Melasma is a buildup of melanin, the pigment that gives skin its color, which results in grey to brown patches most commonly on the cheeks, forehead, and chin. Although it can occur in both sexes in people of all ethnicities, it is more commonly seen in women and those with darker complexions. Melasma is worsened by high levels of estrogen particularly in pregnancy. The patches usually develop slowly and symmetrically, and can last for many years. Pregnancy related melasma often improves after delivery but sometimes the pigment can be very stubborn. An ounce of prevention is worth a pound of cure here so religious use of a good sunscreen is the most important thing. However, sometimes you need something stronger. In part one we discussed the causes and standard treatments for melasma. Here, we will discuss natural treatments for melasma as well as the use of chemical peels and dermabrasion.
Kojic acid is natural compound produced by a Japanese fungus. It is not a formally approved treatment for melasma but kojic acid has been shown to inhibit pigment production in small trials. It probably is not strong enough by itself, but those who do not respond to hydroquinone alone may benefit from the addition of kojic acid. One randomized study of 39 patients with facial hyper-pigmentation showed that kojic acid and 2% HQ (the over the counter strength) are similarly effective in melasma. Almost every patient experienced burning and peeling at first; however, kojic acid was thought to be slightly more irritating. Another study of 40 Chinese women found that melasma cleared in 60% of patients using combined kojic acid and hydroquinone 2% compared to 48% of patients using hydroquinone alone. However, neither formulation was effective in clearing the melasma up completely. All patients in the kojic acid gorup experienced redness, stinging, and mild peeling. Kojic acid has not been formally evaluated for safety during pregnancy so it is probably best avoided until after delivery.
Vitamin C (ascorbic acid) is an antioxidant most commonly found in citrus fruit. One study examined vitamin C as a treatment in 29 women with melasma. Vitamin C solution was applied to one half of the face and distilled water was applied to the other half. After 12 weeks of treatment, there was a clinically significant reduction in darkness on the treated side compared to the control side. Importantly, the researchers used something called iontophoresis, which is basically applying a mild electrical current to help move the vitamin C into the skin. So, it’s not clear how effective a cream with vitamin C would be without it.
Pycnogenol is a French maritime pine bark extract, containing a variety of molecules that have both antioxidant and anti-inflammatory properties. Because sunlight can cause redness and inflammation, which can worsen melasma, it is a potentially attractive, all natural treatment option. A 30-day trial of 30 women found that Pycnogenol (25 mg) administered by mouth 3 times daily decreased the average pigment intensity and the average melasma area compared to placebo. There were no side effects observed during the treatment. The tolerability of the drug was good and it was considered safe. Again, no safety information exists for pregnant women, so pycnogenol should not be consumed until after delivery.
The way chemical peeling agents work is by physically removing melanin, rather than by inhibiting pigment production the way that the other treatments work. Peels are usually well tolerated by individuals with lighter complexions; however, dermatologists need to be careful when performing chemical peels in skin of color because of the risk of aggravating the melasma. Superficial peels, which only work on the very top of the skin, have the lowest risk of adverse effects, but still sometimes cause hyper-pigmentation. All peels cause some redness and iritation, which is to be expected for up to a week after treatment. Although several peeling agents have been studied for the treatment of melasma, glycolic acid is by far the most popular. It is easy to use, generally safe, requires little to no downtime, scarring is uncommon, and post-peel hyper-pigmentation or persistent redness is rarely seen.
Glycolic acid is commonly used as an ingredient (usually around 10% concentration) in skin-lightening creams. It is used at around 15-20% as a peeling agent. Glycolic acid can be added on to other treatments described in this article and part 1. For example, one 26-week study looked at 10 Asian women who were treated with GA peels 20% every 3 weeks on one side of the face and a hydroquinone 2% plus glycolic acid 10% cream applied to both sides. At study end, the side treated with the peels was lighter compared to the other side in all patients. Some stinging and redness was experienced during and after each peel. In the 70% of patients, reduction of pigmentation was apparent after the first peel. Another study of 40 Indian patients with moderate to severe melasma found that addition of glycolic acid peels (3 peels at a 30% concentration) produced average lightening of 46% at week 12 and 78% at week 21 compared to the start. At the end of the study, 80% of patients in the peel group graded their improvement as excellent! Two patients from the peel group developed temporary worsening of their melasma, which resolved with the use of a steroid cream.
A large study of 533 patients with melasma found that 398 patients (75%) achieved clearance of melasma without recurrence after multiple sessions of dermabrasion. However, some patients developed hyper-pigmentation or increasing redness, which was usually the result of sun exposure, and was easily controlled with a mild steroid cream or 4% hydroquinone. Other potential reactions to dermabrasion include keloid formation, itching, enlarged pores, and loss of skin texture. The relative commonness of these reactions, especially in skin of color patients, explains why dermabrasion is not a typical first-line therapy.
Although melasma can be a stubborn thing to treat, you have options. Work with a dermatologist who has a lot of experience with your skin type to determined a personalized treatment plan. That may include standard treatments described in part 1 or newer ones discussed here. In either case, diligent sun protection is essential. What has your experience with pregnancy related melasma been like? Share your stories in the comment section!