Often referred to as the “mask of pregnancy,” melasma is an acquired hyper-pigmentation that occurs exclusively in sun-exposed areas, mostly on the face. Its occurrence is found more in Latins and Asians. With 10 per cent of the total cases reported in men, the disease is mainly encountered in women, especially during the

stage of conception. The causes of melasma include sun-exposure, genetic factors, medications like anti-convulsants (given for seizures) and oral contraceptives as well as hormonal disturbances.
Melasma appears as asymmetrical brownish spots on the cheeks, forehead, nose and upper lip. It may very rarely affect the mandibular (chin) area and forearms. The condition is frustrating both for the patient and the doctor as it is chronic, recurrent and not very amendable to treatment.

What causes melasma?
The rarity of melasma in post-menopausal women on estrogen replacement therapy suggests that estrogen alone is not the causative agent. An excess of estrogen receptors have been found in people who have melasma. However, sun exposure plays a vital role in the exacerbation of melasma, especially in those who have periods of prolonged sun exposure which can worsen the pigmentation. The affliction is less likely in the winter season.
The response to treatment is slow and varies from person to person and is based on the severity, duration, depth of the pigment and occupation of the person (with regard to sun exposure).
Remedies at hand
Various treatments for melasma are available and should be instituted by the dermatologist. The choice of treatment depends on the depth of the pigment and the sensitivity of the individual’s skin. Dermal melasma does not respond well to treatment. It normally takes two months to see a response and it can take up to six months to clear. The most commonly used and effective drug is Hydroquinone 2-4 per cent applied locally alone or in combination with Tretinoin 0.025 per cent to 0.05 per cent and topical corticosteroids, called the triple combination. This treatment can be irritating, and has to be applied with caution and explained to the patient. During pregnancy the above mentioned treatment should be avoided, especially Tretinoin.
Strict sun avoidance is necessary during the treatment period. Other topical treatments which prevent melanin synthesis and thus pigmentation are Azeliac Acid, Kojic Acid, Glycolic Aacid, Niacinamide, vitamin C and Arbutin. Botanicals such as isoflavones, mulberry extract, licorice extract (glabridin) can be used during pregnancy.
Chemical peels undertaken by a trained professional are useful as adjunctive treatments to the applications and in people where there is no response with topicals. Dermabrasion and lasers like Q-switched ruby, Nd:Yag, Medlite, CO2 have been tried with temporary results and sometimes rebound pigmentation.
Oral proanthocyanidin-grape seed extract and antioxidants have shown some benefit. All said and done, the treatment of melasma is prolonged and only partially effective. Dedicated patient compliance and photo-protection are keys to successful treatment. And as melasma can be cosmetically disfiguring, a multi-modal approach is often required along with patient counselling.

The writer is Senior Consultant, Dermatology and Aesthetic Medicine, Max Hospital