Mask of Pregnancy (Chloasma)

What is melasma or the mask of pregnancy?

Appearance of dark patches on the face, especially on the forehead and cheeks is called melasma or melasma gravidarum. The skin darkening usually occurs due to hormonal changes, making women more prone to this symptom than men ^[1]. It is most common during pregnancy, being referred to as the mask of pregnancy or chloasma when occurring in pregnant women ^[2]. It is considered an early sign of pregnancy ^[3], as around 50%-70% of all pregnant women develop these dark patches in their first or second trimester ^[4].

Melasma can also affect women on hormone replacement therapy and those taking oral birth control pills as these lead to hormonal changes as well. ^[5].

What are the characteristic clinical features of chloasma?

Characterized by dark freckle-like spots and large brownish or bluish gray patches on the face ^[6], it does not usually cause any skin irritation or itching. Depending on the area of skin darkening, chloasma is said to have the malar pattern when skin discoloration only affects your cheeks and nose while the mandibular pattern refers to dark patches developing down the jaw line. The centrofacial type occurs when skin darkening can be noticed all over the face, including your forehead, cheeks, upper lips and nose ^[1].

What causes melasma during pregnancy

The occurrence of melasma is usually associated with female hormones estrogen and progesterone ^[7], which partially explains why it is so common among women during pregnancy or those having post-menopausal hormone replacement therapy (HRT). A sudden considerable rise in the hormone levels leads to increased melanin production (hyperpigmentation) causing the skin to darken ^[8].

The melanocyte-stimulating hormone or MSH levels also increase during pregnancy along with your estrogen and progesterone levels. Melanocytes are the skin cells responsible for pigment deposits. Higher amounts of MSH can lead to this problem by boosting the pigment deposits. However, the mask of pregnancy is more often associated with increased progesterone production rather than the estrogen and MSH levels ^[9].

What are the risk factors of the mask of pregnancy or chloasma?

Family history of chloasma as recent studies have found evidence of genetic involvement in its occurrence ^[6]
Exposure to direct sunlight as UV ray tends to darken skin pigmentation ^[10]
Having an Asian or African decent as higher amount of pigmentation in darker skinned women make them more prone to the condition compared to fair skinned women ^[8]
Having a history of melasma in a previous pregnancy as the skin discoloration tends get more prominent with each pregnancy ^[11]
Using cosmetics and medicines that make your skin more sensitive to sunlight ^[5]

How to prevent melasma during pregnancy

It is not possible to prevent the pregnancy mask in most cases as it is often associated with hormonal and genetic factors. However, taking certain measures might help to make it less noticeable:

Wearing full sleeve clothes and using an umbrella to avoid direct sun exposure as much as possible
Applying a sunscreen lotion (at least SPF 15) when going out during daytime ^[12]
Using mild, fragrance-free and oil-free cosmetics and soaps
Including folic acid rich foods, such as whole-grain cereals, leafy green vegetables and fresh fruits (orange and grapefruit) in your daily diet as folate deficiency is often associated with hyperpigmentation ^[8]

Is the mask of pregnancy harmful for the baby?

Although the dark marks covering your face, and sometimes even your neck, chest, arms and legs, can take a huge toll on your self confidence, making you feel hideous at times, it does not actually cause any harm to your baby ^[13].

How to get rid of pregnancy mask on face

The dark patches usually go away on their own once you deliver your baby and your hormone levels go back to normal ^[5]. However, treatment may be necessary in persistent cases.

Over the counter treatments for melasma

There are certain over the counter hydroquinone creams available that are often used for lightening the skin. Most of these products contain 2% hydroquinone, while some of them also contain sunscreen, providing protection from sunlight as well ^[14]. Retin A (tretinoin) is another similar topical treatment option. However, using these medicated creams is not suggested unless your doctor recommends them to be safe for the baby as they are included in the FDA Pregnancy Category C (as risk cannot be eliminated) ^[15]. Many health care practitioners advise to avoid both in pregnancy ^[16].

Natural treatment for melasma in pregnancy (chloasma)

Apple cider vinegar: Topical application of apple cider vinegar on the affected area once or twice a day can help to gradually cure the skin darkening.
Lemon juice: Squeezing some fresh lemon juice and then applying it on your dark skin patches twice daily can help to get rid of the problem within a few weeks.
Horseradish: Applying horseradish paste on the discolored skin areas and leaving it on for 10-15 minutes before washing it off properly with lukewarm water can be effective for this purpose. However, it is not recommended to eat horseradish or use it in a tincture form during pregnancy for possible side effects ^[17].
Grapefruit seed extract: The vitamin C and antioxidants in grapefruit seed extracts can help to fight the skin problem with regular topical application. However, there is a lack of evidence regarding their skin lightening effects.
Essential oils: Various essential oils, such as tea tree and lavender oils, are rich in vitamins and antioxidants, making them highly beneficial for various skin ailments. However, it is recommended to consult your doctor or midwife before using any of these remedies due to certain serious side effects associated with the use of essential oils in pregnancy.
Banana Mask: Applying some fresh banana pulp on the affected skin areas, leaving it on for around 15 minutes before rinsing off with cold water reduces dark marks, making your skin bright and supple.
Aloe vera: Applying an aloe gel or fresh aloe vera on the discolored skin patches is a useful home remedy as well.

Other measures for pregnancy mask removal

Homeopathy: There are various homeopathic remedies as well including sepia offincinalis and sulphur. However, they should not be used without consulting your midwife.
Relaxation techniques: Doing regular yoga or practicing some relaxation techniques can help manage the hormonal imbalance to some extent by reducing stress (as stress contributes in hormonal imbalance).
Makeup to cover melasma: Using a concealer and a foundation that matches your skin tone until the spots clear on their own is one of the safest ways to deal with it. Make sure to use hypoallergenic, non-comedogenic products ^[8] to avoid any further skin problems as your skin is extra sensitive during these nine months.

How to get rid of pregnancy mask after pregnancy

Consult your doctor regarding the possible treatment methods to clear chloasma if it refuses to go away after your baby is born. However, most traditional treatment methods are not safe for breastfeeding women. So, your doctor is likely to recommend the above mentioned non-prescription anti-melasma creams and safe natural remedies for now. You can try the topical therapies, chemical peels and laser treatments if the problem persists even after you wean.

Melasma treatments not recommended for pregnant women

Chemical peels: Chemical peels are not safe to use in pregnancy as they contain various chemical agents that might penetrate the skin to enter your bloodstream, eventually getting in the baby’s body ^[1]. Topical alpha hydroxyacids (lactic acid and glycolic acid), salicylic acids and topical retinoids are all potentially harmful.

Laser treatment: Laser treatments are out of bounds as well, as they can irritate the skin, especially during this time ^[8].

Prescriptions creams and ointments: Most prescription creams contain 4% hydroquinone, with the other ingredients in these combinations being certain phenolic hypo-pigmenting agent, retinoic acid (tretinoin), nonphenolic bleaching agents, azelaic acid and/or kojic acid ^[6]. These are not recommended for pregnant women as the high percentage of hydroquinone, as well as the other components may lead to serious harm to your baby.

Myths related to the mask of pregnancy

According to old wives’ tales, having a dark mask of pregnancy means you are having a boy while not having the symptom at all indicates that you will be giving birth to a girl. However, there is no scientific evidence to these claims.

Melasma ICD-9 and ICD-10 codes

The ICD-9 code used for melasma is 709.09 ^[18], while its ICD-10 code is L81.1 ^[19].

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