Dionne, our skin therapist & Iconic Elements team member, tells more about this.
Melasma, also known as pregnancy mask, is a pigment disorder characterized by symmetrical, pigmented maculae. Macula is Latin for spot. In dermatology, this term is used to indicate a non-elevated color change of the skin. Because melasma is located in the face, it is often experienced as cosmetically disturbing and can even lead to psychosocial and emotional stress.
What is pigment and how does it arise?
The skin consists of three layers, the upper epidermis (0.5-1 mm thick), the deeper dermis (1-2 mm) where, among other things, the blood vessels and nerves are located, and the subcutaneous fatty tissue.
Pigment is a brown dye produced by the pigment cells (melanocytes) located in the lower layer of the epidermis. They are located relatively superficially in the skin. In the pigment cell, the pigment is packaged in pigment granules and delivered to the overlying epidermis cells. Only when the pigment is in the epidermal cells is the skin visibly pigmented.
Pigment production in the skin
Every person, white or dark, young or old, has approximately the same number of pigment cells per unit area. The activity of these pigment cells and the quantity, maturity and size of the pigment granules determine a person’s skin color, as well as the color of the hair and eyes. In darker races, pigment cells contain much more and much larger and more mature pigment granules, and the epidermal cells are much more fully loaded with pigment granules than in whiter races. (Artificial) UV radiation increases the number of active pigment cells and pigment production. The result is a brown discoloration of the skin.
How Does Melasma Occur?
The pigment cells are used to produce pigment by hormones or (artificial) UV rays. When these pigment cells start to produce too much and too local pigment, hyperpigmentation occurs. Melasma is a form of that. Hyperpigmentation occurs when there is an increase in pigment in the skin. The skin produces more pigment and/or the number of pigment cells in the skin increases.
In addition to pigment cells, there are indications that more cells in the skin are involved. Also consider keratinocytes (skin cells), fibroblasts (connective tissue cell involved in the production of collagen, hyaluronic acid, elastin in the dermis), endothelial cells (blood vessel cells). These ‘stimulated’ cells by UV, hormones can stimulate pigment cells.
What Dr. Wu notices is that people with melasma have had many sun exposures (outdoor activities, sun holidays), tanning beds in the past. Tissue research (when you look at a piece of skin sample under the microscope) shows solar elastosis (= elasticity loss in the skin due to UV rays), increased dilated vessels and leaking basal membrane (see below basal layer). The latter is the transition between the horny layer (epidermis) and the dermis (dermis). This layer is damaged by UV rays, causing the pigment to ‘leak’ into the dermis.
Skin layers: epidermis, dermis and subcutaneous fat.
Melasma is easy to recognize by specific preferred locations. Melasma mainly occurs on the forehead, cheeks, temples, around the eyes and on the upper lip. In addition, the spots often occur symmetrically on the face.
The worldwide prevalence of melasma varies from 8.8% to 40% in various studies. This is based on the composition of the population, skin type and intensity of exposure to UV radiation. Melasma mainly occurs in women of childbearing age. Pregnancy is seen as one of the main triggering factors. But pill use with oestrogens, for example, can also play a role. The spots that arise can disappear after pregnancy or after stopping the birth control pill, but unfortunately this is not always the case. UV radiation also plays a major role. All these factors can lead to an increased activity of pigment cells.
NEW is the discovery of a protein called “OPSIN3” in melanocytes. This protein reacts to high-energy visible blue light. People with skin type III (brown eyes and brown hair) and darker can get melasma without coming into contact with UV sunlight.
Opsin3 is a protein in your melanocytes, stimulates pigment through visible blue light – without UV rays
dr. Francis Wu
Although dark skin (Fitzpatrick types IV through VI – for more information on skin pigment) provides better protection against sun damage, it is in itself a risk factor for pigmentary disorders such as melasma. In addition, the propensity for post-inflammatory hyperpigmentation (PIH) is a major limiting factor for treatment procedures such as lasers and chemical peels. The high incidence of PIH in dark skin has been attributed to the deficient pathophysiological response to skin injury, which subsequently leads to increased melanocyte activity. Therefore, prevention and management of PIH after treatment with various agents, including chemical peels, is of paramount importance in the treatment of melasma in dark skin.
Read more about: Pigmentation spots after a skin condition
How Do You Treat Melasma?
