Women can develop pigment changes during pregnancy

This is our second blog in a series of skin changes during pregnancy.  Last month I talked about stretch marks.  This month I will discuss the pigmentation changes that occur with pregnancy.   Many of us are familiar with the “mask of pregnancy” or melasma.  Melasma is an acquired hypermelanosis of sun-exposed areas, which means there is extra melanin in the skin in these areas.  Melanin is a pigment your body produces, which determines the color of your skin, hair and eyes.  When there is too much melanin, your skin may have tan, brown or even black patches.  This most commonly is due to sun exposure, hormonal influence or previous trauma to the skin.  Melasma (or Chloasma) is the diagnosis given when these patches are the result of hormonal changes.  The uneven pigment commonly involves the face including the forehead, cheeks, chin and upper lip; although other sun-exposed areas may also be affected.  You may notice one of three patterns of pigmentation; involving the central face including the forehead, nose, chin and cheeks (centrofacial type), the cheeks only (malar type), or the least common type involving the jawline only (mandibular type).

We are unsure as to why certain women develop melasma during pregnancy and others do not.  There is likely a genetic influence, as many as 30% of women with this condition also have a family member with the diagnosis.  Of course hormonal changes are a contributing factor, but the exact mechanism is unknown.  Estrogen, progesterone and melanocyte stimulating hormone (MSH) are all increased during pregnancy and are likely contributing to these pigment changes.  Also, women who are on oral contraceptives (OCPs) and hormone replacement therapy have also been reported to develop this condition.  Finally, cases that develop during pregnancy may worsen with post partum oral contraceptive use and chronic sun exposure.

So, how do we treat this pigment problem?  First, be aware that this condition may be difficult to treat, but most women do experience improvement if treatment is instituted early and preventative measures are taken.  Recurrences are common, and almost certain, if strict sun protection is not employed.  This means a broad spectrum (both UVA and UVB protection) sunscreen is essential on a daily basis.  If possible, a sunscreen with a physical blocker such as zinc oxide or titanium dioxide would offer the most protection, but occasionally these may leave the skin with a white film.  If you prefer a chemical blocker, I recommend Anthelios SX daily moisturizing cream by La Roche-Posey, with SPF 15.  Also,  Anthelios 60 Ultralight Sunscreen fluid was just released to offer additional protection for the face, just in time for summer.   Additionally, if you develop melasma during pregnancy, you may want to review birth control options with your physician once you deliver your baby, remember oral contraceptives may worsen the condition or hinder treatment.

The mainstay of treatment for melasma is topical bleaching agents.  Hydroquinone is most commonly used and can be found in lower concentrations (2%) in over the counter creams.  I often recommend Ambi products for women with darker natural pigmentation.  Many of these agents also have a sunscreen built right in.  A prescription is required if you need a higher concentration of Hydroquinone, so you should see your dermatologist.  Some doctors also prescribe Retin-A which may be effective but somewhat slower than hydroquinone.   I often prescribe Tri-Luma cream for my patients.  It has Hydroquinone, Retin-A and a mild topical steroid, this combination results in improvement for most women.   These medications may cause skin irritation and very rarely, paradoxical hyperpigmentation so be sure to follow your doctor’s instructions.  Azelaic acid may also be beneficial as treatment for this condition but may also cause skin irritation.  Kojic acid and ascorbic acid have been used by some, mainly as combination therapy, for this condition.  Finally, lasers and medium depth peels have been used with varying success.  Be careful who you choose to perform these procedures; make sure they have experience with this condition and with your skin type.  Superficial glycolic acid peels and microdermabrasion are often used in combination with the depigmenting agents with good success.  These are relatively safe procedures with very few side effects and make actually speed up the lightening process.

Dr. Dara Spearman practices medical and cosmetic dermatology with Dermatology Associates of West Michigan, in Grand Rapids, MI. Dr. Spearman received her BS and BA degrees at Hope College where she graduated summa cum laude and was elected to the Phi Beta Kappa honor society. She completed medical school and dermatology residency at the University of Michigan where she was elected to the Alpha Omega Alpha honor society. Dr. Spearman has a special interest in skin of color and has lectures frequently on the topic. Her office website is www.myskindoctors.com.  Send your questions to Dara@smartnow.com.