Melasma is a skin condition that leads to hyper-pigmentation, or dark patches of skin, especially in sun exposed areas. Melasma is a difficult condition to treat as it is a chronic, recurring disorder without a cure.
We expect relapses, and improvement in skin and remission rate requiring consistent skin care treatments. Treatment options are limited but are best used in combination to target multiple and different pathways that lead to discolored skin.
What causes melasma?
Melasma is a disorder of melanocytes, which are the cells that create pigment in the skin. In melasma, the melanocytes become over stimulated, depositing excessive pigment, or color in the skin, leading to visible skin color issues. The condition most commonly affects women during reproductive ages. There are multiple causes including genetic influences, sun exposure, exposure to hormones and pregnancy.
Exposure to hormones
If melasma is pregnancy induced, the condition can last months to years after delivery. Melasma can be especially difficult to treat during pregnancy given the limited, prenancy safe, options.
How is melasma diagnosed?
For the most part, melasma is a clinical diagnosis involving irregular, brown spots on sun-exposed skin. There are common facial patterns and clinical histories that your physician will be looking for to make the diagnosis. Sometimes, we use special lights and magnifying lamps to look for characteristics specific to melasma. If the diagnosis is still questionable, a biopsy may be necessary for definitive diagnosis.
How is melasma treated?
Melasma is a long term, recurrent condition, although some cases can suddenly resolve after pregnancy or exposure to hormones. A known risk factor for worsening melasma is sun exposure. Sun protection is one of the main stays of treatment and prevention.
Melasma responds best to multiple approaches to treatment. Most importantly, practitioners address causes that will worsen the condition like sun exposure. Our next option is to address the pigment with skin lighteners. We will also decrease the production and size the cells the create the pigment in the first place.
The mainstays of treatments are:
The primary goals of treatment are to reduce the amount of pigment production and to even out discolored skin.
Sun protection as a mainstay of treatment: Strict adherence to sun protection is essential in the treatment and prevention of melasma. You can achieve this with topical sunscreens, sun avoidance, and protective clothing. It is especially important to avoid sun exposure during peak hours between 10 am and 2 pm. You should apply a sunscreen each morning and reapplied every 2-3 hours while outdoors.
The biggest mistake made by patients is not applying enough sunscreen to provide adequate coverage and protection. Using make up with sun protection is often not enough to provide adequate coverage. We recommend applying a broad spectrum sunscreen in addition to any cosmetics that also have sun protection.
Another important ingredient to consider when treating melasma, is to apply a tinted sunscreen with iron oxide. The major ingredient used to create tint in sunscreens is iron oxide, and we recommend it in concentrations above 3%. Iron oxide is beneficial because it is also helps protect against visible light. Visible light can worsen melasma.
First line treatment options: For mild melasma, we recommend starting with hydroquinone 4% topical therapy. Hydroquinone works by inhibiting pigment production. It also increases the breakdown of the cells that release the pigment, leading to less facial dark spots and issues.
You can apply hydroquinone once to twice daily. We typically recommend use for a duration up to six months, but longer if needed. Often, we recommend cycling on and off hydroquinone. A rare side effect known as ochronosis produces worsening dark spots that is very difficult to treat.
Azelaic acid is an alternative to hydroquinone. At a concentration of 20%, azelaic acid is as effective as 4% hydroquinone cream. Improvements can take one to two months of consistent use for a visible difference.
Common side effects of Azelaic acid include skin itching, burning, and stinging. Azelaic acid is one of the only treatments for melasma that is safe during pregnancy.
Kojic acid is another skin lightener that is less effective than hydroquinone. However it offers a good alternative for patients that cannot tolerate other options.
Niacinamide, or vitamin B3 works as an anti-inflammatory agent and seems to be slightly less effective compared to hydroquinone. Many prodicts combine kojic acid and niacinamide to provide improved skin lightening options. They also are great alternatives to use when cycling off hydroquinone.
Moderate to severe melasma:
First line treatment options: For moderate to severe melasma, we treat more aggressively. Typically, with a triple combination cream with hydroquinone, fluocinolone, and tretinoin. Appropriate application of the cream is nightly for two to four months. You can use the cream on and off during periods of remission to prevent a flare up of melasma.
The most common side effects include redness, burning and itching. You must take caution if you have skin of darker complexion. Aggressive lightening can cause unwanted hypo-pigmentation or loss of pigment.
Chemical peels: We commonly use chemical peels for melasma. Most used ingredients are glycolic acid, salicylic acid and Jessner’s peel. Several sessions are necessary, often five to six, spaced two to four weeks apart for best results.
Prior to a chemical peel, the skin should be pre-treated with a skin lightening agent for two to four weeks. This will to improve the results of the peel and avoid post dark spots.
Microneedling: Microneedling works by using tiny needles that penetrate into the skin causing microtrauma that promotes healing. When your body heals the skin from these microtraumas, the resulting skin tends to be more even toned and thicker
Lasers: If topical mediations and peels fail, we can use lasers, but with with caution. Laser treatments for melasma can cause long-lasting dark spots. People often need to repeat these treatments because the results usually don't last very long.
Melasma is a chronic and recurring condition that leads to dark patches of skin, especially in sun-exposed areas. While there is no cure for melasma, there are various treatment options available to manage the condition.
The main goals of melasma treatment are to reduce pigment production and even out the discolored skin. Sun protection is crucial in the treatment and prevention of melasma, and strict adherence to sun protection measures is essential. This includes using topical sunscreens, avoiding sun exposure during peak hours, and wearing protective clothing.
Hydroquinone 4% topical therapy can manage mild melasma. One can also use alternatives such as azelaic acid and kojic acid. These skin lighteners inhibit pigment production and you should cycle them on and off.
We may prescribe a triple combination cream with hydroquinone, fluocinolone, and tretinoin for moderate to severe melasma. Chemical peels, microneedling, and lasers are also options for more aggressive treatment.
There is no cure for melasma. However, it is possible to lessen dark patches and achieve a more even skin tone. You can achieve this through proper management and consistent treatment.