The mask of pregnancy: What mums-to-be need to know about chloasma

As an expectant mum's body makes room for her growing baby, she will experience various physical changes, one of the most common being skin problems, like hyperpigmentation. Learn about chloasma, or melasma in pregnancy here.

Chloasma: Melasma in pregnancy

Hyperpigmentation causes skin darkening due to an increase in melanin production. Melanin is responsible for the colour of our skin.

Melasma, which is also referred to as chloasma, is a type of hyperpigmentation. Also known as the "mask of pregnancy," melasma often appears as brown, tan, or blue-grey patches on the face, particularly around the nose, cheekbones, and jaw.

Melasma is a skin condition in which your skin's melanocytes (pigment-producing cells) create excessive pigment for unknown reasons. It's known as chloasma, or the "mask of pregnancy", throughout pregnancy.

Chloasma is a skin condition. It has no effect on your baby and does not signal any other pregnancy issues.

The cheekbones, nose, chin, area above the top lip, and forehead are where melasma most frequently develops. Your arms, neck, and back can occasionally be affected. Melasma can, in fact, affect any area of your skin that is exposed to sunshine. The majority of melasma sufferers observe that their symptoms worsen in the summer, which explains why.

During pregnancy, the steep escalation of oestrogen (primary female sex hormone) causes an increase in pigmentation on the face — thus why the condition is commonly referred to as the mask of pregnancy.

There are three types of melasma:

• Epidermal melasma. The most superficial and thus the easiest to treat. Occurs on the outermost layers of cells on the skin. It is usually dark brown in colour and has a well-defined border. This form of melasma is more visible under black light.
• Dermal melasma. Occurs in the deeper mid-layer of the skin. It has an ill-defined border and is light brown or bluish in colour. Dermal melasma responds poorly to treatment and is more persistent.
• Mixed melasma. This is the most common type of melasma and as the name suggests, has properties of both epidermal and dermal melasma. It is characterised by a combination of bluish, light and dark brown patches. With treatment, this variant of the condition improves partially.

Why do women get chloasma

Senior Dermatologist and previous Deputy Medical Director at the National Skin Centre, Dr Tham, Tham Siew Nee Skin Clinic (Gleneagles Hospital), explains how the rise in oestrogen during pregnancy triggers excess melanin (responsible for skin and hair colour) production.

This explains the darkening of the skin. Apart from the face, melasma also affects other areas of the skin such as the nipples, areola and vulva. Your existing moles and freckles may darken and there is likely to be a dark line down the centre of your abdomen (linea nigra).

Causes of melasma in pregnancy

As in the case of many medical conditions, it is difficult to pinpoint the exact cause of melasma. There are however a number of factors that increase the likeliness of it occurring.

• Hormonal changes. Oestrogen and progesterone sensitivity are commonly associated with melasma. As such, pregnancy, the consumption of birth control pills and hormone therapy (hormone replacement, intrauterine device and implants) are responsible for about a quarter of melasma cases.
• Genetic predisposition. In her 30 years of practice, Dr Tham has observed that many patients with melasma report a family history. If your mother had melasma during her pregnancy, there are high chances that you too might. Melasma is linked to the presence of overactive melanocytes (cells that produce melanin which gives our skin its colour).
• Exposure to ultraviolet rays. Ultraviolet A (long-wave) and Ultraviolet B (short-wave) rays are known to stimulate the production of melanin. Constant and frequent exposure to the sun in itself, or in conjunction with other triggers can cause melasma to occur.
• Cosmetics. Scented cosmetics and skin products, deodorants, soaps and toiletries may cause a phototoxic reaction (chemically induced skin irritation) which in turn triggers melasma. Melasma that occurs as a result of this may persist in the long run.
• Hypothyroidism. Low levels of thyroid hormone in the body, along with stress has also been linked with the occurrence of melasma.

Risk factors for chloasma

Dr Tham states that melasma can just about affect anyone, but the following groups of people face higher risks:

• Women in their reproductive age. Though not restricted to, women between the age of 20 to 40 are more likely to develop melasma. This is due to the link between melasma and hormonal changes. Chloasma can also occur due to hormonal imbalances outside of pregnancy, such as in individuals taking hormonal contraceptives or undergoing hormone replacement therapy. Fluctuations in hormone levels can contribute to the development of chloasma in these cases.
• Woman with tanned skin. Melasma occurs more commonly among people like Asians and Hispanics, who tan well or have naturally brown skin. People with very fair or black skin are less likely to get melasma. The increased melanin content in their skin makes them more susceptible to hyperpigmentation.
• Women who live in tropical climates. As melasma is closely linked with sun exposure, people living in tropical climates and who are always under the sun are highly susceptible to melasma. Which of course means that Singaporean women are likely candidates!
• Women who have family with melasma. Some individuals may have a genetic predisposition to chloasma. If there is a family history of chloasma or other skin pigmentation disorders, the risk of developing chloasma may be higher.
• Women who are taking certain medications. Certain medications, including oral contraceptives, hormone replacement therapy, and thyroid medications, can influence hormone levels and potentially increase the risk of chloasma development.

