What is melasma?
Melasma is a skin condition most commonly characterized by the presence of brown irregular patches on the face of a woman. Quite often, both sides of the face are involved symmetrically, with the most common sites of involvement being the cheeks, bridge of nose, forehead, and upper lip.

Melasma is extremely common, and it affects five to six million American women annually. Over 90% of melasma cases occur in women, and it is especially common in darker skinned individuals, particularly Hispanics, Asians, and women of Middle Eastern ancestry.

What causes melasma?
Although the causes of melasma are not completely understood, several factors are known to play a role. Clearly genetics is a factor, as women with a family history of melasma are more likely to develop the condition. Also, hormonal factors play a role, as pregnancy and birth control pills may also cause melasma. In addition, sun exposure is an important contributing factor.

It is believed that melasma results from exposure to the hormones estrogen and progesterone combined with exposure to ultraviolet light from the sun. This results in an over-stimulation of the pigment producing cells in the skin, increased production of melanin pigment, and the characteristic brown patches of melasma.

How is melasma treated?
Several modalities are available to treat melasma. Melasma resulting from pregnancy frequently, but not always, disappears spontaneously over a period of several months after giving birth. If melasma develops after starting birth control pills, it may improve after discontinuing their use. However, melasma that results from the use of birth control pills usually persists even after the pills are stopped.

Melasma treatment always starts conservatively. If at all possible, it is preferable for women undergoing treatment of melasma to discontinue their use of birth control pills. Although melasma can be treated while continuing the use of birth control pills, this is not optimal.

Sunscreens, sun avoidance, and depigmenting creams are three of the mainstays of melasma treatment. The sunscreen must provide both UV-A and UV-B protection. Regardless of how melasma is treated, the treatment will fail if sunlight is not strictly avoided. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection.

Topical depigmenting creams should also be used. Hydroquinone is the most commonly used depigmenting agent; it works by decreasing the production of melanin pigment. Some physicians also add tretinoin (retinoic acid) and a steroid to the hydroquinone. The tretinoin acts by increasing cellular turnover, resulting in a quicker response to therapy. Tri-Luma cream conveniently combines hydroquinone, tretinoin, and a steroid in one medication, and is available by prescription. Other medications for melasma include azelaic acid, kojic acid, and peels containing alpha hydroxy acids such as glycolic acid.

Patients who have not responded to conservative treatment can consider laser treatment. The FDA has approved the use of the Fraxel laser for the treatment of melasma. At the Santa Monica Laser and Skincare Center, we have had good success in treating melasma by combining Fraxel laser treatment with hydroquinone, sun avoidance, and the regular use of sunscreen. Generally, an optimal result can be obtained after four or five Fraxel laser treatments given at four to six week intervals.

Melasma treatment is complex and should be managed by a dermatologist. Generally, several months of therapy are required to significantly improve melasma. Any of our patients who believe they may have melasma or who have abnormal pigmentation in their face are invited to make an appointment with Dr. Amerian.

This month, we are inaugurating a new section of our newsletter, the "Question of the month." In this section, we will discuss common skin conditions so that our patients can familiarize themselves with disorders of the skin that occur frequently.

Rosacea is a skin disease that causes red patches, bumps, and broken capillaries on the face. Although it can occur at any age, it is most likely to start in fair skinned people in their thirties and forties. Often, the first symptom noticed by people with rosacea is a tendency to blush (facial flushing), which becomes more frequent and noticeable over time. Eventually, the redness of the face becomes permanent, although it can vary in intensity. Small dilated blood vessels, known as telangiectasias, may appear in the affected areas. Small white bumps, called milia, and red bumps may also occur. Although rosacea is frequently mistaken for acne, rosacea does not cause the blackheads and whiteheads that are common in acne. The most likely areas to be affected by rosacea are the nose and cheeks, but in more severe cases rosacea can affect the entire face and neck.

Doctors grade the severity of rosacea on a mild-moderate-severe scale. If left untreated, rosacea may progress over time from mild to moderate disease, and eventually to severe disease. The severe form of rosacea is characterized by intense bouts of facial flushing, swelling, facial pain, and debilitating burning sensations. At this stage, some patients may also develop a rhinophyma (rino-fi-ma), a bulbous enlargement of the nose. It is said that W.C. Fields developed his famous nose as a complication of rosacea.

Some patients with rosacea may also develop eye problems. Commonly occurring symptoms include dry eyes, itchy or burning eyes, gritty eyes, and a sensation of a foreign body in the eye. Redness and swelling of the eyelid may also occur. Rosacea patients with eye involvement should see an ophthalmologist.

Although there are many theories, the cause of rosacea is still unknown. Genetic and environmental factors probably play roles in the development of rosacea.

The treatment of rosacea begins with sun protection. Patients who have rosacea should carefully monitor their exposure to the sun and routinely use sunscreen. Antibiotics, either taken orally or applied topically to the affected areas, are also regularly used to treat rosacea. Topical azaleic acid may also be used, especially if antibiotics do not give sufficient improvement. The redness and dilated blood vessels associated with rosacea are best treated with either laser therapy or intense pulsed light. The good news is that by combining several skin care modalities, an experienced skin care professional will be able to control nearly every case of rosacea.