What exactly causes melasma? Well, that's a loaded question. Melasma can have many different sources, and frequently it isn’t just one thing that causes it. We will need need a clear definition of what is before attempting to reverse it.
The fact is, the fields of internal medicine and dermatology don't usually communicate with one another. As a result, solving the melasma puzzle can be extremely challenging and frustrating. There are very few dermatologists who consider the whole body when dealing with skin conditions. Modern dermatology treats effects instead of causes. If your skin shows imbalances, it’s safe to assume it’s not only skin deep. This is true for all chronic skin conditions.
The roots of melasma runs much deeper than modern dermatology allows us to look. Realizing this you can understand why modern medicine tells us that melasma is an “irreversible” disease. I am not saying we should avoid topical treatment or that dermatology is bad. On the contrary, we will use all the tools at our disposal to achieve Mind Body Beauty.
The story of my melasma is quite common. Like so many women hormone imbalances due to birth control catalyzed my disease. My first spots melasma showed up right after I stopped taking birth control, which I had been taking for six months. For the first couple years, I only had two tiny spots on each side of my nose and a little bit above my lip.
It wasn’t until an extremely stressful event that those small spots on my face started to spread. If I had known then what I know now I believe it would have been a relatively easy fix. But as the years passed my lifestyle choices fed into my disease and the spots covered my face.
So, what is melasma?
Melasma is a blotchy grey-brown pigmentation that appears on the face or chest but can appear on other body areas as well. It’s usually found on the center of the face or symmetrically displayed on both sides. Some people get raccoon eyes, and others get a mustache.
Melasma is triggered by tyrosinase, a copper-bound enzyme that induces oxidation of the amino acid tyrosine. This process releases hyperpigmentation.
Melasma is a pigmentation disorder caused by excess inflammation in the body. Inflammation can be from external factors like lasers, skincare products, or exposure to the sun. It is also influenced by chronic internal inflammation from things like lifestyle, stress, and diet. Inflammation is one of the primary causes and mechanisms of melasma, and this is why it can be so challenging to reverse. Melasma often has multiple factors influencing its progress. It is a combination of imbalances.
The two phases of melasma are called active and passive.
The two phases of melasma are called active and passive.
Active is when pigmentation is darkening regularly or spreading. Examples include spots spreading immediately after or within 24 hours of exposure to sunlight. Another example includes when pigmentation changes during the menstrual cycle.
Passive melasma is when the spots remain consistent on the face.
Hormones, let's talk about them.
Hormones are probably the most common factor and often the root cause of melasma itself.
Hormones related to melasma are:
-Estrogen.
-Cortisol.
-Thyroid and thyroid autoimmunity.
-Prolactin (rare but likely more possible in men)
Estrogen is the most common cause of melasma. Having too much estrogen is called estrogen dominance. You likely don't have enough progesterone if you have too much estrogen. Excess estrogen will bind to receptors on melanocytes and stimulate melanin production. Another thing to consider with estrogen dominance is that your body can convert testosterone into more circulating estrogen. This process is called aromatase. Too much estrogen can also block thyroid hormone uptake, which can cause hypothyroidism symptoms.
Many conditions are associated with estrogen dominance, like breast and uterine cancers: endometriosis, fibroids, and polycystic ovarian syndrome. Conventional medicine doesn’t treat estrogen dominance as a medical condition, but it should be taken seriously.
Estrogen and progesterone work together and have particular ratios necessary for balance. So if you are in the menstrual phase, you will also want to consider your progesterone levels. Progesterone can also help balance out your estrogen levels.
Low estrogen is also a cause of melasma, and it is less common. There is some association of ovarian dysfunction with low estrogen. Some women get melasma from hormone replacement therapy (HRT), but often, women already have melasma before menopause.
Cortisol, your stress hormone, is caused by a dysregulated stress response which can cause melasma to occur or worsen. We all have stress but having too much is not good.
The HPA axis is what controls the stress response in our bodies. The hypothalamus-pituitary-adrenal axis has a feedback loop, and when we don't manage our stress load, that feedback loop can shut off, and we continue to produce more cortisol. ACTH is a hormone made in the pituitary gland and regulates cortisol production. MSH is a peptide hormone produced by the pituitary, hypothalamus, and skin cells. It protects the skin from UV rays, and it also regulates pigmentation. ACTH and MSH share a pathway; too much cortisol can dysregulate MSH, causing pigmentation.
Cortisol also has a very close relationship with estrogen. A couple of examples are when a woman is on birth control; it can increase cortisol levels.
Stress-induced melasma is very real, and even if this isn't your causation, it is most likely a cofactor.
The thyroid is essential, and I think many women overlook it. There is some association between hypothyroidism, Hashimoto's, and melasma.
