Summer is soon kissing us goodbye; the sun is less intensive and the days become cooler and shorter (at least in the northern hemisphere). Even though most people love summer, if you have melasma, you probably fear it as it brings out your brown spots. 

This article will give answers to your begging questions about this stubborn skin dysfunction. Understand melasma on a holistic level and find the silver lining that health challenges hold for us to step up to better wellbeing. Let’s gear you up for the next summer so you can anticipate the next sunny season as you used to.

What is Melasma?

Melasma is chronic skin hyperpigmentation that leaves the face with symmetrical brown patches on the forehead, cheeks, nose and upper lips. Even though melasma is mostly seen in women, men can have it too.

It seems to be a lot more common these days than 20 years ago, when I started off as an esthetician. While I was working in a busy spa in one of Sydney’s fanciest suburbs, I performed around 100 facials each month. To my surprise, an unusually large percentage of clients on my treatment bed was riddled with melasma (I only had female clients with melasma). A mystery was that many of these women were not the usual melasma patient—pregnant or on the pill. This left me with questions that I knew I had to find answers to.

If you have melasma or you are a skin care professional, you likely experienced that potions and lotions from the skincare shelf are not giving the desired results. And prescription creams from the dermatologist often cause skin irritations or only give temporary success, which applies to expensive laser treatments as well. Are you nodding?

Why It Appears

Estrogen and Sun—the Most Notorious Suspicious

The two most popular theories to the cause of melasma are excess estrogen (the female sex hormone) and sun damage. These theories are not untrue but incomplete and leave us with questions.

Melasma is usually seen in pregnant women hence it received its colloquial term “mask of pregnancy”. The increased estrogen levels during pregnancy (or when “on the pill”) stimulate melanocytes to produce more melanin—the pigment that turns skin, hair and eyes dark.

This excess of hormones in combination with sunlight—specifically the ultraviolet spectrum (UV) of natural sunlight—motivates melanin to exert its primary job, which is the protection of the skin from sun damage.

Even though an excess of the energy rich sunrays can cause damage to skin cells and the DNA, we must remember that this cosmic gas ball on fire is duty-bound to the existence for life on earth. Our bodies have evolved with it and are dependent on sunlight to thrive and survive.

However, staying in the midday sun for hours when your skin is white as the wall will probably leave you lobster red and this level of damage (sunburn) is better to avoid. It is all about the right dose.

The most popular advice that is given to melasma patients is to avoid the sun at all costs and to wear sunscreen at all times. There are challenges with that. Avoiding the sun is highly unpractical—being outdoors is part of a healthy lifestyle. Lack of sunshine causes anxiety and leads to more health issues down the road because we need the sun to make vitamin D! On top of that, you probably agree from own experience that melasma does not disappear despite sunblock or avoidance of sun.

Melanin—the pigment responsible for brown spots—does not exist to create cosmetic inconveniences but is there to supply your built-in sunscreen. In an ideal scenario, melanin gives you a golden and even tan to absorb UV-light. It is one of the strongest antioxidants the body has on offer.

Unfortunately, when the body is imbalanced, the pigmentation process goes awry. In case of melasma, excess estrogen during pregnancy or oral contraceptives cause temporary hormone imbalances and brown patches. The skin should bounce back again once the hormones are rebalanced. The sun is merely a contributor/catalyst to the dysregulated pigmentation process. In other words, if the sun would be the cause, you would have an even tan and not a blotchy brown complexion.

The frustrating reality about melasma is that it doesn’t always disappear postpartum or post-pill and women can have melasma without ever been pregnant or on the pill.

Modern clinical research has done extensive research. Over 500 clinical studies appear when you search for melasma in medical databases like PubMed. Interestingly, 93% of the studies were conducted after year 2000. Only 7% were conducted between 1966 and 1999. The numbers do not only indicate that this skin condition has a large lobby but also that it has attracted more interest in the past two decades. We explore why that could be the case?

