Melasma (Chloasma / "Mask of Pregnancy")

Definition & Epidemiology

• 90% of patients are women

• Most prevalent in Fitzpatrick skin types III-V: Hispanic, East/West/Southeast Asian, Middle Eastern, and Black individuals
• Subtle melasma (by UV light exam) seen in up to 30% of middle-aged Asian women
• Men are also affected, especially those from Central America
• The forearms are the second most common site after the face

Pathogenesis

1. UV / Sun Exposure (Primary Trigger)

• Melasma predominantly affects sun-exposed areas and worsens in summer
• Patients have a lower minimal erythema dose (MED) to UV light
• Affected skin shows increased solar elastosis compared to adjacent unaffected facial skin
• Melasma-affected skin has reduced WIF-1 (a Wnt antagonist), leading to increased Wnt signaling, which stimulates melanogenesis
• Number of melanocytic nevi correlates with melasma risk

2. Female Hormones (Second Trigger)

• Melasma occurs frequently during pregnancy, with oral contraceptive (OC) use, and hormone replacement therapy (HRT)
• Discontinuing OCs/HRT rarely clears the pigmentation - it can persist for years
• Melasma of pregnancy typically clears within months of delivery
• Also seen in other endocrinologic disorders and with phenytoin and finasteride therapy

Clinical Features

Classification by Melanin Location

Note: Most cases show both epidermal and dermal melanin on histology and confocal microscopy. Dermal deposits respond poorly to topical agents regardless of Wood's lamp findings - a therapeutic trial should be offered to all patients.

Differential Diagnosis

Treatment

Universal Recommendations (All Patients)

• Broad-spectrum sunscreen SPF ≥30 daily (ideally with zinc oxide or titanium dioxide as physical blocker)
• Sun-protective hats and clothing
• Camouflage makeup with iron oxide (blocks visible light, which also drives pigmentation)
• Avoid tanning beds
• Discontinue oral contraceptives if possible

First-Line Topical Therapies

• Triple combination (Kligman's formula): Hydroquinone (HQ) + retinoid (tretinoin) + topical corticosteroid - the most effective topical regimen available
  • Use 4% HQ (daily, typically bedtime); OTC formulations contain 2%
  • Twice-weekly application is effective for maintenance
  • Side effects of overuse: fixed erythema, telangiectasias, acneiform eruptions, hypertrichosis; exogenous ochronosis from HQ overuse
  • Typically used daily for 2-4 months, then tapered to 1-2x/week
• Azelaic acid 15-20%
• Tretinoin alone (less effective than HQ but beneficial)

Adjunctive Topical Therapies

• L-ascorbic acid 10-15%
• Kojic acid 1-4%
• Tranexamic acid 2-5%
• Niacinamide 4%

Adjunctive Oral Therapies

• Tranexamic acid 250 mg BID for 8-12 weeks - screen patients for thromboembolic risk factors before use

Second-Line Therapies

• Chemical peels: Glycolic acid (start 30%, increase as tolerated) or salicylic acid (20-30%) every 4-6 weeks
• Peels alone do not reproducibly enhance 4% HQ and can cause hyperpigmentation if irritation occurs

Third-Line Therapies (Procedural)

• Non-ablative fractional laser - improvement in 60% of skin types III-V with 75-100% improvement; may enhance HQ absorption via microscopic channels
• Intense pulsed light (IPL) - can improve melasma but has high relapse rate
• Low-fluence Q-switched lasers - Q-switched Nd:YAG can paradoxically increase pigmentation
• Picosecond lasers
• Er:YAG resurfacing - only temporary improvement, often followed by problematic postinflammatory hyperpigmentation
• Pulsed dye laser - may enhance topical combination treatment

⚠️ All light-based therapies should be approached with caution in darker skin types - complications include hyperpigmentation, hypopigmentation, irritation, and scarring. Always perform a test spot first.

Long-Term Maintenance

• Daily sunscreen + sun protection
• Topical retinoid
• Topical alpha-hydroxy acid (e.g., glycolic acid cream)
• Rotating adjunctive topicals: L-ascorbic acid, azelaic acid, kojic acid, tranexamic acid

Recent Evidence (2024-2025)

⚠️ Disclaimer: This is for educational/clinical reference only. Prescriptions must be individualized by a qualified dermatologist based on patient history, skin type, and contraindications.

Melasma - Sample Prescription

Rx

STEP 1 - Sun Protection (Mandatory, All Patients)

STEP 2 - First-Line: Triple Combination Cream (Gold Standard)

STEP 3 - Adjunctive Topicals (Add-on or Alternative to HQ)

STEP 4 - Oral Therapy (for moderate-severe or refractory cases)

STEP 5 - Procedural (Second/Third Line)

Key Prescribing Notes

1. Tretinoin is Category C in pregnancy - avoid. Use azelaic acid (safer) instead.
2. Hydroquinone is Schedule H in India - requires a valid prescription; do NOT use >4-6 months continuously to avoid exogenous ochronosis.
3. Triple combination cream: use class 5-7 topical steroid (mild-moderate strength like fluocinolone 0.01% or hydrocortisone 1%); avoid potent steroids.
4. Tranexamic acid oral - screen for DVT/PE risk, cardiac disease, or ongoing anticoagulant use before prescribing.
5. Always use iron oxide-containing makeup alongside sunscreen - visible light also drives melanogenesis.
6. Results take 3-6 months to appreciate. Set realistic patient expectations. Recurrence after stopping treatment is common.
7. Do a test patch before any laser/peel in skin type IV-VI.

• Melalite Forte (HQ 4%) at night + Aziderm 20% AM + Traxyl 250 mg BD x 8 weeks + daily SPF 50+ sunscreen

Face Washes for Melasma - Vitamin C & Niacinamide

💡 Note on face washes: Active ingredients like Vitamin C and Niacinamide have limited contact time in a cleanser (rinse-off product), so their benefit is less than serums/creams. However, they help prep skin, gently brighten, and reduce irritation from other actives.

Indian Brands

Dermatologist/Pharma Grade (India)

Top Pick for Melasma

🏆 Best Overall: Bioderma Pigmentbio Foaming Cream - specifically designed for hyperpigmented skin, contains Vitamin C + Niacinamide + Kojic acid (all 3 anti-pigmentation actives in one cleanser). Available at pharmacies and online (₹900-1100).

🏆 Best Budget: Minimalist 10% Vitamin C Face Wash - highest stable Vitamin C concentration in a cleanser at an affordable price point. Widely available online.

How to Use (Melasma Routine)