melasma isn't dangerous. You can treat the condition for cosmetic reasons, but you don't have to. Sun protection is key to reduce the appearance and prevent melasma,.

Types of Melasma

There are different types of melasma, which vary by what skin layer it affects.

The skin is made up of three layers: the epidermis, dermis, and hypodermis. The epidermis is the outermost layer of the skin, which protects your body and produces melanin. Melanin is the pigment in your skin. 

Then, the dermis, the middle layer of skin, consists of sweat glands, hair follicles, sensory neurons, and blood vessels. The hypodermis is the innermost layer of skin, which stores fat and energy.

Epidermal

Epidermal melasma affects the epidermis. Melanocytes, which are skin cells that produce melanin, enlarge. As a result, dark patches appear on the skin.

Dermal

Dermal melasma affects the dermis. Some evidence suggests that dermal melasma also causes thick yellow skin that wrinkles. Dermal melasma may increase blood vessels in the dermis.

Mixed

Mixed melasma is a combination of both epidermal and dermal melasma. This is indicated by dark patches of skin that affect the epidermis and dermis.

Melasma Symptoms

Melasma causes dark patches of skin. Most commonly, melasma appears on the cheeks, chin, forehead, nose, and upper lip. Still, people may notice melasma on their jawline, neck, and arms. In people with lighter skin tones, melasma may appear brown. People with darker skin tones may notice bluish-gray patches.

Characteristics of melasma include:

• Patches that appear darker than your natural skin color
• Symmetrical patches (e.g., patches that develop on both sides of the face)
• Large patches of darker skin
• May appear more prominent on certain body parts than others (i.e., the jawline)

In addition to skin color changes, melasma may lower self-esteem. Some people with skin conditions that alter their appearance have a high risk of anxiety and depression.

What Causes Melasma?

There are several why melasma occurs, such as:

• Sun exposure: The sun's ultraviolet (UV) rays play a primary role in all types of hyperpigmentation, including melasma. UV rays, as well as visible light and heat, activate melanocytes to make more melanin. 
• Tanning beds: Using tanning beds exposes you to artificial UV rays that are stronger than the sun's UV rays.
• Pregnancy: The hormone component sets melasma apart from other types of hyperpigmentation. More specifically, estrogen and progesterone are the culprits. Those hormones rise during pregnancy. Similarly, birth control pills and hormone replacement therapies can also trigger melasma.
• Certain medicines: Like pregnancy, birth control pills and hormone replacement therapies can trigger melasma by increasing estrogen and progesterone. Some retinoids, antibiotics, and blood pressure medicines make your skin sensitive to the sun's UV rays. In addition, certain anti-seizure drugs may trigger melasma.
• Stress: In some cases, stress triggers melasma by increasing cortisol levels.
• Thyroid dysfunction: Typically, your thyroid makes hormones that regulate your metabolism and heart rate. An underactive or overactive thyroid may trigger melasma.

Risk Factors

Anyone can develop melasma. However, some people have a higher risk than others. 

Specifically, melasma risk factors include:

• Sex: The hormones estrogen and progesterone trigger melasma. The condition is more common in those assigned female at birth.
• Skin tone: People with dark skin tones make more melanin than others. 
• Family history: Having blood relatives with melasma also increases your risk.

Diagnosis

A healthcare provider can diagnose melasma by examining your skin. 

Sometimes, a healthcare provider may use a Wood lamp to look closely at the affected area. The healthcare provider will hold the Wood lamp about five inches away from your skin in a dark room. The Wood lamp shines UV light on your skin, which helps examine skin color changes.

Your healthcare provider may also order blood tests to check your hormone levels. A blood test can tell whether thyroid dysfunction, pregnancy, or oral contraceptives contribute to melasma.

Lastly, if the healthcare provider cannot confirm melasma, they will take steps to rule out other skin conditions. For example, they may obtain a sample of your skin for biopsy.

Treatments for Melasma

With melasma, treatment goals include reducing melanin production and evening out your skin tone. The time it takes to achieve those goals varies. However, you may see results within three to 12 months.

Some melasma treatments include:

• Sun protection: Wear a water-resistant, broad-spectrum sunscreen with an SPF of 30 or more daily. Specifically, sunscreens with zinc oxide, titanium dioxide, and iron oxide help with melasma. Sun protection can help reduce the appearance of and prevent melasma.
• Medicines: Hydroquinone helps even out your skin tone. A healthcare provider may also recommend tretinoin and a mild corticosteroid. In some cases, they may advise using a cream that consists of all three ingredients. Other medicines include azelaic acid, kojic acid, and vitamin C.
• Chemical peels: These lift off some of the surface pigment.
• Microneedling: This increases the absorption and efficacy of topical medicines.
• Lasers: Using heat, this treatment targets and breaks up pigment. Though, heat can also trigger melasma. Therefore, lasers that don't generate too much heat are key to treating the condition. 
• Platelet-rich plasma: A healthcare provider injects your blood plasma into the affected area with this procedure. 
• Tranexamic acid: For severe cases of melasma, a healthcare provider may advise using tranexamic acid. This medicine is available as a topical or oral solution. 

Additionally, you can conceal melasma with makeup. A healthcare provider may advise first applying your medicine, then sunscreen. Lastly, apply any makeup to conceal the affected area.

How To Prevent Melasma

You cannot modify some risk factors, like family history or natural skin tone. However, one risk factor that you can control is sun exposure. 

Protecting yourself from the sun's UV rays is one of the best ways to prevent melasma. So, use a water-resistant, broad-spectrum sunscreen with SPF 30 or more daily, reapplying at least every two hours in the sun. 

Also, wear broad-rimmed hats, seek shade, and avoid the sun as much as possible. Not using tanning beds is key, as well.

Comorbid Conditions

Melasma may increase the risk of or cooccur with certain health conditions, such as:

• Hormone imbalance: High estrogen and progesterone levels increase the risk of melasma. People who are pregnant, taking birth control pills, or undergoing hormone therapy during menopause have a higher risk of melasma than others. For example, pregnancy accounts for as many as 56% of melasma cases.
• Anxiety: Research has found that anxiety rates are high among people with skin conditions. In fact, about 11.6% of people with melasma have anxiety.
• Depression: Besides anxiety, some evidence suggests that melasma affects self-esteem, causing depression symptoms.

Living With Melasma

Melasma is not a fatal, or even harmful, condition. Researchers have not found any malignant cases of melasma. In fact, some evidence suggests that melasma might lower the risk of melanoma, a severe type of skin cancer.

Keep in mind that it may take time for melasma to reduce after stopping hormone medicines or giving birth. Also, melasma may return if you start taking those medicines or get pregnant again.

All in all, one of the best ways to minimize melasma is to lower sun exposure. Research has found that avoiding the sun's UV rays can help reduce the appearance of melasma and prevent it from returning.