The Complete Guide to Treat Melasma Effectively

Do you peer into the mirror and suddenly notice these pesky irregular-shaped brown patches that seem to appear out of nowhere? What you are looking at could be melasma, a type of hyperpigmentation, where the skin is darkened or discoloured. Melasma may be hard to treat but not impossible. I am here to help you understand more about this common skin condition, how to prevent melasma, and introduce a combination approach to effectively lighten your melasma. Let’s go!

 

What is melasma?

Melasma is a common pigment disorder we see in Asian women and it usually presents in their 30s to 40s. It can affect the cheeks, forehead, nose bridge, and upper lip areas and it is notoriously hard to treat. Various factors, such as ultraviolet (UV) exposure, pregnancy, hormones and certain cosmetic products are known to worsen melasma, so it is important for us to identify and reduce these triggering factors during treatment.

 

Melanin is produced by melanocytes (pigment cells) and it is a dark brown pigment that is responsible for our skin colour. One of the most common causes is UV and visible light exposure, which are known to stimulate melanocytes, leading to overproduction of melanin and worsening of melasma.

 

How to prevent melasma?

A key preventative measure is therefore adequate sun protection. It can be achieved by proper application of sunscreen and also reducing the total amount of sun exposure. I would recommend using broad spectrum sunscreen with sun protection factor (SPF) of 30 and above. Sunscreen should be applied at least 2-3 times a day, every 2-3 hours, and in a thick layer to get the full SPF protection. About 3-4ml of product is needed for each application. Sunscreen should also be used even if you are at home as infrared light can also trigger melasma. However do bear in mind that even if sunscreen is properly applied, it will not block out all UV exposure. Hence one should still reduce the amount of time spent in the sun. Other sun protection measures include using umbrellas and wearing hats.

 

Using a combination approach to effectively treat melasma

In terms of treatment, there are many different treatments for melasma but I find a combination approach to yield the best results as melasma is difficult to treat.

 

1. Topical creams – Hydroquinone, retinoid and cysteamine. Hydroquinone (HQ) is a tyrosinase inhibitor that is commonly used to treat melasma. It helps to suppress the production of melanin and also reduces the number of melanocytes.

 

• Topical retinoid is also used as it can help to increase skin cell turnover. A popular formulation is a combination of hydroquinone, retinoid and steroid cream. The retinoid helps to increase the skin penetration of HQ and the steroid helps to reduce the irritation from the HQ and the retinoid.

 

• Cysteamine (Cyspera) is another product used in the treatment of melasma. It is a natural antioxidant and it works by inhibiting melanin production and hence reduces melanin in the skin. Its main advantage over the use of HQ-containing creams is its safety. As it does not contain HQ or steroid, it can be used for prolonged periods, and also has a lower risk of skin irritation.

 

2. Chemical peels – Glycolic acid, mandelic acid, lactic acid and trichloroacetic acid. These peels help with exfoliation and increase skin cell turnover, resulting in faster pigment dispersion. They generally work best for epidermal (superficial) melasma and in combination with other treatments.

 

3. Lasers – Nanosecond Q-switched, picosecond, yellow lasers. Low-dose laser toning (low energy, multiple sessions) can help to reduce melanocyte activity which will help to suppress melasma. Picosecond lasers can generate laser pulses in picoseconds compared to nanoseconds, and this creates more of a photo-acoustic (mechanical) effect compared to a photo-thermal (heat) effect. As less heat is generated during the treatment, the risk of post-inflammatory hyperpigmentation (PIH) is also reduced.

 

• Another advantage of picosecond lasers over nanosecond lasers is the added laser induced optical breakdown (LIOB) effect which helps to shatter pigments and stimulate collagen at the same time.

 

• Yellow lasers can also be used to target the blood vessels that modulates the melanocytes. However lasers should not be used by itself in the treatment of melasma, and should always be combined with creams and chemical peels to manage melasma effectively.

 

4. Oral medication – tranexamic acid. It can be used off label for stubborn and refractory melasma. It has shown very promising results so far but more studies are needed to evaluate the long term efficacy and safety of this medication.

If you have melasma, the good news is good sun protection combined with medical treatment (lasers and chemical peels) and daily use of topical creams are typically sufficient to see a gradual improvement in 60-80% of the cases. In treating stubborn and refractory cases (especially dermal melasma), oral medication can be added with caution.  I really want to encourage you to see a board certified doctor or dermatologist so that the most effective combination can be worked out for you.

 

References:

 

1. Sarkar R, Gokhale N, Godse K, et al. Medical Management of Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group. Indian J Dermatol. 2017;62(6):558–577.
2. Mahajan R, Kanwar AJ, Parsad D, Kumaran MS, Sharma R. Glycolic Acid peels/azelaic Acid 20% cream combination and low potency triple combination lead to similar reduction in melasma severity in ethnic skin: results of a randomized controlled study. Indian J Dermatol. 2015;60(2):147–152.
3. McKesey, J., Tovar-Garza, A. & Pandya, A.G. Melasma Treatment: An Evidence-Based Review. Am J Clin Dermatol(2019).
4. Sarkar R, Aurangabadkar S, Salim T, et al. Lasers in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group. Indian J Dermatol. 2017;62(6):585–590.
5. Evaluation of the efficacy of cysteamine 5% cream in the treatment of epidermal melasma: a randomized double-blind placebo-controlled trial. Br J Dermatol. 2015 Jul;173(1):209-17.

 

Written by Dr. Wu Jiwei,

MBBS, PG Dip (Clinical Derm) (UK)