Melasma Treatment: Latest Breakthroughs and Advances

Melasma(पोतो)  is a common skin condition that causes dark pigmentation typically on the face. Often referred to as the “mask of pregnancy,” it is harmless but can cause self-consciousness and affect a person’s quality of life. This article provides a comprehensive overview of the latest advancements in melasma treatment, drawing on recent studies, clinical trial and expert opinions.

Understanding Melasma

Melasma occurs when melanocytes, the cells responsible for producing pigment, become overactive. This leads to increased melanin production and the characteristic brown or grayish-brown patches³. Several factors contribute to melasma development, including:

• Sun Exposure: Ultraviolet (UV) radiation from the sun is a major trigger for melasma. It stimulates melanocytes and can worsen existing pigmentation.
• Hormonal Changes: Fluctuations in hormone levels, such as those occurring during pregnancy or with the use of hormonal contraceptives or hormone replacement therapy, can trigger melasma. Estrogen, in particular, has been found to stimulate melanocytes and increase melanin production⁴.
• Certain Medications: Some medications, including anti-seizure drugs, retinoids, and certain blood pressure medications, can cause melasma as a side effect.
• Genetic Predisposition: Individuals with a family history of melasma are more likely to develop the condition.
• Drug-Induced Melasma: Certain drugs can cause melasma, potentially due to various mechanisms like photosensitivity, focal melanocyte stimulation, or drug accumulation. A summary of some of these drugs and their potential mechanisms is provided in Table 1.
• Alcohol Consumption: A recent study suggests that alcohol consumption may be a contributing factor to melasma. More research is needed to confirm this link.

Melasma is more common in women, especially those with darker skin tones. While it was previously considered primarily a melanocyte disorder, recent research has shown that dermal components, such as mast cells, solar elastosis, and neovascularization, also play a role in its development.

Types of Melasma

Melasma can be categorized into three main types based on the depth of pigment deposition:

• Epidermal Melasma: The pigment is concentrated in the epidermis (the outermost layer of skin). This type typically has well-defined borders, appears dark brown, and responds well to treatment.
• Dermal Melasma: The pigment is located deeper in the dermis (the second layer of skin). It has ill-defined borders, appears light brown to blue-gray, and is generally less responsive to treatment.
• Mixed Melasma: This is the most common type, with pigment present in both the epidermis and dermis. It presents with a combination of colors and shows a partial response to treatment.

Understanding the type of melasma can help guide treatment decisions and set realistic expectations.

Treatment Modalities

Sun Protection

Protecting the skin from the sun is paramount in managing melasma. UV radiation can trigger melasma and worsen existing pigmentation. Dermatologists recommend the following sun protection measures:

• Sunscreen: Apply a broad-spectrum sunscreen with an SPF of 30 or higher every day, even on cloudy days. Sunscreens containing zinc oxide, titanium dioxide, or iron oxide offer enhanced protection against visible light, which can also contribute to melasma. Consider using a mineral sunscreen with a physical block like zinc oxide or titanium oxide in addition to chemical sunscreens for added protection.
• Protective Clothing: Wear protective clothing, such as wide-brimmed hats and sunglasses, when outdoors.
• Seek Shade: Limit sun exposure, especially during peak hours (10 am to 4 pm).
• Vitamin D Supplementation: If you are diligently limiting sun exposure, consider taking vitamin D supplements to ensure adequate levels.

Topical Therapies

Topical treatments are commonly used as the first line of treatment for melasma. They work by reducing melanin production, increasing skin cell turnover, and reducing inflammation. Some of the key topical agents include:

