Integrative Dermatology Approach to Melasma

Melasma or chloasma is a skin condition that causes darker patches and spots on the skin, most commonly on the face. The word melasma means “black spot,” referring to the darkening of skin patches that occurs with this condition. This type of pigmentation is most common in women, especially those with medium to dark skin tones. 

Because this condition often appears during pregnancy, melasma is sometimes called the “mask of pregnancy.” In fact, it impacts around 15% to 50% of pregnant women. Overall, 1.5% and 33% of the population experience melasma. It is most common in women of reproductive age and commonly begins to appear between 20 and 40 years of age.

An integrative dermatology approach to melasma looks at factors that contribute to hyperpigmentation and creates an individualized treatment approach to even out pigmentation and improve skin tone.

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What is Melasma?

Melasma causes blotchy, darkened patches and freckle-like spots on the skin, especially on the face, that does not itch or cause pain. The areas of increased pigmentation can be tan, brown, grayish brown, or bluish-gray, appearing as patches of affected skin and freckle-like spots. The most common locations impacted by melasma are skin in certain areas of the face, like the cheeks, forehead, chin, and above the upper lip. It can also impact the arms, neck, or other parts of the body that are exposed to sunlight. The darkened patches of skin are typically flat and on both sides of the face.

This skin condition has been coined the “mask of pregnancy” because it often appears for the first time during pregnancy or when starting birth control pills due to hormonal fluctuations. Sometimes, melasma will resolve on its own after delivering the baby or stopping hormonal medications, while it can be long-lasting and persist for months or years in other cases.

Depending on the depth of the pigment, melasma is divided into three types. Epidermal melasma is dark brown with well-defined borders. Under the black light of a Wood’s lamp, it appears obvious. Dermal melasma is more light brown or bluish with blurrier borders. This type does not appear differently under black light and is less likely to respond well to treatment. The mixed type of melasma is most common and is characterized by a combination of bluish and brown patches.

What Are The Possible Causes of Melasma?

The skin has three layers that form a barrier between you and the outside world. The outer layer or epidermis contains melanocyte cells that produce and store a pigment called melanin. When melanocytes are stimulated by exposure to light, heat, ultraviolet radiation, or hormonal stimulation, they are triggered to produce more melanin, which causes the skin to darken. 

Therefore, melasma is generally caused by radiation (ultraviolet, visible light, or infrared light) and/or hormones. For example, elevated levels of estrogen and progesterone during pregnancy stimulate melanocytes to make more pigment, which can contribute to your melasma. Less commonly, other medications like anti-seizure drugs (e.g., Clobazam (Onfi®)) and medications that make you more sensitive to the sun (phototoxic drugs) like some antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), diuretics, retinoids, hypoglycemics, antipsychotics, and targeted therapies can make you prone to developing melasma.

Genetics also play a role in the development of melasma, with around 33% to 50% of people with melasma having a family member who also experiences the condition. Melasma is also more common in those with hypothyroidism.

Functional Medicine Labs to Test for Root Cause of Melasma

Functional medicine laboratory testing can help to assess factors contributing to melasma and evaluate for the presence of accompanying health issues.

Hormone Balance

Since elevated levels of estrogen, and to a lesser degree progesterone, are associated with increased skin pigmentation seen in melasma, hormonal testing can assess any imbalances. The DUTCH Complete is a dried urine test that looks at various hormone levels and how they are broken down in the body. 

Thyroid Testing

Since people with melasma are more likely to also have thyroid disease, especially hypothyroidism, testing for thyroid hormone imbalances can provide insight into the overall health picture. 

Functional medicine testing can evaluate how the thyroid is functioning using a Complete Thyroid Panel. This blood test looks at levels of thyroid-stimulating hormone (TSH), T3 (free and total), T4 (free and total), and reverse T3, as well as thyroid antibodies such as thyroid peroxidase (TPO) and anti-thyroglobulin (TG) and antibodies to evaluate autoimmune involvement that occurs in Hashimoto’s hypothyroidism or Grave’s hyperthyroidism. These tests can be assessed using functional medicine ranges to look at how well the thyroid is functioning.

Micronutrient Testing

Studies suggest that melasma may be associated with vitamin B12 deficiency and iron deficiency anemia. Levels of B12, iron, and ferritin can be measured in the blood to assess sufficiency. To get a sense of overall nutrition level and look at various vitamins, minerals, and other nutrients that impact skin health and may contribute to the development of melasma, including zinc, vitamin D, and glutathione, Micronutrient Testing can be valuable. 

Additional Labs To Test 

Sometimes, a dermatologist will take a small sample of skin tissue by performing a skin biopsy to help differentiate melasma from other skin conditions such as lichen planus, guttate hypomelanosis, lentigo (age spots), Nevus of Hori, Nevus of Ota, or post-inflammatory hyperpigmentation. If you have melasma, a skin biopsy will typically show the branched (dendritic) pigmented melanocytes with melanin in the basal and suprabasal keratinocytes and melanophages, as well as solar elastosis and elastic fiber fragmentation.

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Conventional Treatment for Melasma

While melasma can often go away on its own after delivering the baby or stopping birth control pills, for example, conventional treatment approaches can help fade the discoloration. 

Topical treatments utilizing a combination of hydroquinone, tretinoin, and a moderate steroid are commonly used. Other topical treatment options include tyrosinase inhibitors like azelaic acid, which prevent the formation of melanin.

Functional Medicine Treatment for Melasma

While a conventional approach aims to reduce hyperpigmentation using a variety of topical medications, an integrative dermatology approach to melasma incorporates a functional medicine view to uncover and address underlying contributing factors and address them. Diet, lifestyle, supplements, and integrative therapies can help reduce hyperpigmentation and heal the skin to improve quality of life.

