Addressing the Challenges of Pigmentary Disorders in Women Across the Fitzpatrick Skin Spectrum

Pigmentary disorders, notably melasma and hyperpigmentation, disproportionately affect women, particularly those with skin of color.^1,2 Melasma is estimated to affect women 9 times more than men and has a prevalence rate of 15% to 50% in pregnant women,¹ whereas postinflammatory hyperpigmentation (PIH) affects approximately 56% of women.³ Women with higher Fitzpatrick skin types are at a greater risk of developing melasma² and PIH,³ particularly Asian, Latina, and Black women.^2,3

Valerie Harvey, MD, MPH, FAAD, a board-certified dermatologist specializing in pigmentary disorders and dermatologic conditions in patients with skin of color, shared key insights for clinicians on the diagnosis, treatment, and broader impact of these conditions in women and patients with darker skin types. Harvey is an active member of several boards and committees of the American Academy of Dermatology, a past president of the Skin of Color Society, and a Dermatology Times Editorial Advisory Board member.

Valerie Harvey, MD, MPH, FAAD

Q: In your opinion, what is the prevalence and impact of pigmentary disorders such as melasma among women, particularly those with skin of color?

A: The prevalence of melasma varies significantly depending on the population studied. For example, a population-based study in São Paulo, Brazil, which included 515 adult employees of the University Campus of Botucatu, Sao Paulo State University, found that melasma affected 34% of women and 6% of men.⁴ In a US-based study focusing on the Latino population in Texas, the prevalence was approximately 8%.⁴

Q: How do hormonal changes during pregnancy, perimenopause, and other transitions impact the onset or progression of melasma in women?

A: Melasma has a complex etiology and is considered a pancutaneous disease, resulting from an interplay of both endogenous and exogenous factors, including genetic predisposition, hormonal influences, the dermal microenvironment, and photodamage. Hormonal changes during pregnancy, perimenopause, and other transitions can significantly impact the onset or progression of melasma in women, as hormonal fluctuations are key contributors to its development.

Women make up 80% of melasma patients, with the typical age of onset occurring in the second to fourth decades of life. Approximately 10% of cases arise during the postmenopausal years. Notably, patients with higher Fitzpatrick skin types, or darker skin, tend to experience a later onset of melasma compared to those with lower Fitzpatrick skin types, presumably due to the protective effects of melanin.

Q: Are there specific challenges or considerations in diagnosing or treating melasma or other pigmentary disorders in patients with skin of color compared with lighter skin types?

A: Melasma is typically diagnosed clinically, based on the classic appearance of well-demarcated hyperpigmented brown patches, commonly located on the forehead, cheeks, nose, upper cutaneous lip, and chin. Extrafacial involvement, such as on the cervical area, sternum, and forearms, can occur in 10% to 14% of cases. For patients with darker skin tones, diagnosing and assessing the depth of pigmentation can be more complex. A Wood’s lamp examination can be useful in identifying subclinical disease, while color intensity and network regularity on dermoscopy may indicate pigment depth. These tools can be useful for determining the appropriate treatment approach, as the treatment response may vary based on the pigmentation depth and skin type.

Q: Could you discuss current safe and effective treatment options for pregnant patients with pigmentary disorders, and what gaps exist in this area?

A: Pregnancy is a known risk factor for the development of melasma, with approximately one-half to two-thirds of women experiencing it during pregnancy. However, many conventional therapies for melasma, such as topical retinoids and hydroquinone, are contraindicated due to concerns about their potential impact on pregnancy.

A recent review by Ahuja and Lio highlights several safe alternatives for treating melasma in pregnant patients.⁵ These include topical kojic acid, nicotinamide, turmeric, ascorbic acid, and azelaic acid, which have been shown to be effective and safe during pregnancy. In addition to these treatments, sun protection along with the use of mineral-based sunscreens remain a critical component of a melasma treatment regimen.

Despite these alternatives, there are still gaps in research regarding the optimal long-term safety and efficacy of these treatments during pregnancy. More studies are needed to further refine therapeutic recommendations.

Q: How do pigmentary disorders such as melasma affect women’s mental health and quality of life, and what strategies can clinicians use to address
these challenges?

A: Pigmentary disorders such as melasma, due to their frequent involvement of the face, can have a significant impact on women’s quality of life, affecting physical, social, and emotional well-being. Quality-of-life studies for melasma patients reveal that the condition often negatively impacts their social interactions and causes emotional distress.

Dermatologists can address these challenges by providing a supportive environment where patients feel heard and understood. Additionally, dermatologists should consider a multidisciplinary approach and refer patients to support groups or mental health professionals when needed to help patients cope with the psychological impact of their condition.

Q: What would you say are the most critical gaps in health care access and outcomes for women of color with pigmentary disorders?

A: In my opinion, some of the most pressing gaps in health care access and outcomes for women of color with pigmentary disorders include the lack of evidence-based clinical care guidelines and treatment algorithms for both clearance and long-term management. There is also a need for more rigorous randomized, placebo-controlled clinical trials focused on non–hydroquinone-based alternatives, as these options may offer safer, more accessible treatments.

Another critical gap is treatment access. Many of the medications commonly prescribed for pigmentary disorders are not covered by health insurance plans, leaving patients to bear the high out-of-pocket costs. This financial burden can be a significant barrier to consistent and effective treatment, especially for women of color who may already face systemic health care disparities. Addressing these gaps is essential to improving both the access and outcomes of care.

Q: What areas of research do you believe are crucial for improving clinicians’ understanding and management of pigmentary disorders in women?

A: One of the most critical areas of research for improving our understanding and management of pigmentary disorders in women is quality-of-life studies. These studies can help us better understand the emotional, social, and psychological impact of these conditions across different patient populations, including among women of color. Gaining deeper insights into how pigmentary disorders affect daily life, mental health, and overall well-being has the potential to help guide more tailored and effective treatment approaches.

Q: How can dermatologists play a larger role in advocating for women’s health, particularly for conditions such as melasma that disproportionately affect women?

A: Dermatologists, as experts in skin diseases, are uniquely positioned to diagnose and treat pigmentary disorders, including melasma, which disproportionately affect women. We must continue to advocate for our patients, ensuring they have access to timely, effective treatments. Additionally, raising awareness about the emotional and physical impact of pigmentary disorders can help remove stigmas and empower women to seek treatment and support without hesitation.

References

1. Basit H, Godse KV, Al Aboud AM. Melasma. In: StatPearls [Internet]. StatPearls Publishing; 2025-. Updated August 8, 2023. Accessed February 17, 2025. https://www.ncbi.nlm.nih.gov/books/NBK459271
2. Morgado-Carrasco D, Piquero-Casals J, Granger C, Trullàs C, Passeron T. Melasma: the need for tailored photoprotection to improve clinical outcomes. Photodermatol Photoimmunol Photomed. 2022;38(6):515-521. doi:10.1111/phpp.12783
3. Kerob D, Passeron T, Dreno B, et al. Prevalence of post-inflammatory hyperpigmentation, impact on quality of life and social stigmatization: results of the first large international survey. J Amer Acad Dermatol. 2024;91(3):AB73. doi:10.1016/j.jaad.2024.07.297
4. Handel AC, Miot LDB, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014;89(5):771-782. doi:10.1590/abd1806-4841.20143063
5. Ahuja K, Lio P. An integrative approach to treating hyperpigmentation in pregnancy. J Integr Dermatol. Published online February 1, 2024. https://www.jintegrativederm.org/article/92164-an-integrative-approach-to-treating-hyperpigmentation-in-pregnancy