• Hydroquinone: This has been a mainstay in melasma treatment for decades. It works by inhibiting tyrosinase, the enzyme responsible for melanin production. However, concerns about potential side effects like ochronosis (a skin discoloration condition) and its ban in some countries have led to the exploration of alternatives.
• Triple Combination Creams: These combine hydroquinone, a retinoid (like tretinoin), and a corticosteroid to enhance efficacy. While effective, long-term use carries risks. This combination is often considered the most favorable topical treatment but long term use causes various skin damage from thinning of skin, redness of skin, hair growth etc.,
• Newer Topical Agents:
  • Azelaic Acid: A dicarboxylic acid that targets melanocytes and reduces inflammation. It is generally safe for skin of color.
• • Kojic Acid: A natural skin-lightening agent that inhibits tyrosinase and has antioxidant properties.
• • Cysteamine: An aminothiol that inhibits melanin production and promotes the conversion of eumelanin (dark brown pigment) to pheomelanin (reddish-yellow pigment). It also has antioxidant properties that help protect the skin from damage.
• • Thiamidol: A novel tyrosinase inhibitor that has shown promising results in reducing pigmentation.
• • Rucinol: A potent anti-tyrosinase botanical extract with comparable efficacy to hydroquinone.
• • Methimazole: Originally a thyroid medication, it inhibits peroxidase and alters melanocyte morphology.
• • Malassezin: A naturally occurring indole with potential skin-lightening effects.
• • Topical Tranexamic Acid: While oral tranexamic acid is more established, topical formulations are also being explored.
• • Isoniazid: A recent clinical trial demonstrated the efficacy of topical isoniazid in treating melasma. It is thought to work by inhibiting peroxidase in melanocytes.
• Other Beneficial Ingredients: In addition to the agents listed above, other ingredients like Vitamin C, Glycolic acid, Alpha-Arbutin, and Niacinamide can be helpful in treating melasma. These ingredients offer various benefits, such as protecting the skin from environmental stressors, inhibiting melanin production, breaking up discoloration, and soothing the skin.

Tranexamic Acid (Topical and Oral)

Tranexamic acid is an antifibrinolytic agent that has shown promising results in treating melasma. It works by inhibiting the activity of plasmin, an enzyme involved in inflammation and melanogenesis. Tranexamic acid can be used both topically and orally:

• Topical Tranexamic Acid: Topical formulations are being explored as a potentially safer alternative to oral tranexamic acid.
• Oral Tranexamic Acid: Oral tranexamic acid is particularly beneficial for moderate to severe melasma.

Oral Therapies

In addition to tranexamic acid, other oral therapies may be used to support melasma treatment:

• Oral Antioxidants: Supplements like green tea extracts, procyanidins, and zinc may help reduce oxidative stress, a contributing factor to melasma.
• Oral Photoprotecting Agents: Oral photoprotecting agents like Polypodium leucotomos extract offer systemic protection against UV-induced pigmentation.

Procedures

Several procedures can be used to treat melasma, either alone or in combination with topical therapies:

• Chemical Peels: These remove the outermost layer of skin, helping to reduce pigmentation. However, they require careful application, especially in darker skin tones, as they can potentially worsen pigmentation or cause scarring.
• Lasers and Light Therapies: Various lasers, including Q-switched Nd:YAG, fractional lasers, and intense pulsed light (IPL), can target melanin and improve melasma. However, they can have side effects and may not be suitable for all skin types. Lasers can also be used to enhance the delivery of topical treatments.
• Microneedling: This creates microscopic wounds in the skin, stimulating collagen production and potentially improving pigmentation. It can be combined with topical treatments for enhanced results.

Emerging Trends

The field of melasma treatment is constantly evolving. Some of the emerging trends include:

• Combination Therapies: Combining different modalities, such as topical agents with lasers or oral tranexamic acid with topical treatments, often yields better results.
• Personalized Treatment: Melasma is a heterogeneous condition, and treatment should be tailored to individual needs and risk factors.
• Focus on Dermal Component: Addressing the dermal changes associated with melasma, such as inflammation and vascular abnormalities, is gaining importance.
• Nanotechnology: Nanoparticles and other nanotechnology-based delivery systems are being explored to improve the efficacy and safety of topical treatments.

Key Takeaways

• Melasma is a complex condition with multiple contributing factors. Understanding these factors can help guide prevention and treatment strategies.
• Sun protection is essential in managing melasma. Consistent use of sunscreen, protective clothing, and shade is crucial.
• A variety of topical and oral treatments are available. These include traditional agents like hydroquinone, newer agents like thiamidol and rucinol, and oral therapies like tranexamic acid.
• Procedures such as chemical peels, lasers, and microneedling can be effective. However, they should be used with caution and tailored to individual needs.
• Combination therapies and personalized treatment plans often yield the best results.
• Melasma treatment requires patience, persistence, and realistic expectations.

Conclusion

Melasma treatment is an evolving field with ongoing research and development of new therapies. While challenges remain, a deeper understanding of the condition’s pathogenesis, combined with a personalized and multi-modal approach, offers hope for improved outcomes and a better quality of life for those affected by melasma.

Contact US:
If you’re in Kathmandu,Nepal contact Derma Clinic for proper melasma treatment from expert dermatologist of Melasma.
Call 9801358600 or Visit Derma Clinic at Basundhara Chowki to start you treatment.

Summary of Treatment Modalities

Table 1: Drug-Induced Melasma

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