Melasma exposed – what else can you do!
Updated: 12 january 2025
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 the blood vessels and nerves are located, and the subcutaneous fatty tissue.
Pigment is a brown dye that is 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 packed into pigment granules and thus delivered to the overlying epidermis cells. Only when the pigment is in the epidermis 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 breeds, pigment cells contain many more and much larger and mature pigment granules, and the epidermis cells are much more fully loaded with pigment granules than in whiter breeds. Ultraviolet Radiation (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 (= loss of elasticity in the skin due to UV rays), increased dilated vessels and leaking basement membrane. 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.
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.
Causing factors
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 to VI) is better protected against sun damage thanks to a higher content of melanin, this also carries an increased risk of pigment disorders such as melasma. A common problem in people with dark skin is post-inflammatory hyperpigmentation (PIH), a form of dark discoloration that occurs after inflammation or skin damage. This makes treatments such as lasers and chemical peels more challenging, as they can trigger or worsen PIH.
The high sensitivity to PIH in dark skin is explained by an overactive response of the melanocytes (the pigment-producing cells) to skin injury. This causes extra pigment to form more quickly. Therefore, it is essential to not only treat melasma, but also prevent and actively address PIH with the right remedies, such as mild chemical peels and depigmenting bleaching creams, to achieve improvement.
Read more about: Pigmentation spots after a skin condition
Vascular melasma – new phenomenon
Vascular melasma is distinguished from ‘normal’ melasma by the presence of an increased vascular component, meaning more blood vessels are involved in the affected skin areas. While traditional melasma is mainly characterized by an overproduction of melanin by melanocytes, vascular melasma leads to more visible redness or a purple hue due to the enlarged or increased blood vessels. The exact cause of this vascular component is complex and may be related to sun exposure.
Histological examination of tissues, also known as a biopsy, shows that vascular melasma is characterized by increased blood vessel formation. This can occur as a result of damage to the area between the epidermis and the dermis, often caused by sun exposure. This damage can trigger an immune response that leads to an increase in the number of blood vessels as part of the body’s natural repair process. This increased vascularity may contribute to the typical redness or purple hue that occurs in addition to the classic brown pigmentation in vascular melasma.
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 back into the sun and have a hormone imbalance, such as during 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.
In a randomized controlled trial of 40 Caucasian melasma patients, tinted sunscreen with iron oxides for visible blue light protection was found to provide better protection against melasma relapse than the same sunscreen without visible blue light protection.
Another study conducted by Castanedo-Cazares and colleagues also confirmed this. They looked at the effect of different types of sunscreen on people with melasma. In this double-blind, randomized study, participants were also divided into two groups: one group used a sunscreen that only protected against UV rays, while the other group used a broad-spectrum sunscreen that blocked both UV and near-visible light.
What turned out? The group that used a sunscreen with HEV protection – one that protects against both UVA/UVB and visible blue light – saw a clearly better improvement in their melasma than the group that only had UV protection. This confirms that near visible light, which you are constantly exposed to in everyday life, can have a greater impact on melasma than you might think.
More about mineral sunscreen and why we recommend it.
Melasma – a combined approach for lasting results
Melasma is a persistent skin condition that is difficult to treat. There is therefore no single treatment that is sufficient to fully control melasma. Instead, a combination of treatments is used, the aim of which is to reduce pigment spots, prevent new pigmentation and camouflage existing pigmentation. In addition, the right advice is needed to maintain the results achieved.
An integrated treatment approach
The treatments focus on different aspects of melasma:
- Preventing new pigmentation
The use of sun protection is essential to prevent worsening of melasma by UV radiation and near visible light. A sunscreen with broad protection against both UV and visible light is recommended. - Inhibiting pigmentation
Depigmenting creams such as hydroquinone and azelaic acid are often used to inhibit the production of new pigment. These products are usually applied to the pigment spots once or twice a day.- Hydroquinone is effective, but has a risk of side effects, including irritation. Recent research has also raised concerns about a possible increased risk of skin cancer with long-term use of hydroquinone.
- Azelaic acid is a safer alternative with fewer side effects and can also effectively reduce pigmentation.
- Arbutin is another safe alternative that works in a similar way to hydroquinone, but without the associated risks. The Targeted Pigment Serum from Iconic Elements contains arbutin and other active ingredients such as resveratrol, emblica, niacinamide and malic acid, which together help to reduce pigmentation and even out the skin.
- Removal of pigmentation
Techniques such as chemical peels, dermabrasion and lasers are used to remove existing pigment spots. Choosing the right laser is important, because some lasers (such as IPL) emit heat that can aggravate melasma.- The Picoway laser is one of the better choices because it reaches the deeper layers of the skin without unnecessary heat and can safely break down the pigment.
- Camouflage
In addition to medical and cosmetic treatments, the use of camouflage products can help to reduce the visibility of pigment spots, contributing to greater self-confidence in social situations.
