Melasma is a chronic skin condition characterized by dark blotches primarily on the face, and occasionally, the arms. It develops due to a combination of genetic predisposition and sometimes other influences such as a change in hormone status which may be brought about by pregnancy or starting an oral contraceptive.
However, a change in hormone status is not required, and men get melasma too.
The most important thing to know about treatment is that melasma is a chronic condition. Once it appears, it is often there to stay. In some patients whose melasma is triggered by pregnancy, it resolves after delivery. However, for many, their pigmentation doesn’t go away.
Therefore, it’s really important to think of treating melasma as improving (hopefully clearing) and controlling it, rather than curing it. It is VERY UNLIKELY that melasma will resolve with treatment and never come back.
Nonetheless, many treatments can improve melasma to an acceptable level and keep it under control.
Sun Avoidance and Protection
The number one most important treatment for melasma is sun avoidance and protection. Without sun, this type of pigmentation would not be present. Thus, taking every measure possible to avoid any exposure on the affected areas is key to getting great results.
This means avoiding direct exposure, wearing protective hats or visors, and applying an adequate amount of sunscreen multiple times a day.
Regarding sunscreen, a zinc based product is best. Micronized zinc is transparent and blocks all rays of light. It even blocks infrared radiation (heat) which may contribute to increased pigmentation. It’s important to apply enough sunscreen adequately cover your face – about 1/3 of a teaspoon – and to reapply often, at least every 2 hours.
Topical Treatments for Melasma
After sun protection, topical creams are the mainstays of treatment. One of the most effective is a prescription combination of hydroquinone, retinoic acid, and hydrocortisone. In my experience, this combination cream benefits most patients, but you can’t use it forever. Long term use of hydroquinone can very rarely lead to an increase in skin discoloration called ochronosis.
Also, this combination cream may irritate sensitive skin. For those who cannot tolerate it, I often start with hydroquinone alone. Irritation can initially make melasma look darker before it makes the skin feel rough and sensitive.
Two oral treatments may help melasma. The first is Helioplex, a non-prescriptoin oral supplement derived from a certain type of fern. It provides a certain level of sun protection from the inside out.
The other is tranexamic acid. This is a prescription medicine that improves melasma by blocking one of the mechanisms ultraviolet light uses to induce pigmentation.
Chemical peels are a great treatment option. Again, it is important to remember that all the treatments we have including peels improve melasma but do not cure it. A variety of peels help including glycolic acid, Jessner’s, ViPeel, and trichloracetic acid (TCA). I particularly like the ViPeel and TCA. Three to four treatments often improve melasma significantly.
Although patients continue to use the other treatments previously described after a series of peels, melasma often starts to recur requiring periodic maintenance peels.
Lasers and IPL
Low intensity fractional lasers and pigment specific lasers are often my last resort options for treating very stubborn melasma. I use Clear + Brilliant (and sometimes microneedling). Clear + Brilliant creates micro-channels in the skin allowing the pigment to extrude during healing. I usually recommend four to five treatments initially.
IPL is my absolute last resort. The main reason is that some patients get an unexpected darkening of their pigment after treatment. However, it is worth keeping as a treatment option because I have seen good results in some patients.