Everything You Need To Know About Treating Melasma, By An Expert

Illustrated by Olivia Santner
Melasma, sometimes referred to as the 'mask of pregnancy' (which sounds kind of Zorro to me, but whatever), is possibly one of the most poorly understood skin conditions – at least by regular people, not doctors. Often grouped in with pigmentation and other kinds of sun spots, it’s actually a distinct condition with a unique set of characteristics and treatment.

"While melasma appears on the skin as a sort of pigmented patch, it is not simply pigmentation," explained consultant dermatologist Dr Mary Sommerlad. Now there’s a riddle. "It is its own entity from the kind of pigmentation you might get from acne scarring," she said. According to Dr Sommerlad, melasma has a very specific pattern that you don’t see with other kinds of pigmentation in that it appears on 'sun-exposed' prominences like the forehead, upper cheek and top of the collarbone. "It occurs most commonly in women but men do get it sometimes," added Dr Sommerlad. In darker skin tones, the patch will usually be your skin tone but darker; in fairer skin tones, it can have a slightly yellow or brown shade, rather than the pinkness or redness that scars can leave behind. It’s perhaps more noticeable in those with olive skin or lighter Asian skin tones, said Dr Sommerlad, but it can affect all skin tones and types. The patches are flat, not raised, and shouldn’t be itchy or sore. 
"If you took a biopsy of a patch of skin with melasma, you’d see that it has a very characteristic pattern, different to any other kind of pigmentation. A trained dermatologist would be able to identify it as melasma," said Dr Sommerlad. So what causes it? We don’t know for sure but there appears to be an interplay between some female hormones during pregnancy or while on hormonal contraception. "There are a lot of different theories but it’s most likely to do with progesterone and oestrogen," explained Dr Sommerlad. "There really is no consensus on what causes it exactly but one theory is that folate, which is produced by women during pregnancy, is destroyed by UV light, so your body produces more melanin in order to protect the folate," said Dr Sommerlad. "As such, you get these darker patches from sun exposure."

Oh yes – did you really think I wasn’t going to bring up the sun? One thing we know for sure about melasma is that sun exposure exacerbates it. Depending on your skin tone, melasma may not be very visible at all during the winter months but once you catch a little bit of sun, the patches will darken even more and become more visible. There isn’t a confirmed genetic link but if your mum or sister has developed it, it’s slightly more likely that you will, too. Generally speaking, it’s considered to be a hormonal condition more than anything else. 
So how can you manage it? "The first thing you need is the correct diagnosis," said Dr Sommerlad. This means speaking to your GP and asking for a dermatology referral, or making a dermatologist appointment privately if you can afford it. "Melasma is often trivialised as a cosmetic issue but it is a medical issue and needs to be addressed as such. It can cause a lot of distress," sympathised Dr Sommerlad. Of course, getting a dermatology referral is not always easy but if your GP refuses, you should ask them to make a note in your medical history that they refused a dermatology referral and why, and ask for an appointment with another doctor. There are also online dermatology services like Dermatica, where you can access prescription products and services after an online consultation – Dr Sommerlad is one of the dermatologists who offers services through them.
Then, according to Dr Sommerlad, it’s about induction of remission and maintenance of remission – basically, making it start to go away and keeping it from coming back. The most common treatments for melasma from a dermatologist include hydroquinone, which Dr Sommerlad said often gets a bad rap. Prescription-only in the UK, when used correctly and under the guidance of a consultant dermatologist, it treats melasma by stopping the production of an enzyme that causes melanin formation. It is often found in skin-bleaching creams, which is why it has a negative image, but Dr Sommerlad said it would not cause skin bleaching or lightening when used in the right concentration under medical supervision. Azelaic acid may also be given at a prescription-strength level, or retinoids, however, those aren’t safe during pregnancy or breastfeeding. Dr Sommerlad said she personally wouldn’t advise chemical peels for melasma as they are unlikely to offer the desired result, and said that vitamin C does brighten the skin and could help liven up the complexion but doesn’t necessarily treat melasma.
Once the melasma has been brought into remission, you’ll need to ensure it stays that way and by that I mean wearing a broad spectrum, high factor SPF every single day and avoiding sun exposure – I’m talking big hats and staying in the shade, people. Dr Sommerlad said that wearing a full coverage foundation will also help block visible light which can exacerbate melasma, and that your dermatologist or doctor may suggest changing your contraception if the melasma was triggered by something like the pill. Again, these are complex decisions and need to be made under medical supervision. 
I’m sorry I can’t give you more of a DIY answer but some things go above the pay grade of our favourite skincare products.
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