In her practice, Dr Tham notes that melasma is a common condition in Singapore and that all racial groups seem to have equal chances of developing it. She emphasised that melasma is definitely more common among those who are constantly outdoors.

So mums-to-be, it might be a good idea to give the tanning a break and head indoors instead!

The good news

Chloasma is common and there is nothing about it that is serious enough to cause you to be a bundle of nerves or make your blood run cold. The hyperpigmentation usually disappears after delivery or at times, when you stop breastfeeding. It is an aesthetic problem more than anything else.

The bad news

As melasma is not exclusive to pregnancy, there are chances that it may reappear later in life. It is generally caused by hormonal changes and as such, throughout your reproductive age, you remain susceptible to the condition.

Symptoms of melasma

Dr Tham describes melasma to be an asymptomatic (a disease or infection with no symptoms) condition. It is mainly a cosmetic problem appearing as irregular pigmentation mostly on the cheeks, nose and forehead.

Patches of discolouration, darker than your normal skin colour tend to appear on your face in a symmetrical manner.

Melasma causes coloured patches to appear on your cheeks, chin, forehead, the bridge of your nose and at times even your upper lip. Other areas of your skin such as your neck and forearms, which are in more contact with sunlight may also face discolouration.

Melasma typically presents itself as freckle-like spots or larger, flat and brown patches. It appears symmetrically on both sides of your face with an irregular border. At times you may also encounter reddened or inflamed forms of melasma.

Symptoms of chloasma

Meanwhile, here are five common symptoms associated with melasma in pregnancy:

Hyperpigmented patches

The hallmark symptom of chloasma is the presence of hyperpigmented patches on the face. These patches are typically brown or greyish-brown in colour and appear symmetrically on the cheeks, forehead, nose, and upper lip.

Mask-like appearance

Chloasma often takes on a mask-like appearance, hence its name. The patches may resemble a butterfly shape across the cheeks and nose or appear as larger areas of pigmentation on the forehead.

Darkening upon sun exposure

Sunlight can exacerbate chloasma, causing the patches to darken further. The affected areas may become more pronounced and visibly darker after sun exposure.

No associated itching or pain

Chloasma is typically a cosmetic concern and does not cause any associated itching, pain, or discomfort. The patches are primarily a result of increased pigmentation and do not involve inflammation or other physical symptoms.

Resolution after childbirth or hormonal changes

In cases of chloasma during pregnancy or hormone use, the condition may gradually fade and improve after childbirth or discontinuation of hormonal treatments. However, it's important to note that complete resolution may take time, and some individuals may require further treatment or management.

When does melasma show up in pregnancy

According to Healthline, although melasma can start at any stage during pregnancy, it often does so in the second or third trimester.

Once more, there are many variables at play as pigment darkens. Depending on your skin type and tone, this issue may be more or less evident. When you first notice it may also depend on how much time you spend outside in the sun or even the season when you're pregnant.

Tests and diagnosis

Melasma is not a very complicated condition and its appearance is highly characteristic. A simple visual examination is usually sufficient for diagnosis.

At times, your doctor might advise you to undergo other tests to rule out certain conditions or specific causes. In rare situations, a skin biopsy (sample skin tissue taken for close examination) may be ordered to confirm the diagnosis of melasma and rule out serious skin conditions.

One of the testing methods that may be used is known as the Wood's lamp examination. This involves holding a special kind of light up to your skin. This examination aids in determining if there is any infection present and the type of melasma (how many layers of skin are affected) that has affected you.

Dr Tham wishes for you to know that although melasma is generally harmless, it is necessary to get the diagnosis confirmed by an experienced doctor as some conditions like drug-induced pigmentation or contact dermatitis may appear similar.

Treatment for melasma and chloasma

While melasma treatment options are aplenty, many treatments are not safe during pregnancy or while breastfeeding. Azelaic acid, a topical cream and a glycolic acid chemical peel are considered safe but it is a must to consult your doctor before using any of these.