The Reasons for Increased Estrogen Nobody Talks About

Buckle up for some surprising news—there are environmental reasons that cause high estrogen levels and could explain the surge of melasma.

Endocrine Disruptors

Endocrine disruptors (ED) are a class of compounds that are hormonally active. Some of them are man-made, like BPAs and phthalates found in plastic items. ED also occurs naturally as toxins expelled from molds (mycotoxins), like the mycotoxin zearalenone from black mold. Endocrine disruptors act like fake estrogen and cause confusion in the hormone system. They plug into estrogen receptors where they block the spot that was meant for the real estrogen. Imagine the following scenario: The newest, hilarious romance with your all-time heartthrob is out in the movies. You buy a ticket and when you get into the crowded theatre, all excited for the flick and ready to claim your seat; you are flabbergasted to see someone sitting on your chair with no intention to move. Imagine half of the seats were occupied by bill-dodging squatters, and everyone who has bought a ticket has to sit on the floor or call the manager for action. The theatre soon becomes a scene of hysterical mayhem. A chaotic scenario like this takes place when fake estrogens (ED) come along. They create chaos in the endocrine system.

Liver Overburden

The liver deserves a lot of credit in doing its daily tasks. Every substance absorbed into the body gets noticed, needs permission to pass, or is repackaged and eliminated by the liver. This organ is like the border custom of chemicals, hormones and everything fat soluble. Having an overburdened liver from alcohol, too much fat, environmental toxins or drugs makes it hard for this organ to function properly.

The liver is a recycle site for fat soluble hormones like estrogen. When compromised in its function, estrogen is recycled into the blood system instead of eliminated. You probably have heard of the term liver spots to describe moles on the skin. Western medicine doesn’t support the idea of moles having anything to do with the liver, but there is anecdotal evidence and logic if we see it from a holistic perspective.

Gut Microbiome Dysbiosis

In the past 10 years, the gut made headlines in the media and literature when medicine came to an understanding of the connection between mental health, skin disorders and other chronic health conditions. Recent research suggests the gut as part of the endocrine system as it modulates hormones like estrogen. Particular gut bacteria that are called the estrobolome, excrete a specific enzyme (beta-glucuronidase) that converts estrogen into its active form for reabsorption. When there is an imbalance in the gut microbiome, and estrobolome takes over, too much active estrogen is reabsorbed, which leads to increased estrogen [1].

Other Factors for Melasma

Research shows that melasma is linked to stress, thyroid imbalances, inflammation and oxidative stress. These factors are rarely discussed when melasma patients sit in the doctor’s office.

Thyroid Dysfunction

Studies found that women with melasma had out of the norm thyroid levels compared to control groups [2,3] and a 4-fold higher likelihood of a thyroid dysfunction [4]. The skin and thyroid are connected through pathways that modulate hormone function and skin pigmentation [5]. Pharma exploited this connection when designing the drug Melanotan (Barbie-drug)—which promised a tanned skin and weight loss [6].

Inflammation, Oxidative Stress and Air Pollution

You probably have experienced a sunburn at least once in your live. Oftentimes, once the acute redness (inflammation) is gone, the skin reveals a tan. For this reason, the relationship between inflammation and pigmentation, shouldn’t leave us surprised. Yet, inflaming environmental factors other than sun receive little attention.

Environmental toxins cause low-level inflammation in tissues and the skin is not spared by it. Women with melasma are three times more likely to develop post-inflammatory hyperpigmentation from acne [7]. Research discovered inflammatory markers in skin samples and supports the correlation [8]. The same inflammatory markers are present when oxygen supply to tissues is poor and during oxidative stress [9].

Have you ever expected air pollution to be linked to melasma? A chemical reaction in the skin triggered by airborne particles (air pollution) creates free radicals and subsequently oxidative stress. This causes inflammation and cells to break down. The high incidence of melasma in heavily air-polluted countries like India, South East Asia, China, and United States supports this hypothesis [10].