Nutritional Recommendations for Melasma

To keep your skin healthy overall, an anti-inflammatory like the Mediterranean diet can balance inflammation, heal the gut and skin, and keep the skin barrier healthy. This way of eating focuses on whole fresh vegetables and fruit while avoiding inflammatory foods like processed foods, factory-raised meats, and additives, as well as foods that one is allergic or sensitive to. 

Incorporating plenty of vitamin D-rich foods into an anti-inflammatory approach to eating can help to keep skin healthy. Almonds, mushrooms, eggs, oily fish, and cod liver oil are rich in this vitamin.

Antioxidants like glutathione have also been shown to reduce hyperpigmentation and support skin health. Incorporating foods such as asparagus, avocado, spinach, and red pepper can help support the formation of glutathione in the body. 

In addition, foods high in vitamins C and E, like citrus fruits, kiwis, almonds, colorful vegetables, flaxseeds, pistachios, and fatty fish like salmon, can support the repair of radiation damage that contributes to melasma.

Supplements & Herbs for Melasma

In addition to an anti-inflammatory diet incorporating skin-supporting nutrients, targeted supplements, and herbs may reduce hyperpigmentation and improve quality of life.

Glutathione

Glutathione is a powerful antioxidant that helps to lighten the skin by inhibiting tyrosinase and skewing the production of eumelanin to pheomelanin to prevent pigmentation. Both oral and topical glutathione have been studied for their ability to lighten skin hyperpigmentation and improve melasma.

Soybean Extract 

Soybean extract (Glycine max) can be applied topically to the skin to reduce the transfer of color from melanocytes to the skin cells. Studies suggest that soybeans decrease the activation of protease-activated receptor 2 found on keratinocytes, resulting in reduced melanosome transfer and depigmentation.

Mulberry Extract

Similar to soybean extract, mulberries (Morus alba) have antioxidant activity and can block tyrosinase in the skin to decrease melanocyte activity and melanin production. A randomized, single-blind, placebo-controlled trial showed a 29% improvement in melasma when a topical treatment of 75% mulberry in coconut oil base was applied over eight weeks.

Carotenoids

Carotenoids, including beta-carotene, an agonist of vitamin A, and lycopene, found in tomatoes, reduce melanin production in the skin. Studies suggest that carotenoids may augment other therapies to treat the hyperpigmentation seen in melasma.

Parsley tea

Parsley has anti-inflammatory and antioxidant activities and is commonly used as a natural skin lightener in traditional medicine. A randomized control trial of 54 women showed that a tea prepared by brewing parsley in hot water significantly decreased the severity of hyperpigmentation over eight weeks when applied topically.

Vitamin C

Ascorbic acid (vitamin C) inhibits melanin synthesis by reducing the activity of tyrosinase enzymes to prevent the formation of melanin. Research shows significant lightening of the skin when vitamin C is applied topically to melasma.

Zinc sulfate

Zinc sulfate is essential for skin health and has been studied for its use in reducing hyperpigmentation in people with melasma. 

Complementary and Integrative Medicine for Melasma

Integrative medicine approaches can be added to dietary and supplement approaches in order to improve the health of the skin and reduce hyperpigmentation.

Acupuncture

Acupuncture is an important component of traditional Chinese medicine based on inserting dry needles at specific sites to promote healing. Studies show that acupuncture can successfully treat melasma and reduce pigmentation. It is thought that facial acupuncture can improve skin pigmentation and texture by increasing blood flow and muscle tone, balancing qi, and balancing internal Zang Fu organs.

Microneedling

Several studies show that microneedling or percutaneous collagen induction therapy can improve melasma pigmentation. This procedure uses tiny needles to create pores in the top layers of the skin (epidermis) to reach the deeper layer of skin where the blood vessels and inflammatory/pigment cells are located (dermis). This stimulates fibroblasts to produce new collagen and elastin to improve the appearance and fullness of the skin and can also be used in combination with the application of a topical medicine that penetrates through the newly created pores to the deeper layers of the skin. 

Light-Based Treatments

Light-based treatments, including intense pulsed light, non-ablative fractionated laser, and low fluence Q-switched laser, can help to reduce the pigmentation of melasma.

Platelet-rich Plasma (PRP)

Platelet-rich plasma (PRP) is a procedure that involves removing a small amount of your blood and separating it into layers to extract the plasma, which is injected into the skin with melasma to help even your skin tone.

Protect Yourself From the Sun

Exposure to the UV rays in the sun can worsen the darkening caused by melasma, so sun protection is important. Using mineral-based sunscreen and protective clothing like a wide-brimmed hat and sunglasses can reduce your exposure to UV, especially during the strongest rays of midday. 

Avoid LED Light

LED lights emit a narrow band of radiation ranging from infrared to ultraviolet. LED light from your lighting, television, laptop, cell phone, and tablet can trigger melanocytes and worsen melasma. Opt for non-LED lighting and consider anti-radiation glare filters for screens.

Stick with Natural, Unscented Skin Care Products

Irritating chemicals and fragrances in skin care products can make your melasma worse. Opt for unscented natural products that are gentle on the skin.

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Summary

Melasma can cause brown to gray-brown patches and freckling, especially on the face. This condition commonly appears during pregnancy or when taking hormonal medications like birth control due to hormonal impacts on the production of melanin or pigment in the skin. In addition to hormones, radiation exposure from the sun, heat, or other sources can result in hyperpigmentation, as seen in melasma.

Fortunately, an integrative medicine approach can assess underlying causes and associated conditions and develop a plan that can rebalance the skin. An anti-inflammatory diet full of skin-supporting nutrients, targeted supplements to reduce hyperpigmentation, and integrative dermatological treatments like microneedling and PRP show promise for treating melasma and improving skin tone.