What is Melasma?
Melasma, also called chloasma, is a skin condition with darks spots on the face, upper lip and mustache area. It is caused by an excess of the skin pigment melanin that appears on the cheeks, forehead, chest, back, and upper lip. This frustrating skin condition can be seen in men and women. It is usually caused by sun exposure, heat, and hormones. It is so common in pregnancy that it is often called the “mask of pregnancy”.
Melasma on the face is stubborn and often won't go away without a targeted skin care routine with skin lightening ingredients.
How to Diagnose Melasma
The definition of melasma is dark spots in sun exposed areas in people with a history of sun exposure, estrogen use, pregnancy, or heat exposure and no history of inflammation in the affected area.
You do not need a skin biopsy to diagnose melasma. It is usually diagnosed by history, location of the dark spots, hormone status (such as pregnancy or on estrogen or oral contraceptives), and by the color of the patches.
Melasma patches can be a grey/brown color but can be very dark in darker skin types.
Melasma can also occur in men but is less common. Melasma is almost always associated with increased estrogen levels. In men, a dark patch on the face is more likely to be PIH.
Types of Melasma
Melasma is a hyperpigmentation condition of uneven skin tone that occurs in sun exposed areas. When it happens in pregnancy, it is often called chloasma or "mask of pregnancy".
There are the different types of melasma:
- Brachial: This type of melasma occurs on your upper arms and shoulders.
- Centrofacial: With centrofacial melasma, brown spots appear on your cheeks, forehead, nose and upper lip.
- Lateral cheek pattern: Doctors diagnose you with lateral cheek pattern melasma if it appears on both cheeks.
- Malar: Malar melasma is when the spots appear on your nose and cheeks.
- Mandibular: The melasma occurs around your jawline with mandibular melasma.
- Neck: This melasma type occurs on any side of the neck.
Melasma Mustache
A "melasma mustache" refers to the hyperpigmented patches that appear on the upper lip region, mimicking the appearance of a mustache. This form of melasma is very common. Any time I see a dark patch above the lip I immediately think it is melasma but it is important to remember that other causes of hyperpigmentation of the upper lip are possible.
Inflammation leads to hyperpigmentation in a disorder called post-inflammatory hyperpigmentation or PIH. This means that any condition that causes inflammation on the upper lip can be misdiagnosed as a melasma mustache.
When you have dark patches on the upper lip, rule out the following:
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- Perioral dermatitis- a facial rash that tends cause a red ring that surrounds the mouth and can turn dark.
- Lip licking dermatitis
- Eczema around the mouth
- A substance on lip causing sun sensitivity such as an aftershave, cologne or perfume.
Melasma Causes
Melasma or chloasma occurs when the cells that make pigment in your skin, called melanocytes, increase the production of melanin pigment. There are many reasons this can happen but the most common causes of melasma are:
- Sun exposure
- Heat
- Inflammation
- Injury resulting in inflammation
- Estrogen
There are lots of studies looking at why these cause melasma, but the focus of research is on what turns the melanocyte on and makes it make more pigment?
These are the causes of the increased pigment production seen in melasma:
- Ultraviolet light stimulation of the protective tanning response
- Infrared heat
- Increase of melanocyte stimulating hormone
- Stimulation of the transcription factor p53 in the keratinocyte (epidermal skin cell)
Melasma and the Microbiome
Recent studies (14) have linked gut microbiota imbalances to various skin diseases, including psoriasis, atopic dermatitis, and acne. This imbalance can influence estrogen metabolism, with gut bacteria-produced β-glucuronidase enhancing estrogen reabsorption. Since melasma's development is tied to abnormal estrogen metabolism, understanding the gut-microbiota relationship is crucial. In a study comparing melasma patients to healthy subjects, 16S rRNA sequencing revealed significant differences in the abundance of certain bacteria, notably Collinsella spp., Actinomyces spp., Parabacteroides spp., and others. Many of these bacteria are associated with β-glucuronidase production and estrogen regulation. Alterations in gut microbiota, particularly the presence of Collinsella spp., may influence melasma development by impacting estrogen metabolism. This research offers insights for future melasma studies and potential treatment avenues.
Melasma in Dark Skin
Melasma in dark skin is harder to treat. One reason is that dark skin types have more melanin granules in the skin and they are harder to get rid of because there are more.
The other reason it is harder to clear melasma in dark brown or black skin is skin lightening treatments can cause a halo affect around the treated dark spot. This halo is a light colored ring surrounding the dark melasma spot.
Why Is Melasma Hard To Treat?
Melasma is hard to treat because it is caused by things we cannot avoid: such as light, sun, heat, stress and hormones. Our face is exposed to these on a daily basis.
