Melasma: Definition
Melasma is an acquired brown pigmentation of the facial skin that develops slowly and usually symmetrically, and is no accompanied by redness.  It can start spontaneously even in men but occurs often with pregnancy or with the use of oral contraceptives. Although melasma may affect people of any age, sex, or race, the condition is far more common in women.

Frequency
Melasma is found in 50% to 70% of pregnant women, with an onset usually during the second half of pregnancy.  It occurs in 20% of women taking birth control pills and this incidence is increasing.  It also can occur in women who are not on birth control pills and who have never been pregnant, and even occasionally occurring in children and men.

Cause

1. Estrogen levels during pregnancy and with oral contraceptives are the main stimulating cause but there must be exposure to the sun, either natural or from sun tan parlors, to induce the pigmentation. The genetic predisposition is found in at least 25% of patients.
2. Perfumed ingredients in cosmetics, creams, lotions, and cleansers have a significant role in melasma.  Therefore perfumed agents of any kind should not be used on the face or hands because of the photo reaction creating an exaggeration of the brown blotchiness from sun exposure.

Clinical Features
Melasma presents as a symmetrical, irregular but sharply limited brownish pigmentation of the face.  It can occur in a mask like pattern and therefore the old name “mask of pregnancy”.  The color can be very light to dark brown.  It starts out very subtle and innocent and with each year the exact area has a memory so with further sun exposure the area increase in it colo0r, getting darker and larger.

Treatment
There is no immediate cure and no preventative treatment that is absolute. Treatment is far from an exact science.

A. Preventative Measures

• If warnings to protect the skin from the sun are given early enough, many of the unwanted pigmentary changes can be minimized by using sun screens.  The best sunscreens available at the time will be discussed with you.
• Cosmetics or toiletry items that contain perfumes or scents of any kind should not be applied to patients who have a melasma tendency.  You can use colognes or perfume on your clothes but not on your skin.

B. Topical Therapy
Newer and better fading creams are coming on the market.  The best option for your type of melasma will be explained.

C. Chemical Peel
Very rarely will I recommend a chemical peel except for some of the lighter peels using 25% to 50% trichloroacetic acid or Alpha hydroxy acid peels.  This is done as an office procedure, but only in special cases. If you are a good candidate this will be discussed in detail.

D. Q-Switched Ruby Laser
A Q-Switched Ruby Laser is a special form of laser surgery that is essentially painless and selectively removes the excessive melanin – brown pigment from the skin and the normal skin color is left intact. There are no needles involved.  The Q-Switched Ruby Laser is a very expensive unit to own, operate and maintain. The cost of your treatment is your personal responsibility and would be discussed with you.

Patients who consider sun bathing a prerequisite part of their lifestyle are not encouraged to use treatment programs for melasma as the melasma has a high recurrence rate with sun exposure.  I believe that such patients do not understand the basic principles behind sun induced melasma and are not likely to benefit from the token use of faders and Retin-A peel combinations to lighten their skin.

The correct use of topical fading products is far from an exact science.  The treatment requires a motivated, disciplined patient with some lateral thinking ability, being able to adjust the treatment from twice a day to once a week depending on the patient’s clinical response.