Emotional Stress and Trauma

Small stressors that continue over long periods without restoration and regeneration deplete our mind and spirit. Ongoing life force taking stress often erupts as a skin issue. Brown spots from stress are real since precursors of stress hormones stimulate melanocytes and hyperpigmentation as a natural response of the skin to pressures [11]. Hyperpigmentation is a common side effect in people with Addison’s disease—a condition of chronic adrenal exhaustion.

If you can recall a traumatic event around the onset of melasma, it is likely stress related. A case report from the 80s mentions women who have endured extreme emotional distress right before the onset of melasma [12]. When I spoke to clients, intense hardship was true for some women when the brown spots first appeared.

Artificial Light

If you love skincare and follow the latest trends, blue-light filters in cosmetics are probably not new to you. Blue light in a natural setting is not bad for us—this spectrum of the natural sunlight is needed to keep us awake during the day. The increased exposure to artificial light sources like lamps and screens has created an imbalance compared to the array of the natural light spectrum. Excessive blue light messes with your sleep, hormones, and creates unwanted skin pigmentation. Research found that blue light causes darker and longer lasting brown spots than UV light [13].

What It Means to those Affected

The melasma support groups on Facebook give insight into the number of people affected—some of them have up to 75k members. Sometimes, non-life-threatening skin conditions that are classified as cosmetic challenges are taking a back seat and the support needed is thin. The term “skin-deep” is often used to describe the skincare industry.

The reality is that skin disorders of the face are emotionally distressing. It goes so far that sufferers feel shame to show themselves in public, which leaves them lonely and isolated. The skin plays a very important role, not only physically but emotionally and spiritually. The face is the first line of non-verbal communication. When people encounter each other, they make a judgement about the other person within a fraction of a second.

 The decision is made so quickly, it is obvious that a preference of the other person goes beyond rational reasons. For example, if communication goes well or not so well and if opinions are shared. If you like someone is truly based on the initial visualimpression [14].

This is not superficial but simply human nature. Even babies who come to earth with very few biases, prefer harmonious facial features and more likely smile at a person that is considered beautiful [15].

Given this perspective, the pressure on women with melasma is clear and more than skin-deep. Whoever had the experience of waking up with a breakout in the morning knows how this affects the self-esteem.

What Are the Options?

For chronic skin conditions like melasma, there are two routes. One is traditional western medicine—your General Practitioner or dermatologist. The other option is the alternative healing route, for example, naturopathy, traditional Chinese medicine (TCM) and Ayurveda, just to name a few. The difference between western and alternative medicine is that western medicine treats the symptoms, while alternative medicine treats the root-cause of a disease.

What Dermatology Has on Offer

Dermatologists usually agree that melasma has no cure. The interventions offered by traditional western medicine are creams with hydroquinone or retinol and the fairly new prescription drug tranexamic acid. Advanced treatments like laser are available in many dermatology practices to those willing to pay out of their own pocket.

Hydroquinone

Hydroquinone is an active ingredient incorporated in a cream. Concentrations up to 2% are still available over the counter in Australia. Anything above requires a prescription by a physician. Even though hydroquinone is available over the counter in “Down-under”, non-prescription cosmetics that contain this skin-lightening ingredient are banned in most EU countries and the US.

Hydroquinone suppresses the melanin production by inhibiting tyrosinase—the enzyme that turns melanin into its brown colour. The bans are based on several health concerns regarding this bleaching agent. The Environmental Working Group identifies hydroquinone as carcinogenic and the FDA reported skin issues like swelling and discoloration [16].

Hydroquinone was originally used as a component in photographic developers. Several papers published in the 1980s reported about the toxic effect on melanocytes. Skin contact with this compound left workers in the photo developing industry with permanent white marks [17,18].

The toxic effects on melanocytes with the potential destruction of these cells, raises concerns that the skin is more vulnerable to sun damage and skin cancer.