HPT axis is the hypothalamus, pituitary, thyroid axis. It has a significantly close relationship with the HPA axis and cortisol production. ACTH, as mentioned above, can suppress thyroid production through decreased TSH. Even if you don’t have thyroid problems, elevated cortisol can impact thyroid function. Hypothyroidism usually causes high levels of cortisol, and hyperthyroidism can cause increased ACTH. Both outcomes can affect or cause melasma, whether hypothyroid or hyperthyroid.
The thyroid needs to be supported to reverse melasma.
I can’t stress the importance of the relationship between estrogen, cortisol, and the thyroid. Each of these three hormones independently can cause melasma, and yet their balance is so deeply intertwined that they all need to be in harmony or properly supported to reverse it.
Prolactin is similar to the HPA axis in the hypothalamus, pituitary, prolactin axis, or HPP axis. Prolactin induces the release of dopamine, after which dopamine signals to the hypothalamus to stop producing prolactin. Under chronic emotional or psychological stress, the production of prolactin can suppress dopamine and shut off the feedback loop. Too much prolactin can induce hyperprolactinemia; there is also stress-induced hyperprolactinemia. Hyperprolactinemia increases the secretion of ACTH, which stimulates MSH or pigmentation in the skin.
Prolactin could be a possible hormonal imbalance in men and probably less likely for women; however, it may be a contributing factor after a woman gives birth if she got melasma from pregnancy.
Free radicals and inflammation.
Free radicals are unstable molecules that can damage cells, tissue, and DNA. They are also called reactive oxygen species. Free radicals are molecules that have missing electrons. They scavenge your system for other atoms and molecules to steal their electrons; this process results in oxidative stress.
Let’s think of it like this: when you take an avocado and leave it out, it is exposed to oxygen and begins to oxidize. Your system reacts similarly to foreign unstable molecules and toxins.
Pollution, smoking, alcohol, heavy metal exposure, pesticides, improperly cooked seed oils, overcooked animal fats, prescription drugs, industrial chemicals, and UV exposure are all things that can cause free radicals to enter your body. In addition, things like processed foods, physical or emotional stress, lack of sleep, and poor diet contribute to free radicals. Even your cosmetics can be a source of free radicals. Long-term exposure to free radicals can cause chronic inflammation.
Inflammation caused by foreign agents like pathogens, allergens, toxic chemicals, or bodily injury can activate the immune system. This response comprises inflammatory cells and cytokines, causing more cells to respond. There are pro-inflammatory and anti-inflammatory cells and cytokines. Many of the pro-inflammatory cytokines are involved in developing melasma. In addition, several different inflammatory cytokines are secreted by multiple skin cells; the negative impact of inflammatory factors can easily overwhelm cell pigmentation communication.
Histamine plays an important role in inflammation and can significantly impact hyperpigmentation. Melasma skin or hyperpigmentation has an increase of mast cells in the discoloration. Histamine is released through mast cells after UV exposure and binds to histamine receptors on melanocytes inducing a cascading effect stimulating pigmentation or melanogenesis. People with histamine intolerance may want to explore this avenue for causation.
Histamine is the chemical that triggers symptoms like runny nose, sneezing and other allergy symptoms. The process isn’t entirely understood of how histamine causes pigmentation but it seems to play an important role.
Hormones can also influence inflammation; cortisol can weaken the gut lining, causing inflammation to rise. Estrogen participates in the regulation of immune and inflammatory processes. Both outcomes can lead to chronic inflammation, whether your estrogen is high or low. Estrogen also influences the activation of autoimmunity. Women are more likely to have autoimmune conditions than men; this may have to do with the estrogen factor. Inflammation can also influence thyroid function. So not only is inflammation directly responsible for skin cell signaling, but it is also heavily affecting your hormones and their ability to regulate or communicate with other cells and receptors to keep your body in balance.
Is melasma hereditary?
Not likely, and there isn't a ton of science on that. There are a lot of different genes that are upregulated or downregulated during melasma. It doesn't make it a cause of melasma but will affect your ability to reverse any skin condition, particularly melasma.
Your genes can turn on and off based on diet, lifestyle, and toxicity load.
MTHFR is a genetic mutation that affects many different functions. It is in every cell in the body and can affect how your body detoxifies the liver, influence estrogen metabolism, regulate inflammation and neurotransmitters. As a result, it can impact your overall balance and health.
Liver-related genes might make it harder for your body to process toxins, leading to a sluggish detox pathway. For example, there is a gene that doesn’t allow you to process certain types of B12, leading to deficiencies that could be worse than the average person.
Metallothionein is a cysteine-wrapped protein that affects how your body processes heavy metals, DNA damage, and oxidative stress. A mutation in this gene could inhibit or slow your body’s ability to process these toxins.