Why a combination of treatments is necessary
Melasma is a chronic condition that has a tendency to recur. Therefore, a combined approach, in which both prevention and active treatment are applied, is necessary. Only through a combination of sun protection, whitening creams and advanced technologies such as the Picoway laser can the best and long-lasting results be achieved.
In addition, good guidance from a specialist is important.
Vascular melasma treatment
The treatment of vascular melasma largely follows the approach of normal melasma, first focusing on reducing pigment with a pigment laser, followed by the use of anti-pigment products and daily sun protection. For vascular melasma, an extra step is added: follow-up treatment with a vascular laser to address the increased blood vessels that contribute to the redness and purple coloring of the skin. This layered approach aims to effectively reduce both pigmentation and vascularity, the two hallmark aspects of vascular melasma.
What can you do at home?
Step 1: Mineral sunscreen with visible blue light protection
Start with mineral sun protection that offers protection against UVA, UVB and visible blue light. This protection must also have a high protection factor of 30 or 50. 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 becoming darker due to sunlight or visible light.
More about: why do the spots remain on my face despite sun protection
Step 2: Bleaching cream
In addition to the daytime sunscreen, it is advisable to use a night cream with niacinamide. Niacinamide downregulates melanogenesis. This means that less melanin is formed because melanosome transfer is inhibited. This prevents an abundance of melanin from being produced.
Spotreducer Cream is suitable for people with sensitive skin.
Our Targeted Pigment serum is suitable for people with normal or oily skin, it tackles pigment formation at different pigment levels. You can combine the serum with other Iconic Elements cream.
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Targeted Pigment Serum€49,95 -
Spotreducer (AWARD WINNING)€49,95
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%.
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Anti-Aging Cream€49,95
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.
Melasma and your mental well-being: more than just a skin problem
Survey conducted by Utrecht University of Applied Sciences skin therapy students
Loubna, Ouafae and Roos, third-year skin therapy students at Utrecht University of Applied Sciences, have delved into the impact of melasma on the quality of life of women for their research project. To better understand the experiences and needs of people with melasma, they conducted a survey. Their research shows that melasma is not only a physical problem, but can also have a major influence on how you feel.
Melasma can significantly affect your self-image. Many people report feeling insecure, which can lead to stress, anxiety or even feelings of depression. You may recognize the feeling that social situations are becoming more difficult or that you are constantly concerned with the appearance of your skin. This can significantly affect your daily life and mental well-being.
It is important to know that you are not alone. By talking about it with a dermatologist, therapist or people around you, you can better process these feelings and come up with a treatment plan that suits your personal situation. Your mental well-being is just as important as the physical recovery of your skin.
Scientific research confirms how important it is to pay attention to the mental side of melasma:
- Chen et al. (2024) show that as many as 43% of people with melasma experience feelings of depression. Healthcare providers are recommended to also take the mental aspect into account, as this not only improves your well-being, but can also ensure better treatment results.
- Zhu et al. (2022) describes how melasma can lead to avoidance behavior and obsessive focus on the skin. This can increase feelings of hopelessness and cause you to take less good care of your skin, making recovery more difficult.
To support you, skin therapy students have set up a Facebook group: “Stronger with Melasma”. Here you can share experiences, find support and receive practical tips in a safe environment. By sharing your story and learning from others, you can work on more mental resilience and better care for your skin.
Skin therapy initiative, closed Facebook group founded, called:
Stronger with Melasma
By addressing both the mental and physical impact of melasma, you can take steps towards a better quality of life. Don’t hesitate to talk to your healthcare provider and remember: you don’t have to do it alone.
While you are here
For many people, pigment spots are not just an innocent, cosmetic issue. Although at first glance they are only visible on the skin, they can have deeper effects on mental well-being and self-confidence. Various studies show that pigment spots, such as melasma, hyperpigmentation or post-inflammatory hyperpigmentation, can have a significant impact on how people feel in social situations and how they view themselves.
The psychological impact is often underestimated, but the effect can be significant. Many people with pigment spots experience feelings of insecurity, frustration and sometimes even depressive symptoms. Being constantly aware of the appearance of their skin can lead to avoidance behavior and an obsessive focus on skin care.
This is confirmed by a recent survey we conducted via Instagram, which shows that no fewer than 71% of participants indicate that pigment spots are more than just a cosmetic problem for them. This shows how important it is to pay attention not only to the physical aspect of pigment spots, but also to the mental well-being of people affected by them.
Would you like to know more about how pigment spots arise, what treatments are available and how you can deal with the psychological impact? Read more: Pigmentation is more than just a cosmetic problem
Literature:
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.
Boukari F, Jourdan E, Fontas E et al. Prevention of melasma relapses with sunscreen combining protection against UV and short wavelengths of visible light: a prospective randomized comparative trial. J Am Acad Dermatol 2015; 72: 189–90.e1.
Castanedo-Cazares JP, Hernandez-Blanco D, Carlos-Ortega B, Fuentes-Ahumada C, Torres-Álvarez B. Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Photodermatol Photoimmunol Photomed. 2014 Feb;30(1):35-42.
