Pregnancy & Nursing Safe Melasma Treatment

Key points about melasma in pregnancy

Picking out pregnancy-safe skincare can seem complicated. I have an entire page on pregnancy beauty, dedicated to which skincare ingredients to avoid during pregnancy, breastfeeding, or IVF.
Today is about melasma in pregnancy.

• Melasma typically begins in the second or third trimester.
• Upto 50% of pregnant women may be affected by it.
• There is no one/single best treatment for melasma.
• When pregnant, the options for melasma treatment are limited for the safety of the growing baby.
• A broad-spectrum, zinc-oxide based mineral sunscreen that is tinted (with iron oxides) is the sine qua non for melasma management.
  The tint in the sunscreen will not only help with blocking visible light but also camouflage the pigmentation.
• Sun protection will not only help fade the melasma but also prevent it from recurring.
• Before you decide to undertake treatment for melasma, it is essential to keep in mind that melasma tends to fade when the trigger is no longer there- in this case, pregnancy. Many will find their melasma fading once the pregnancy is over.

General care in melasma

Strict UV & visible light protection

• Use appropriate sunscreen.
• Use hats and sunglasses, and seek out shade when out.
• No tanning beds, sunlamps, or sun basking.

Basic skincare practices

• Use non-perfumed products (perfumes are a source of allergens & can irritate your skin)
• Use cosmetics minimally or use products tailored for sensitive skin.
• Do not rub the affected areas vigorously.
• Avoid waxing areas with melasma, which can cause inflammation and worsen it.

What are my options for treating melasma when pregnant?

During pregnancy, melasma typically does not require any particular treatment besides the use of an effective sunscreen, sun protection with hats and sunglasses, seeking shaded areas, etc., and avoiding the use of any photosensitizing products and an inappropriate skincare routine.
Furthermore, it often fades away a few months after birth esp. when combined with a sun-protective routine.

The options for melasma management in pregnancy are:

1. Sunscreen & sun protection
2. Vitamin-C
3. Azelaic acid

1. Sunscreen & Sun Protection

There is a good body of evidence in the medical literature about the efficacy of sunscreens alone for treating melasma when pregnant.

• A study conducted on 200 Moroccan women who were <3 months pregnant showed that using a broad-spectrum high SPF of 50 resulted in only 2.7% developing melasma compared to 53% in the same time period and geographical area as studied by the same investigators.
  The study also found improvement in 8 of 12 women who had pre-existing melasma.
• This study evaluated the role of sunscreen alone in melasma. It concluded that there was a statistically significant improvement in melasma after 12 weeks of sunscreen alone, which also improved the quality of life of the patients.

A tinted (containing iron oxide), broad-spectrum mineral sunscreen of predominantly zinc oxide, with a minimum SPF of 30, is the mainstay of treatment for melasma.

Details on how to choose the right sunscreen and a list of the best sunscreens for melasma and hyperpigmentation are given here:
Top 10 pregnancy & lactation-safe sunscreens for melasma & hyperpigmentation.

2. Vitamin C

Vitamin C (ascorbic acid) has the following benefits:
1. A potent antioxidant
2. Blocks the enzyme tyrosinase needed for melanin production- this inhibits melanin production and, thus, reduces the dark spots.
3. Promotes collagen synthesis.
4. Photoprotective action against UV-A rays.

Few considerations before you incorporate it into your skincare regimen:

• Alone, it is not a potent agent for the treatment of melasma. It might lighten the hyperpigmented spots and even out the skin tone.
• Its efficacy increases as the concentration does, but only up to 20%. Higher concentrations only lead to increased skin irritation.
• In melasma, always start at a lower concentration, as starting immediately at a higher percentage may irritate and inflame your skin, causing more damage.
• It comes in various forms, and not all forms are created equal. Choose one that is best suited for your skin type. E.g., sodium ascorbyl phosphate is water-soluble and better suited to oily skin; ascorbyl palmitate is fat-soluble and thus better for drier skin types.
• L-ascorbic acid is the most active form and the gold standard; it is highly unstable and needs dark, airtight packaging and additives like vitamin E & ferulic acid to stabilize it.
• Always patch test on a small area of skin.
  
