Melasma is a common skin condition characterized by the development of brown or gray-brown patches, primarily on sun-exposed areas of the skin, such as the face. It is most frequently seen on the cheeks, forehead, nose, upper lip, and chin. While melasma can affect anyone, it is especially prevalent among women, particularly during their reproductive years, and individuals with darker skin tones. Though it is harmless from a medical standpoint, melasma can have a significant cosmetic and psychological impact due to its visibility on the skin. It is often called the "mask of pregnancy" when it appears in pregnant women.

Causes

The exact cause of melasma is not fully understood, but several contributing factors have been identified. The most significant triggers include:

• Sun exposure: Ultraviolet (UV) light from the sun stimulates melanocytes (pigment-producing cells) to produce more melanin, leading to the development of dark patches.
• Hormonal changes: Fluctuations in hormones, especially during pregnancy, use of oral contraceptives, or hormone replacement therapy, are major contributors to melasma.
• Genetic predisposition: Individuals with a family history of melasma are more likely to develop the condition.
• Skin type: People with darker skin types (Fitzpatrick skin types III–V) are more prone to melasma due to higher baseline melanin levels.
• Certain medications: Some drugs, including anti-seizure medications, may trigger melasma as a side effect.
• Cosmetic products: Skin irritation from certain cosmetics can worsen melasma in susceptible individuals.

Symptoms

The primary symptom of melasma is the appearance of blotchy, hyperpigmented patches on the skin. Common features include:

• Color: Patches are typically light brown to dark brown or gray-brown.
• Location: Most commonly found on the cheeks, bridge of the nose, forehead, chin, and above the upper lip. Less commonly, melasma can appear on the neck and forearms.
• Symmetry: Patches are often symmetrical, affecting both sides of the face in a similar distribution.
• No other symptoms: Melasma usually does not cause itching, pain, or discomfort.

Melasma is purely a pigmentary disorder and does not cause any systemic symptoms or lead to any serious health problems.

Diagnosis

Melasma is generally diagnosed through clinical examination. Dermatologists usually identify melasma based on the appearance and distribution of skin patches. Diagnostic steps may include:

• Physical examination: A visual inspection is usually sufficient for diagnosis.
• Wood’s lamp examination: This special light helps to determine the depth of pigmentation, whether it is epidermal, dermal, or mixed.
• Dermatoscopy: Sometimes used to further assess pigmentation patterns.
• Skin biopsy: Rarely needed but may be performed if the diagnosis is uncertain or to rule out other skin conditions.

It is crucial for clinicians to differentiate melasma from other causes of hyperpigmentation, such as post-inflammatory hyperpigmentation, lichen planus pigmentosus, or drug-induced pigmentation.

Treatment

Treatment of melasma can be challenging and often requires a combination of strategies. The primary goals are to lighten the dark patches, prevent worsening, and maintain results. Common treatment options include:

• Sun protection: The cornerstone of melasma management. Daily use of broad-spectrum sunscreen (SPF 30 or higher) with protection against UVA and visible light is essential. Wearing wide-brimmed hats and avoiding direct sun exposure also help.
• Topical depigmenting agents: Commonly used creams include hydroquinone, azelaic acid, kojic acid, and tranexamic acid. These agents help reduce melanin production.
• Combination creams: Triple combination creams containing hydroquinone, tretinoin, and a corticosteroid are considered highly effective for many patients.
• Chemical peels: Mild chemical peels such as glycolic acid may be used under professional supervision to enhance skin turnover and reduce pigmentation.
• Laser and light treatments: Procedures like low-fluence Q-switched lasers or fractional lasers may be used in select cases, though there is a risk of worsening pigmentation, especially in darker skin types.
• Oral medications: In some cases, oral tranexamic acid has shown benefits in reducing melasma but requires medical supervision due to potential side effects.

Treatment is often long-term, and maintenance therapy is needed to prevent recurrence. Consistency in sun protection and skincare routines is vital for sustained improvement.

Prognosis

Melasma is a chronic condition with a tendency for recurrence, especially when exposed to triggers like sunlight or hormonal fluctuations. With proper treatment and diligent sun protection, significant lightening of the dark patches can be achieved in many cases. However, complete and permanent clearance is rare. Some key points regarding prognosis include:

• Melasma tends to improve during winter months and worsen in summer due to increased sun exposure.
• Women who develop melasma during pregnancy (chloasma) may experience spontaneous fading within a few months postpartum, although in some cases it persists.
• Regular maintenance therapy with sunscreen and mild depigmenting agents is often required to maintain results.
• Early treatment and strict sun avoidance generally lead to better outcomes.

Overall, while melasma is a benign condition, it can have a considerable impact on quality of life, making early dermatological consultation and adherence to treatment regimens important.