Developing melasma or pekas has always been a concern among Filipinos. Even the elderly would rather treat their melasma more than their wrinkles. Many younger patients, however, will consult for this pigmentation problem.
I remember a patient of mine who noticed the hyper-pigmented spot above her lips—like a mustache—after a trip to Europe with her family. They were sightseeing in France at that time but got lost so they walked under the scorching heat of the sun. And since they were busy roaming around, she failed to reapply her sunscreen throughout the day.
When they got back to the Philippines, she found out that four of her cousins on both sides of the family suffer from melasma. It’s in their genes!
Everyone’s melasma journey is different. Its severity is actually dependent on many factors as well, so different people have different triggers, different severities, and different duration of achieving correction or improvement. The list of possible melasma triggers includes:
Sunlight. When sunlight hits our skin, it triggers the body to produce more melanin. This seems to explain why melasma develops on skin that gets the most sunlight, such as the skin on the face, arms, etc. UVA and UVB are the main radiations that induce melanogenesis. Infrared radiation (from lamps, fire, electrical heaters, thermal imaging cameras) and visible light (from computers, cellphones, microwave) have a significantly inferior melanogenic potential. Its role in the development and maintenance of melasma is unclear. However, the authors identified that nighttime workers exposed to the heat of ovens (e.g. bakers), and professionals exposed to a high intensity of light (e.g. dentists) experienced great difficulty in treating melasma and reported worsening after exposure to their working conditions.
The aim of melasma treatment is to eliminate already existing pigmentation and to block new pigmentation.
Pregnancy. An increase in the hormones estrogen and progesterone, which occurs during pregnancy, is thought to trigger melasma. If pregnancy is triggering melasma, it may clear up on its own. This often happens after a person gives birth or stops taking medications that trigger the melasma. Some of the medications that may trigger melasma include anti-seizure drugs, birth control pills, and medications that make your skin more sensitive to sunlight (like retinoids, some antibiotics, and some blood pressure medications).
Stress. Some patients report the onset of melasma after a stressful event and affective disorders (e.g. depression). Hormone propiomelanocortins (ACTH and MSH) are related to stress and can activate melanocortin receptors in melanocytes, inducing melanogenesis (increase in pigment formation).
Tanning beds. A tanning bed or sunlamp tends to produce stronger ultraviolet (UV) rays than sunlight. When you expose your skin to UV light, it triggers the body to produce more pigment. Sometimes, this pigment appears unevenly, causing blotchy patches and freckle-like spots of melasma.
Thyroid disease. Your thyroid is a gland located in your neck. It makes hormones that help your body with important jobs, including breaking down food you’ve eaten and regulating how fast your heart beats. If your thyroid gland develops a problem, this may increase fourfold your risk of developing melasma. Sometimes, treating the thyroid problem clears up the melasma.
Cosmetic procedures. Melasma can be triggered or aggravated by a cosmetic procedure that induces skin inflammation, like peels and therapies with laser/light. There is an increase in inflammatory mediators, inflammatory cells, and vascularity to damage skin, like in melasma. Melasma patients were found to have a six times greater chance of developing dark discoloration after an inflammation such as an injury from a cosmetic procedure.
The aim of melasma treatment is to eliminate already existing pigmentation and to block new pigmentation. Numerous treatment options are currently available for melasma. The choice of treatment options or their combination depends mainly on the type of melasma, effectiveness of prior treatments, and the expectations of the patient.
New regimens aim to shorten and simplify the treatment. Difficulties in treatment of melasma arise from the following:
- Melasma is often recalcitrant to treatment.
- High tendency for recurrence/reappearance if you stop maintenance regimen care
- Risk of adverse events
- Successful treatment requires long-term patient compliance, because therapeutic effects usually become evident after one to two months.
- Treatment costs
The basic principles of melasma treatment include retardation of the pigment-producing melanocytes, inhibition of the melanosome (which produces, stores, and transports melanin), and melanosome degradation.
- Bleaching agents. Recently the practice has been to use newer chemicals in new combinations, and complex mixtures of agents that target different mechanisms, like tyrosinase expression, the transfer of melanosomes, antioxidant, and anti-inflammatory effects.
- Chemical peels. These are selected according to the patient’s needs, skin type, and sensitivities.
- Laser and light therapies. Based on actual evidence, these treatments show the best response from light-skinned patients and are considered the third choice of management, as darkening or worsening of the discoloration remains the most important side effect of lasers and light. Recurrences are common and are seen in up to 50%.