  Here is a list of the best vitamin C serums for your skin:
  10 Best Pregnancy Safe Vitamin C Serum for Healthy & Glowing Skin

3. Azelaic Acid

Azelaic acid, a naturally occurring chemical in some grains like wheat and barley, helps in melasma through its following properties:

1. Inhibition of hyperactive melanocytes, thus reducing melanin production.
2. Reduction of free radicals that can cause skin dullness.
3. Mild exfoliative action that encourages cell turnover to promote new and healthy skin growth.

It is typically available in a cream formulation at 10% or 20% concentration.

Some studies have found 20% AA alone to be superior to 2% hydroquinone and as effective as 4% hydroquinone without the latter’s side effects.

It is often combined with other actives like topical retinoids and glycolic acid in the non-pregnant for improved efficacy and results.

The additional benefit of using azelaic acid?
It is also helpful for pesky acne that can often crop up in pregnancy, making it one of the safe treatment options for treating acne during pregnancy.

Here is a list of the best Azelaic Acid face products:
Best Pregnancy & Lactation Safe Azelaic Acid Serums & Creams

Note on Kojic acid & Arbutin.

Kojic acid is a naturally occurring acid that is extracted from mushrooms or Japanese rice wine (sake).
Arbutin is produced from hydroquinone through chemical reactions.
Both inhibit the enzyme tyrosinase, essential for melanin production, and are effective, although not a treatment standard for hyperpigmentation.

These two agents are relatively newer in melasma management.

The safety profile of Kojic acid was studied in the following two studies, and it was found to be safe for use as a cosmetic ingredient when pregnant:

1. Assessment of the genotoxicity and human health risk of topical use of kojic acid
2. Final report of the safety assessment of Kojic acid as used in cosmetics

Arbutin, a chemically modified form of hydroquinone, is considered to have much lower toxicity than the parent compound. However, hydroquinone is contraindicated in pregnancy, and the safety concerns of using its derivative remain.

However, these drugs have not been classified and are not yet FDA-approved.

Also, used alone, they are not very effective for melasma management.

Before using kojic acid and arbutin in pregnant women, the other options and the risk vs. benefit ratio should be assessed.

What treatments can I not use when pregnant?

• The Gold Standard and very effective treatment for melasma is what is known as ‘Triple Combination Cream.’
  This is a mixture of 3 very effective depigmenting chemicals- hydroquinone, tretinoin, & corticosteroid. The first two are absolutely contraindicated, and corticosteroids have a very restricted use in pregnancy.
• Lasers
  These are being increasingly used for melasma treatment with mixed results. There is no study of the effects of these devices on the pregnant human population for cosmetic purposes, and we do not know how they will affect the developing baby. Thus, lasers are typically avoided when pregnant.
• Chemical peels
  Peels, while pregnant, are not advisable due to the increased concentration of the chemicals used in a peel.
  The use of peels in managing melasma is also tricky, as it is a second-line treatment and should be avoided in certain types of melasma and patient population (or used with discretion) due to increased chances of scarring and worsening pigmentation.

And most importantly, melasma tends to improve after childbirth when you have access to broader and more effective treatment options.
Furthermore, due to the continued presence of pregnancy hormones, melasma will likely return soon.

Does melasma go away on its own?

Once the trigger of melasma (in this case, pregnancy) is over, melasma may fade within a few months after birth.
Undertaking suitable basic skin practices and the use of appropriate sunscreen & sun protection can enhance the fading.

However, melasma, in some cases, can be persistent and often hard to treat.

Takeaway

• About 50% of pregnant women may experience melasma in the second or third trimester due to hormonal changes.
• It typically tends to fade once the pregnancy is over.
• Pregnancy-safe zinc-oxide based tinted sunscreen with a minimum SPF of 30, combined with sun protection measures, is the most important and often the only line of management that is required.
• Vitamin C and Azelaic acid may be used for melasma treatment during pregnancy.
• Hydroquinone, retinoids, steroids, lasers, and chemical peels are contraindicated when pregnant.