The following are melasma treatment options available out there, but most of them can only be done after you have delivered and/or stopped breastfeeding:

• Hydroquinone. This medication works by blocking the activity of melanocytes (melanin-forming cells that contribute to pigmentation). It is a prescription cream that you need to get from your doctor. Dr Tham cautions that high concentrations of hydroquinone should be avoided as it can cause increased pigmentation.
• Combination creams. tretinoin, cortisone and hydroquinone combination creams have been found to be effective in lightening the appearance of melasma, but may also cause skin irritation. But do remember this tip for this melasma treatment: the cream should be used only under close supervision by your doctor.
• Cosmeceuticals. Some cosmeceuticals like kojic acid, azelaic acid and arbutin are also reported to be effective but the effects appear to be milder than hydroquinone.
• Vitamin creams. These are anti-oxidants and may be used to complement the above treatments. Vitamin C creams are generally quite safe for use during pregnancy but as always, it is best to check with your doctor prior to using any product during pregnancy.
• Folic acid intake. Studies have proven that folic acid deficiency is linked to hyperpigmentation. In addition to your pre-natal supplements, you can consume food like green leafy vegetables, oranges, whole-wheat bread, and whole-grain cereal. All of these contain folic acid.
• Chemical peeling. Chemical peeling in combination with lightening agents may be useful melasma treatment for some people.
• Laser treatment. Laser treatment with Nd:YAG laser have been used to treat deep pigmentation but this has to be done with care and only by experienced doctors.

It is unpleasant to have blotchy skin and it is only natural to want to do something about it at soonest, but it is very important not to do anything that is unsafe for you or your baby during this crucial period. Peels, bleach and other lightening treatments should not be used during pregnancy for they may penetrate your skin.

Don't even think about laser treatments as a melasma treatment option!

Real story of a mum with chloasma

Administrative manager Mdm Fauziah developed melasma during her first pregnancy. She shares her experience:

"I have always been very conscious about the way I look and so pregnancy, and the changes it brought, put me on an emotional roller-coaster. First it was the weight gain, then the puffiness, then the skin patches (melasma), the line down my belly and whatnot.

Initially, I became self-conscious and even depressed whenever I saw a change and when my face started having these pigmentation problems, it was like the icing on the cake. I was so upset and wanted to do whatever I could to get rid of it. Then when I consulted my doctor and read up about how some treatments might be unsafe, I snapped out of it.

Suddenly I felt quite ashamed of myself. I realised that all these things that were changing in my body were a small price to pay for a bigger blessing. My husband also comforted me by reminding me that these changes are not permanent."

So remember ladies, if you feel self-conscious or that your confidence is shaken, you are definitely not alone. Hang in there and you can seek treatment options when the time is right!

Does chloasma go away after pregnancy

The good news is that this hyperpigmentation is unlikely to worsen after your baby is born. However, without any focused treatment, it may take a long time, possibly months, to totally diminish.

Many people find that their dark spots due to melasma improve once they're no longer pregnant, when their hormonal levels return to their pre-pregnancy levels. Keep in mind, though, that once you've had this patchwork pigmentation, you're more likely to get it again if you get pregnant in the future.

Chloasma usually disappears after birth or when you stop breastfeeding. Once the hormones return to its original hormonal balance, dark spots will fade away.

Thankfully, it simply affects your skin's appearance, and it's not the type of skin disorder that causes cancer or can lead to cancer. However, because there are skin malignancies that resemble melasma, it's critical to contact your dermatologist for a proper diagnosis.

Consult your doctor for advice on how to manage your chloasma. For more information, your doctor could suggest that you consult a dermatologist.

Some medical professionals advise against treating melasma when pregnant. One explanation is that it might get better on its own. Additionally, using some treatments while pregnant may not be safe or effective.

With the aid of a few lifestyle modifications, prevention might potentially be the greatest form of treatment.

How to avoid melasma during pregnancy

Avoid sun exposure

This does not, however, imply that you must remain indoors when the sun is shining. It's beneficial to use a good pregnancy-safe sunscreen with an SPF of 30 or higher.

Rather than chemical blockers, look for sunscreens that contain zinc oxide, titanium dioxide, or other physical blockers (mineral sunscreens). Physically applying sunscreens provides more coverage and may be less irritating to the skin.

Use protective clothing

Clothing with or without UV protection, such as SPF rash guards or sun-protective clothing, is another alternative for sun protection. Loose-fitting clothing, even if it's warm outside, can keep you cool and protect your skin.

How about the face? Hats with a wide brim are your best friend. Don't forget to wear a trendy pair of sunglasses, the larger the better.