Though it is often said that melasma is genetic, I can find no strong evidence to support this in my research. That said, genetic factors can affect treatment, so understanding genetic and epigenetic conditions can be a valuable tool in reversal.
The most important thing to know is that even if you have a mutation that affects your body, and most of us do have one or two, there are ways to support that pathway; it isn’t an end-all situation. It’s just something to be aware of because maybe one supplement might be better than another, or you might understand why your melasma is extra stubborn.
Drug-induced melasma.
Birth control is the most commonly understood drug that induces melasma, but it is not the only one. Medications can disrupt hormones, influence the gut microbiome, congest the liver, slow detox pathways, and influence vitamin and mineral uptake.
When healthcare providers prescribe these drugs to their patients, side effects are rarely discussed.
Some categories are:
Being on medications for long periods can cause so many imbalances if one is not getting the proper nutrition or micronutrients at the same time.
Now you know!
These are the primary causes of melasma. There are more factors to consider, which I will be discussing in upcoming articles. There is still some unpacking to do before we get into the healing process.
Be sure to subscribe so you can follow the conversation.
Tell me how you got melasma or what you think started yours.
References
https://jsstd.org/current-concepts-in-melasma-a-review-article/
https://onlinelibrary.wiley.com/doi/full/10.1111/exd.13915
https://jcadonline.com/catamenial-hyperpigmentation/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002987/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839836/
https://pubmed.ncbi.nlm.nih.gov/24854026/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8747646/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926358/
https://link.springer.com/article/10.1007/s13555-022-00779-x
Hi.
I have had melasma for 4-5 years now. I’ve tried all of the med spa treatments that ended up making matters worse.
I’ve controlled it with creams and trying to be disciplined about using sunscreen.
I read your info on the internal issues that can cause melasma and completely agree with you.
I had my hormones checked a couple years back and my progesterone was low. She gave me something to help bring that back up.
I didn’t notice any difference and never went back.
I just recently did a hormone test that I did at home and sent it.
According to those test, I was good on all my levels.
I’m not sure what to do anymore.
The medspa I go to wants me to pretreat my skin with a cream and then do something they call the “Halo” that basically burns the top layer of your skin off, and that it’s helped with removing melasma.
I’m really nervous about it. I’ve heard a lot of different views on it.
I’m just ready to have normal skin again.
Hi Janell,
I completely understand how you feel. I will be doing an article on how to read hormone test levels for optimum ranges and tests that help read with better accuracy than most blood serum tests. There is a difference and that will help you understand the difference between optimum ranges and what conventional medicine says “normal” ranges are. There are other contributing factors that I’ll be getting into. As far as the “halo” treatment, it is a fractional laser and can highly aggravate melasma, I would say that one is a hard no. I was never willing to take risks with my skin.
Wonderfully written as always! Thank you so much for all your hard work on this topic. For me mine coincidently started a year after I had my 1st myomectomy op (and also after I was prescribed esmya) – a drug which helps shrink fibroids before surgery, but I found out later that can cause some people liver damage and they stopped prescribing to patients for a time. . In my ignorance I was having such a great life on it for a few months, no periods or pain it was a dream! Felt like I was a teenager again. My liver is fine from blood tests and scans so that is good . But Makes me wonder if my microbiome is all messed up as I’ve never had the best gut health, plus I used to have extreme stress, years on iron tablets, tranexamic acid, nsaids and I had previously smoked. Sometimes I wonder if I’m just a walking mess of inflammation, altho my crp levels are low (<5)… Can low grade inflammation show up on a high sensitivity crp test I wonder. Anyway sorry for this essay, potential melasma solutions seem to overtake my life these days! Looking forward to your next blog post! Xx
Hi Claire,
Did you mean .5mg/L? This would be considered low unless you meant 5.0mg/L then that would be very high CRP levels. Most people generally fall around 3.0mg/L which is fairly high. CRP is generally a good indication of inflammation so it just depends on how the range is being read. The gut and liver both play a major role, too much iron can also be a factor. Yes like most, it is always a combination of things that disrupt the skin cell signaling.
Hi Ariana so our range for regular crp is 0-5 mg/L and my result just shows <5.0 So from that it could be any number below 5. Perhaps nhs doesn't bother with exact figures. As it's in their range might not even be worth to go for hs crp in that case.
Yes, so you may want a more accurate test for CRP.
Thank you so much for sharing all your knowledge and helping those us who are plagued by this awful condition. This is one of the best summaries of the different causes of melasma I’ve ever seen. Written in plain English, but very thorough. You have powerfully connected the dots that so few medical professionals do…thank you. I’m excited to read more of your blog!
Natasha! Thank you so much for the thoughtful comment. I plan to lay out a road map of how’s and why’s, I look forward to sharing more with you.
Thank you for sharing. Very informative
Hi Sian,
You are very welcome. Thanks for being here!