Treating melasma is a difficult and often lengthy process. The deeper the pigment is in the skin, the worse the prognosis can be. Superficial pigment (epidermis) is easier to treat than deeper pigment (dermis). Unfortunately, treatment is often not permanent, but recurrence can often be seen. Especially when people go out into the sun again and have hormone imbalances such as pregnancy or menopause. Applying a daily mineral sunscreen with a high protection factor is therefore a must. Mineral sunscreen has broad UV coverage (both UVA and UVB) and also captures some of the visible blue light.
More about mineral sunscreen and why we recommend it.
Mineral sunscreen Iconic Elements
In addition, several treatment methods are used to achieve the best result. Current treatments include topical and systemic agents, such as chemical peels and laser- and light-based therapies. Treatment aims to improve existing lesions and prevent recurrence. Hydroquinone is a topical therapy that is commonly used and is considered the gold standard in many countries.
Unfortunately, hydroquinone also has some disadvantages, such as the fact that you can only use it for a short time and that it can irritate the skin considerably. Various other treatment methods that can be used for melasma are: azelaic acid, tretinoin, peels, dermabrasion and IPL or the picolaser. These treatments are aimed at inhibiting melanin synthesis and/or normalizing melanin distribution.
As mentioned above, melasma is difficult to treat. There is therefore not a single treatment that is performed. Combination treatments are used during the process. These treatments are aimed at preventing pigmentation, inhibiting pigmentation, removing pigmentation and camouflaging the pigmentation. In addition, the right advice is crucial to maintain the results.
The Picoway laser is currently one of the better lasers to treat melasma. With IPL and other types, unnecessary heat is often injected into the skin, which can trigger the melasma. The picoway laser does not do this and can safely reach the deeper skin layers.
In addition to the laser treatment, the bleaching products inhibit pigmentation and prevent new hyperpigmentation. Hydroquinone/azelaic acid are the most commonly used depigmentation agents. Both creams can be applied to the pigment spots once or twice a day. Unfortunately, these creams are not without side effects. But when you compare both creams in the pharmacotherapeutic compass, the list of side effects of azelaic acid is considerably shorter than that of hydroquinone.
Another option is to cover the melasma with medical camouflage products. Lycogel is one of the best-known products and has a wide range in the field of camouflage. A product is available for every skin tone / skin type. These products are mineral based and immediately offer complete sun protection. However, the disadvantage is that this has to be repeated every day and the melasma is not reduced.
What can you do at home?
Step 1: Mineral sunscreen
Start with a mineral sun protection that offers protection against both UVA and UVB, in addition, this protection must have a high protection factor of 30 or 50, containing antioxidants. Apply this protection daily and repeat it several times a day, this is most important in case of (sensitivity to) melasma. This prevents the pigment spot from darkening due to sunlight or visible light.
Step 2: Night cream with Niacinamide
In addition to the sunscreen for the day, it is advisable to use a night cream with niacinamide. Niacinamide down-regulates melanogenesis. This means that less melanin is formed because the melanosomes transfer is inhibited. This prevents an overabundance of melanin from being produced.
Step 3: Any combination of ingredients
In combination with vitamins C and E, niacinamide is perfect for use on skin pigmentations. This composition has been proven effective with too much pigment in the skin, provided that it is used in the right concentration. For example, niacinamide is effective at a percentage of 5%, vitamin E at at least 1% and vitamin C at at least 4%.
Melasma pigmentation can sometimes be deep in the skin and will not disappear with the cream alone. In addition, every skin / melasma is different and every skin reacts differently, so be well informed with a skin therapist / dermatologist.
Hakozaki T, Minwalla L, Zhuang J, et al. The effect of niacinamide on reducing cutaneous pigmentation and suppression of melanosome transfer. The British Journal of Dermatology. 2002 Jul;147(1):20-31.
McKesey, J., Tovar-Garza, A., & Pandya, A. G. (2019). Melasma Treatment: An Evidence-Based Review. American Journal of Clinical Dermatology.
Sarkar, R., Bansal, S., & Garg, V. K. (2012). Chemical peels for melasma in dark-skinned patients. Journal of cutaneous and aesthetic surgery, 5(4), 247–253.
Bronzina E, Clement A, Marie B, Fook Chong KT, Faure P, Passeron T. Efficacy and tolerability on melasma of a topical cosmetic product acting on melanocytes, fibroblasts and endothelial cells: a randomized comparative trial against 4% hydroquinone. J Eur Acad Dermatol Venereol. 2020;34(4):897-903.
While you are here
Pigmentation is not only a cosmetic problem, a study shows that people can suffer psychologically. Read more about pigment and psychological impact.
Below is a survey on instagram: 71% recognize the problem that pigment spots are more than just a cosmetic problem.