Use gentle skin products daily

Irritating face cleansers, lotions, and serums may aggravate your melasma. Instead, slather on some soft products. If you're overwhelmed in the beauty aisle, look for words like "non-comedogenic," "sensitive," "fragrance-free," or "dermatologist approved" on the label.

The same can be said for whatever cosmetics you could use to cover up the dark spots. Look for foundations, concealers, powders, and other cosmetics that are non-comedogenic or hypoallergenic.

Avoid drugs, products, and procedures that may aggravate your pigmentation, such as:

• Hormone therapy, particularly those involving estrogen
• Birth control, particularly estrogen and progesterone-containing oral contraceptives
• LED light from your TV, laptop, phone, and tablet
• Any makeup that irritates your skin
• Medications that can induce or exacerbate melasma
• Soaps with scents
• Skincare items that cause irritation
• Beds for tanning
• Waxing, which worsens melasma

Melasma treatment in pregnancy

Now, you may be wondering how to treat melasma during pregnancy. Here are some ways or some melasma treatment in pregnancy that you may try:

1. Use topical lotion

If chloasma doesn't disappear after giving birth, talk to your dermatologist about other options. Since it may take months before the discolouration completely fades, many women are prescribed topical medications, like hydroquinone, tretinoin, and corticosteroids.

Certain acids that lighten the skin, either alone or in combination, may be recommended by your doctor but take note that it can only be treated after childbirth.

2. Home remedies

There are also home remedies that are effective in treating melasma. If you prefer to treat melasma the natural way, here are some home remedies to try: lemon juice, apple cider, milk of magnesia, oatmeal and honey.

• Lemon juice

Combine half fresh lemon juice and half cucumber juice (or water) in a solution. The acid in the juice may aid in the removal of pigmentation in the skin's top layer.

• Apple cider vinegar (ACV)

To use as a toner on dark areas, make a solution with half ACV and half water.

• Milk of magnesia

After washing your face, use a cotton ball to apply milk of magnesia to dark areas. Allow to sit on the skin overnight and then wash off the next morning.

• Oatmeal and honey

Make a mask with raw honey and baked oats (let it cool so it's not too hot). Allow 10 minutes for the product to absorb into the skin before rinsing. The honey enzymes help to exfoliate your skin, and the mask may brighten it slightly.

If none of these treatments work, dermatologists usually recommend a chemical peel, microdermabrasion, or dermabrasion treatment.

3. Traditional Chinese medication (TCM)

TCM generally uses manual acupuncture (thin needles inserted into the body) and a range of herbs to treat melasma. Some mums are most comfortable with TCM and swear by it while others are sceptical due to the lack of medical evidence backing up TCM.

Whatever your choice is, similar to the other treatment options, most of these are not safe during pregnancy and breastfeeding. Wait until you have weaned your baby to explore these treatments.

Melasma treatment after pregnancy

Ask your dermatologist about your choices if melasma persists after you've weaned. Any number of therapies that can help reduce melasma may be approved, but they aren't safe to use if you're pregnant or nursing.

If your melasma doesn't go away naturally after pregnancy, talk to your dermatologist about other options. Topical drugs like hydroquinone, tretinoin, or corticosteroids are used as treatments.

Additionally, your doctor might advise you to use one or more of the acids that alone or together lighten skin. Additionally, there are other treatments that might be effective, such as chemical peels, microdermabrasion, laser therapy, and other light therapies.

How long will it take the drugs to start working? It is dependent upon the individual and the medication taken. Melasma may take some time to improve after treatment. Rarely do the aforementioned treatments completely eliminate all melasma.

Dealing with changes in your skin during pregnancy can be aggravating. Thankfully, chloasma usually goes away after a few months of giving birth.

You can try a variety of lifestyle adjustments to keep the issue from worsening during pregnancy. Otherwise, talk to your doctor about your treatment options and the advantages and disadvantages of each. Before you know it, you'll be glowing again!

Just so you know ladies, there is no completely foolproof method of preventing the occurrence of chloasma. Although in most cases prevention is quite successful, pregnancy hormones are a greater power than we can contradict and they thwart even the best of preventive measures!

The journey to meeting your little one is definitely interesting and those mischievous pregnancy hormones will never fail to surprise you. On some days you may strut around in full confidence and on other days you might not want to step out of your house.

But remember mummies, you are on one of the most beautiful journeys in your life and despite all these physical changes, you are beautiful. Don't ever let anything make you feel otherwise!

ALSO READ: Getting mood swings during pregnancy: Why it happens and how to manage it

This article was first published in theAsianparent.