The paradox is that even though hydroquinone is used to reduce pigmentation, it can over time cause hyperpigmentation. Reports provided to the FDA have claimed that women who applied over-the-counter cosmetics, developed ochronosis—a skin condition with brown-grey or bluish-black lesions. The scandalous thing about this is that the FDA assumes hydroquinone was slipped in to cosmetics without being labelled by the manufacturers [19].

Retinol

Retinol, also known as vitamin A, has become a superstar in the world of cosmetics. When treating hyperpigmentation, it helps to shed skin cells and therefore overly pigmented cells are flushed out faster. Retinol comes in a myriad of different derivates and concentrations, which determines the efficacy of the ingredient. Strong concentrations and active forms of retinol (retinoic acid) require a prescription from a physician.

Tranexamic Acid

Tranexamic acid is a relatively new prescription drug in pill form. It is generally used to control bleeding, for example heavy periods. In the case of melasma, it inhibits pathways of the melanin production as it reduces the number of blood vessels around the brown spots. Research discovered that melasma lesions are supplied by an abnormally high number of blood capillaries. More blood flow means increased oxygen supply, which “feeds” melanin.

Laser Treatments

Lasers work in two ways—they either destroy the little melanin packages (vesicles) or they help the extrusion of this pigment. Melasma is more common in people with dark skin types and lasers are often not suitable. There is a risk that laser cause hyperpigmentation or that results are only temporarily [20].

The Pro’s

Easily accessible.

Prescription drugs are fairly inexpensive.

Relatively fast acting within months.

The Con’s

Prescription drugs can come with side-effects like skin irritations and increased sensitivity to the sun.

Laser treatments are costly.

Laser can have risks, for example damage from heat.

Lasers are not suitable for darker skin types.

Prescription drugs are absorbed into the body and have to be filtered through the liver, which can burden the liver and makes it harder to eliminate estrogen out of the body.

The root-cause is not addressed.

Most often long-lasting results are achieved and melasma reappears as soon as intervention has stopped.

Note

If you are at war with brown spots on your face, I bet that anything that suppresses pigmentation sounds like a good idea. The problem is, the destruction of melanocytes or the suppression of melanin production, compromises the natural defence mechanism of the skin to shield from radiation damage. In other words, if the skin is deprived of its innate protection, the slightest exposure to sunlight poses the risk of skin cancer and accelerated skin aging.

Natural & Holistic Alternatives

I have a begging question. Now that you are aware that melasma is linked to hormone imbalances, inflammation, and emotional and oxidative stress, do you believe that laser treatments or creams are going to be the best solutions?

When you recall the evidence and contributing factors discussed earlier, it is hard to deny that melasma requires a holistic healing approach. The brown spots are merely a symptom of a root-cause in the body. Addressing the root-cause, not only treats melasma in a more sustained way, it takes your entire wellbeing to a different level.

Just a warning, restoring body, mind and spirit (holistic) is not for the fainthearted. Holistic healing requires your daily input, often lifestyle changes, patience and faith. The reward is transformational.

Hormone Rebalancing

A first step to rebalance hormonal chaos is identifying how your hormones are produced and eliminated with a comprehensive test. The most common hormone test is an evaluation via blood, which can be done with your GP. A more accurate testing method is a urine test, called DUTCH test, which is only performed by practitioners specialised in this test.

Clean Living

One of the most effective ways to achieve optimum physical wellbeing is detoxing your body and environment. Chronic low-level inflammation, hormone imbalances and oxidative stress can be effectively reduced by simply creating a cleaner lifestyle. Clean in this context means:

· A dust, mold and dirt-free home—mold, dust mites and bacteria metabolise particles of furniture, textiles and wallpaint. The metabolites expelled by microorganisms are toxic.

· Toxin-free or toxin reduced household items and cooking ware

· Toxin-free cleaning products

· Toxin-free and organic cosmetics

· A clean diet (organic, prepared from scratch, fermented, fresh)

· Toxin-free clothes and jewellery

· Less screen-time and using screen-filters or blue blocking glasses

It is worth to learn where endocrine disruptors lurk to eliminate them out of your life. The website of the Environmental Working Group is a helpful and comprehensive resource for that.

