Melasma in aging skin

Is it melasma or age spots?

Melasma usually causes brown patches on the cheeks, forehead, nose or upper lip, often in a matching pattern on both sides of the face. The only symptom is a change in color. Age spots are flat brown, tan or black marks that typically develop after sun exposure. Both can appear on an older face, but a new dark mark should not automatically be treated as either.12

Have new or changing discoloration checked, especially a mark that changes shape, size, texture or color. Rough, scaly patches, bleeding spots and sores that heal and return also need assessment. A dermatologist can examine the pattern and use a Wood's lamp, a device that uses ultraviolet light, to help assess pigment depth. Sometimes a small skin sample is needed to distinguish melasma from another condition.123

Why can melasma continue as you get older?

Melasma is most common in women aged 20 to 40, but it can affect anyone and persist for years. Hormone replacement therapy is a relevant possible contributor during menopause. Aging alone is not a reason to assume that new facial pigmentation is melasma.14

Melanocytes, the cells that make skin pigment, are more active in melasma, although the exact reason is not fully understood. Possible triggers include sunlight, birth control pills, some seizure medicines and medicines that increase sun sensitivity, including some antibiotics and blood pressure medicines. Thyroid disease can increase risk. Family history and a medium or dark skin tone also increase the likelihood of melasma. Discuss possible medication triggers with the prescriber rather than changing a prescription yourself.4

Melanin is the pigment that gives skin its color. Sun exposure makes the body produce more melanin, and excess production can make patches darker than surrounding skin. Melanin absorbs harmful ultraviolet rays, but natural pigmentation does not replace sunscreen or protective clothing, even in darker skin.5

How to protect your skin each day

1. 1Apply prescribed melasma medication as directed before sunscreen and makeup.
2. 2Before going outdoors, apply broad spectrum sunscreen with SPF 30 or higher. Broad spectrum covers both UVA and UVB light, which is more useful than a bottle that merely looks serious.
3. 3Reapply sunscreen at least every two hours while in the sun, and use it throughout the year, including winter.
4. 4Add a hat and protective clothing, seek shade and avoid midday sun when ultraviolet light is strongest.
5. 5Apply camouflage makeup after sunscreen if you want coverage. Makeup can hide discoloration while treatment works, so coverage and treatment can have separate job descriptions.

Avoid tanning beds and sun lamps. Reflected sunlight near water, sand, concrete and white surfaces increases exposure, so shade is only part of protection. A tinted sunscreen is an option if a white cast makes sunscreen difficult to use; dermatologists often recommend zinc oxide, titanium dioxide and iron oxide for melasma.13

Which treatments are worth discussing?

How is hydroquinone used?

Hydroquinone comes in concentrations of 1% to 5% and treats pigment in the outer skin layer, not pigment deeper in the dermis. Availability and approved directions differ by country. Use the directions for your prescription, especially if hydroquinone is part of a combination cream.6

General instructions for starting hydroquinone alone are:

1. 1Test an area about 1 cm across and check for redness or irritation over 24 hours.
2. 2If tolerated, apply a thin film to the darkened skin once daily initially. After one week without irritation, application can increase to twice daily.
3. 3Keep hydroquinone away from the eyes and mouth. Do not add other topical medicines, particularly benzoyl peroxide, unless the prescriber directs the combination.
4. 4Wait 10 minutes before applying sunscreen or cosmetics.
5. 5Review progress at three months. Stop if there has been no benefit; maintenance treatment needs a separate plan.

Stop hydroquinone for excessive redness, scaling, itching or weeping. Concentrations above 4% can cause irritation, and high concentrations used repeatedly for years can cause ochronosis, an abnormal darkening of skin. Avoid hydroquinone if you are allergic to it or an ingredient in the formula. Safety during pregnancy and breastfeeding has not been established.6

Can one treatment address melasma and skin aging?

Prescription tretinoin, a vitamin A derived medicine, can be combined with other ingredients for melasma. Used for more than six months, tretinoin can also reduce fine wrinkles, freckling and sun spots. Those aging benefits have a separate timeline from melasma treatment. Cosmetic retinol and retinaldehyde are also retinoids, but the melasma combination treatment discussed here uses tretinoin.7

Retinoids can cause dryness, redness, peeling and sun sensitivity, and can worsen eczema. Cream formulations are generally less irritating than gels. Night application and daytime moisturizer and sunscreen help manage dryness and sun sensitivity. Avoid applying close to the eyes or lips, and follow the prescribed frequency rather than borrowing directions from another retinoid product.7

Some topical retinoids are contraindicated during pregnancy. If pregnancy is possible or planned, discuss the exact medicine with the prescriber before using it; effective contraception is a precaution for women of childbearing age using topical retinoids.7

What if creams are not enough?

A dermatologist can add a procedure for persistent melasma. A few studies support adding laser or light treatment to medication and sun protection. Have these procedures performed by a board certified dermatologist. Tranexamic acid is another prescription option for difficult cases; disclose any history of blood clots before considering it.3

Treatment usually takes 3 to 12 months to show results, and longstanding melasma can take longer. Pigmentation can fade over several months after a hormone trigger ends, but return with sun exposure or renewed hormone use. Ask about costs before starting: most insurers do not cover melasma treatment, so the billing department is unlikely to share the enthusiasm.13