Melasma

Q: What is melasma?

Melasma is a darkening/discoloration of the skin that often occurs in pregnancy or in women taking birth control pills and/or hormonal supplements. It is often seen on the cheeks, nose and forehead but can sometimes be seen elsewhere. It can occur in all skin types but is more common in skin of color.

Q: What is the best starting treatment for people with melasma?

Triple combination therapy with products that contain hydroquinone, a retinoid product, and a topical steroid is the best initial treatment. We caution our patients that for it to be successful they need to do 3 things:

1. apply it regularly, as directed.
2. Use meticulous sun protection that includes the proper sunscreen (not sunscreens are equal when it comes to melasma)
3. Be patient – don’t expect results before 6-8 weeks. If you see a 20-30% improvement by then, you are doing well.

Q: Are there any risks to using that treatment?

Hydroquinones are meant to be used for short periods at a time. After around 3 months, we usually recommend a break for several months before resuming. This is because there have been reports of something called ochronosis from long term hydroquinone use. Ochronosis appears as dark pigment deposits in the skin – which is what we were trying to get rid of in the first place! Too often, a provider not experienced in melasma and other pigment disorders will not identify the ochronosis. He/she may simply think the melasma is coming back and then advise the patient to apply the product more frequently, often with poor outcomes.
During the breaks from the hydroquinone product, we recommend second-line skin lightening agents that also work, but not always as well as the triple combination products. Second line agents include things like cogic acid, azelaic acid, and others.

Q: What is new in melasma treatment?

Tranexamic acid is an oral medication that can be used to treat melasma. It’s taken twice per day. It is off-label and not FDA-approved, but studies thus far have shown promising results. It’s not for everyone – especially people that have a history of blood clots, pregnant/nursing women or women taking birth control pills. Like topical agents, it usually takes 6-8 weeks before seeing results.

Q: Are there any treatments for melasma that you don’t recommend?

There has been a trend lately for using IV infusions of glutathione for skin lightening in some medspas. At Lumen Aesthetics, we don’t offer this nor do we recommend it because there has been no data in the medical literature to support it.
Another important point is making sure the diagnosis of melasma is correct. Too often we see patients in a consultation that have received melasma treatment for years with minimal success. In some cases, the discoloration was not from melasma, but from another condition – a medication side effect or a dermatologic condition that can mirror melasma.

Q: What are the conditions that can help predict success?

There are several things. First is the willingness to undergo treatment. Melasma can be improved and managed, but there is no permanent cure. Treatments take time and can be expensive. Not everyone is willing to proceed.

Second, the longer someone has melasma, the more resistant it is to therapy. Someone that has had it for 5 years will respond more quickly than someone who has had it for twenty years.

Third, there are different types of melasma. When the pigment is in the upper skin, the epidermis, it appears brown in color and tends to respond more quickly. When more pigment settles into the lower skin, the dermis, it looks grey and can be more resistant. Usually, there is a component of both.

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