It can be overwhelming. Start with baby steps. Slow and steady wins the race. One brickstone laid each day will eventually become a house.

Dealing With Emotional Stress

Let’s not sugarcoat it, stress is ubiquitous and here to stay. As long as we are in a state of growth and adaption to our environment and not dropping out of society to live cut off from society, stress is part of our modern life. But what if I tell you that you are not at the mercy of stress and the right tools and daily habits help you to build stamina to cope better? Yoga, meditation and breathing exercises are tried and tested tools. If you are not a lover of these practices and new age technologies make your eyes roll, there are plenty of methods that suit your needs and personality. Maybe it is reading poetry, singing, listening to a podcast, a chat with a friend, sex with your lover or dancing to trance techno. Anything that moves negative energy out of your system is great. Becoming aware of stress when it arises and prioritising yourself by regularly using your favourite stress reliever is the key.

Here a first aid breathing exercise for sudden anxiety and panic attacks:

Hold your right nostril and breath slowly and deeply through your left nostril until you feel calmer. Breathing through your left nostril deactivates your fight and flight response for a calmer self.

Skincare

People tend to choose fruit acids and harsh cosmetics to lighten brown spots. However, melasma’s inflammatory temperament—even though inflammation is not that obvious—calls for tender loving care and ingredients that counteract irritation. Some of the most potent botanical ingredients that work wonders on pigmentation are liquorice extract, frankincense and German chamomile.

Other amazing ingredients are vitamin C and gallic acid. Living in Australia, you are particularly lucky as you have an array of native plants locally available that burst of high levels of vitamin C. Best known for its high content of vitamin C is Davidson Plum and Kakadu plum.

Most often melasma doesn’t need much exfoliation either. Research shows that those affected have a compromised skin barrier [21]. Therefore, please go easy on exfoliation during the healing process.

The Pro’s

It is safe.

If the root-cause is addressed, brown spots are gone for good.

Addressing the root-cause leads to enhanced well-being and prevention of health problems in the future.

The Con’s

Can take months to years for melasma to fade.

Often lifestyle changes are necessary.

A Final Note

Without optimal conditions, like clean air, toxin-free food and water, the body cannot function at its optimum. To treat melasma, the first step is to get the basics right and to become internally as healthy as you can—your skin will follow.

You have to decide if you want to take the traditional route with your physician, the alternative practitioner, or to take it into your own hands. Hopefully, this article equipped you with the information you need to make the right choices on your melasma healing journey—cheers to “bye-bye melasma” with fresh spring water.

For personalised support, finding the root-cause and a tailored protocol, please check out my consultation offerings.

The Truth About Melasma offers detailed and no -nonsense information to melasma and holistic solutions that bring you on the right path.

References

1. Romm A. The Estrobolome: The Fascinating Way Your Gut Impacts Your Estrogen Levels [Internet]. Aviva Romm, MD. 2021 [cited 2024 Apr 10]. Available from: https://avivaromm.com/estrobolome/

2. Rostami Mogaddam M, Iranparvar Alamdari M, Maleki N, Safavi Ardabili N, Abedkouhi S. Evaluation of autoimmune thyroid disease in melasma. J Cosmet Dermatol. 2015;14:167–71.

3. Ameneh Y, Banafsheh H. Association of Melasma with Thyroid Autoimmunity: A Case-Control Study. Iranian Journal of Dermatology. Iranian Society of Dermatology; 2010;13:51-3. at DuckDuckGo [Internet]. [cited 2024 Apr 15]. Available from: https://duckduckgo.com/?q=Ameneh+Y%2C+Banafsheh+H.+Association+of+Melasma+with+Thyroid+Autoimmunity%3A+A+Case-Control+Study.+Iranian+Journal+of+Dermatology.+Iranian+Society+of+Dermatology%3B+2010%3B13%3A51%E2%80%933.&t=newext&atb=v318-1&ia=web

4. Lutfi RJ, Fridmanis M, Misiunas al, Pafume O, Gonzalez EA, Villemur Ja, et al. Association of Melasma with Thyroid Autoimmunity and Other Thyroidal Abnormalities and Their Relationship to the Origin of the Melasma*. The Journal of Clinical Endocrinology & Metabolism. 1985;61:28–31.