There is no cure for melasma, but it can be controlled by changing your lifestyle habits and using the correct melasma skincare routine consistently.
Melasma on the chest
Melasma can occur in any sun exposed are such as the chest. However, it is more likely that dark spots on your chest are caused by phytophotodermatitis or fragrances and cologne that make you sun sensitive.
Look at the pattern o the dark spots on your chest. Do they look like fingerprints? Or are they in an aerosolized pattern like cologne would cause? If so, this may be due to a substance that increased the skin's ability to tan upon sun exposure such as foods like celery, limes, or figs or perfumes or colognes.
Melasma on the back
Melasma is uncommon on the back unless you get a large amount of sun exposure on your back.
If your back is itchy, the dark spots on your back may not be melasma.
Notalgia paresthetica (NP) is a sensory neuropathic syndrome of the back, typically the upper to mid-thoracic region, characterized by localized pruritus (itching) in the affected area. This chronic condition can result from nerve impingement or damage to the posterior rami of the spinal nerves. The itching sensation is described as a burning or prickly itch that is difficult to reach and relieve. Chronic scratching or rubbing of the area in an attempt to alleviate this itch can lead to post-inflammatory hyperpigmentation which resembles melasma. If you have notalgia paresthetica, using soothing anti-inflammatory ingredients and barrier repair moisturizers and oral antihistamines to relive the itch are more important than using skin lighteners to lighten the dark spots on the back.
Melasma and self esteem
Many studies have shown that melasma is stressful and can affect self esteem.
Let us help you treat your hyperpigmentation and build the best skin lightening care routine for your Baumann Skin Type.
Dr. Leslie Baumann MD, FAAD
Best References and Scientific Publications on Melasma:
- Gutierrez, D. Ch. 20 Skin Pigmentation Disorders in Baumann's Cosmetic Dermatology 3rd edition (McGraw Hill 2022)
- Baumann, L Ch. 14 Uneven Skin Tone in Baumann's Cosmetic Dermatology 3rd edition (McGraw Hill 2022)
- Baumann, L Ch. 32 and 33 in Baumann, L Cosmeceuticals and Cosmetic ingredients (McGraw Hill 2015)
- Pawaskar MD, Parikh P, Markowski T, McMichael AJ, Feldman SR, Balkrishnan R. Melasma and its impact on health-related quality of life in Hispanic women. J Dermatolog Treat. 2007;18(1):5-9.
- Freitag FM, Cestari TF, Leopoldo LR, Paludo P, Boza JC. Effect of melasma on quality of life in a sample of women living in southern Brazil. J Eur Acad Dermatol Venereol. 2008;22(6):655-62
- Yalamanchili R, Shastry V, Betkerur J. Clinico-epidemiological Study and Quality of Life Assessment in Melasma. Indian J Dermatol. 2015;60(5):519.
- Jiang J, Akinseye O, Tovar-Garza A, Pandya AG. The effect of melasma on self-esteem: A pilot study. Int J Womens Dermatol. 2017;4(1):38-42.
- Grimes, P. E. (1995). Melasma: etiologic and therapeutic considerations. Archives of dermatology, 131(12), 1453-1457.
- Kim, E. H., Kim, Y. C., Lee, E. S., & Kang, H. Y. (2007). The vascular characteristics of melasma. Journal of dermatological science, 46(2), 111-116.
- Espósito, A. C. C., Cassiano, D. P., da Silva, C. N., Lima, P. B., Dias, J. A., Hassun, K., ... & Miot, H. A. (2022). Update on Melasma—Part I: Pathogenesis. Dermatology and Therapy, 12(9), 1967-1988.
- Zhu, Y., Zeng, X., Ying, J., Cai, Y., Qiu, Y., & Xiang, W. (2022). Evaluating the quality of life among melasma patients using the MELASQoL scale: A systematic review and meta-analysis. PLoS One, 17(1), e0262833.
- Yang, J., Zeng, J., & Lu, J. (2022). Mechanisms of ultraviolet‐induced melasma formation: A review. The Journal of Dermatology, 49(12), 1201-1210.
- Phansuk, K., Vachiramon, V., Jurairattanaporn, N., Chanprapaph, K., & Rattananukrom, T. (2022). Dermal pathology in melasma: an update review. Clinical, Cosmetic and Investigational Dermatology, 11-19.
- Liu, C., He, D., Yu, A., Deng, Y., Wang, L., & Song, Z. (2022). Correlation analysis between gut microbiota characteristics and melasma. Frontiers in Microbiology, 13, 1051653.
- Box, N. F., & Terzian, T. (2008). The role of p53 in pigmentation, tanning and melanoma. Pigment cell & melanoma research, 21(5), 525-533.
