Level 4 brown is a classification used to describe the severity of the pigmentation or discoloration of skin affected by melasma. Melasma is a common skin condition characterized by brown or gray-brown patches that most often appear on sun-exposed areas of the face like the cheeks, nose, forehead and chin. The level of pigmentation associated with melasma can range from light to dark, with level 4 representing the most severe grade of discoloration.
What are the levels of melasma pigmentation?
There are 4 levels used to classify the severity of facial pigmentation seen in melasma:
| Level | Description |
|---|---|
| Level 1 | Minimal pigmentation visible under Wood’s lamp |
| Level 2 | Mild pigmentation visible under Wood’s lamp |
| Level 3 | Moderate pigmentation visible under Wood’s lamp |
| Level 4 | Severe pigmentation visible without Wood’s lamp |
The Wood’s lamp is a diagnostic tool used by dermatologists that emits ultraviolet light, which causes areas of excess melanin like melasma patches to appear darker. At level 4, the pigmentation is so pronounced that it is clearly visible without any special lighting.
What does level 4 melasma look like?
Level 4 represents the most severe grade of facial hyperpigmentation seen in melasma. At this level, the discoloration is very dark and easily visible to the naked eye.
Some characteristics of level 4 melasma include:
- Very dark brown or gray-brown facial patches
- Pigmentation is clearly visible without Wood’s lamp
- Patches frequently affect multiple areas of the face like cheeks, forehead, upper lip, nose and chin
- Discoloration is very noticeable from several feet away
- Dark patches do not lighten significantly with skin bleaching treatments
The pigmentation at this stage is very pronounced, making the melasma patches obvious even with makeup or from a distance. The dark areas stand out in sharp contrast against the surrounding normal skin tone.
What causes level 4 melasma?
There are several factors that can contribute to the development of severe, level 4 melasma pigmentation:
- Intense or prolonged UV light exposure – Excess sun exposure without sunscreen causes more melanin production
- Genetic predisposition – Having a family history of melasma increases risk
- Hormonal changes – Pregnancy, birth control pills or hormone therapy can trigger melasma in some women
- Skin trauma – Injuries, burns, or procedures like dermabrasion can activate melanocytes
- Skin bleaching or irritation – Hydroquinone or harsh products may worsen pigmentation
- Certain medications – Anticonvulsants, antimalarials and oral contraceptives may induce melasma
In most cases, there are multiple contributing factors leading to the development of severe discoloration. A combination of sun overexposure, genetics, and hormonal influences is often responsible for level 4 melasma.
Who is most at risk for level 4 melasma?
Those at greatest risk for developing the most severe grade of melasma hyperpigmentation include:
- Women – Due to hormonal effects on melanocytes, females account for about 90% of melasma cases
- Pregnant women – Increased estrogen and progesterone can cause melasma, especially with sun exposure
- Those on birth control pills or HRT – The hormones can stimulate excess melanin if skin is exposed to UV light
- Middle age adults – Most common between the ages of 30-55 due to cumulative sun exposure
- Hispanics and Asians – More prone to developing melasma and tyrosine activity
- People with darker skin tones – Increased epidermal melanin makes dark patches more obvious
- Those with a family history – Genetics accounts for over 30% of melasma cases
While anyone can get melasma, these groups are the most susceptible. Taking preventative measures like sunscreen, hats, and skin-lightening products can help reduce the chances of developing level 4 pigmentation.
How is level 4 melasma diagnosed?
Dermatologists can easily recognize level 4 melasma upon visual examination, as the facial discoloration is quite pronounced. However, they may use additional diagnostic techniques to confirm the diagnosis and rule out other pigmentary disorders, including:
- Wood’s lamp exam – The ultraviolet light causes areas with excess melanin to appear very dark brown or black
- Skin biopsy – Examining a small sample of the abnormal skin under a microscope
- Blood tests – To check for conditions like thyroid disorders, diabetes or liver disease
Once melasma is confirmed, the dermatologist will often classify the degree of pigmentation using the levels 1-4 scale. This helps determine the most effective treatment options for that particular severity.
How is level 4 melasma treated?
Treating the most severe grade of melasma can be challenging, as the dark facial patches are often resistant to therapy. Common medical treatments used for level 4 melasma include:
- Hydroquinone – The skin bleaching agent is applied topically to inhibit melanin production
- Triple combination creams – Contain hydroquinone, a retinoid, and a steroid to lighten skin
- Chemical peels – Glycolic, lactic or trichloroacetic acid peels help exfoliate and fade pigmented lesions
- Laser therapy – Devices like the Q-switched and fractional CO2 lasers can help destroy melanin
- Phototherapy – Exposure to specific wavelengths of light helps reduce excess melanin
- Microneedling – Creates tiny skin punctures to promote collagen growth and skin lightening
Unfortunately, level 4 melasma is often persistent and recurs easily. Maintaining strict sun protection and avoiding triggering factors like hormones and irritants is equally important for long-term management of severe pigmentation.
What is the prognosis for level 4 melasma?
The prognosis refers to the likely long-term outcome of a disease. For level 4 melasma, the prognosis is generally poor for complete resolution of the facial pigmentation.
Key facts about the prognosis of severe melasma include:
- Pigmentation often recurs after initial improvement from bleaching treatments
- Life-long strict sun protection is required to help prevent the melasma from worsening
- Topical lightening creams must be used continuously to maintain results
- Discoloration often gradually worsens with age due to chronic sun exposure
- Multiple treatment modalities are frequently needed to achieve gradual lightening of dark patches
- Melasma often improves temporarily during pregnancy but worsens after giving birth
While treatments can lighten areas of pigmentation, level 4 melasma is difficult to eliminate completely. Managing patient expectations regarding the prognosis and need for ongoing therapy is important.
How can you prevent level 4 melasma from developing?
The best way to prevent the most severe grade of facial melasma is to avoid the main triggering factors. Recommended preventive measures include:
- Daily broad-spectrum sunscreen with SPF 30 or higher
- Wearing wide-brimmed hats and clothing that covers the skin
- Avoiding excess sun exposure during peak hours (10am-2pm)
- Using a tyrosinase inhibitor like hydroquinone preventatively if prone to melasma
- Skipping hormone replacement therapy unless necessary
- Taking oral contraceptives with lower progestin levels may help
- Not using overly aggressive skin peels or laser treatments
Being diligent about sun protection and avoiding melasma triggers can help keep facial pigmentation limited to the milder level 1-2 range for those predisposed to this chronic skin condition.
Conclusion
Level 4 represents the most severe grade of hyperpigmentation seen in melasma. The dark facial patches are clearly visible without a Wood’s lamp and do not lighten easily with bleaching treatments. While melasma is difficult to cure, especially once it progresses to level 4, diligent sun protection, lightening creams, and laser therapy can help improve its appearance. However, the discoloration often recurs over time. Preventing melasma from developing in the first place or catching it early when pigmentation is still mild offers the best long-term prognosis.