5. Martin NM, Smith KL, Bloom SR, Small CJ. Interactions between the melanocortin system and the hypothalamo-pituitary-thyroid axis. Peptides. 2006;27:333–9.

6. Administration (TGA) TG. Beware the Barbie drug: the dangers of using Melanotan | Therapeutic Goods Administration (TGA) [Internet]. Therapeutic Goods Administration (TGA); 2022 [cited 2024 Apr 15]. Available from: https://www.tga.gov.au/news/news/beware-barbie-drug-dangers-using-melanotan

7. The association between melasma and postinflammatory hyperpigmentation in acne patients - PubMed [Internet]. [cited 2024 Apr 15]. Available from: https://pubmed.ncbi.nlm.nih.gov/24349727/

8. The dermal stem cell factor and c-kit are overexpressed in melasma - PubMed [Internet]. [cited 2024 Apr 18]. Available from: https://pubmed.ncbi.nlm.nih.gov/16704639/

9. Rey S, Semenza GL. Hypoxia-inducible factor-1-dependent mechanisms of vascularization and vascular remodelling. Cardiovasc Res. 2010;86:236–42.

10. Pollution as a risk factor for the development of melasma and other skin disorders of facial hyperpigmentation ‑ is there a case to be made? - PubMed [Internet]. [cited 2024 Apr 11]. Available from: https://pubmed.ncbi.nlm.nih.gov/25844605/

11. Slominski A, Wortsman J. Neuroendocrinology of the skin. Endocr Rev. 2000;21:457–87.

12. Wolf R, Wolf D, Tamir A, Politi Y. Melasma: a mask of stress. Br J Dermatol. 1991;125:192–3.

13. Mahmoud BH, Ruvolo E, Hexsel CL, Liu Y, Owen MR, Kollias N, et al. Impact of long-wavelength UVA and visible light on melanocompetent skin. J Invest Dermatol. 2010;130:2092–7.

14. The Psychology of First Impressions | Psychology Today [Internet]. [cited 2024 Apr 9]. Available from: https://www.psychologytoday.com/us/blog/talking-apes/201708/the-psychology-first-impressions

15. Quinn PC, Kelly DJ, Lee K, Pascalis O, Slater AM. Preference for attractive faces in human infants extends beyond conspecifics. Dev Sci. 2008;11:76–83.

16. Research C for DE and. FDA works to protect consumers from potentially harmful OTC skin lightening products. FDA [Internet]. 2022 [cited 2024 Apr 12]; Available from: https://www.fda.gov/drugs/drug-safety-and-availability/fda-works-protect-consumers-potentially-harmful-otc-skin-lightening-products

17. Chivers CP. Two cases of occupational leucoderma following contact with hydroquinone monomethyl ether. Br J Ind Med. 1972;29:105–7.

18. Kersey P, Stevenson CJ. Vitiligo and occupational exposure to hydroquinone from servicing self-photographing machines. Contact Dermatitis. 1981;7:285–7.

19. Affairs O of R. Skin Products Containing Mercury and/or Hydroquinone. FDA [Internet]. 2023 [cited 2024 Apr 6]; Available from: https://www.fda.gov/consumers/health-fraud-scams/skin-products-containing-mercury-andor-hydroquinone

20. Poon VKM, Huang L, Burd A. Biostimulation of dermal fibroblast by sublethal Q-switched Nd:YAG 532 nm laser: collagen remodeling and pigmentation. J Photochem Photobiol B. 2005;81:1–8.

21. Lee DJ, Lee J, Ha J, Park K-C, Ortonne J-P, Kang HY. Defective barrier function in melasma skin. J Eur Acad Dermatol Venereol. 2012;26:1533–7.