What is Melasma?
Melasma is a skin condition that presents as diffuse pigmented patches on the skin, especially on the face. Melasma is much more common in women than men, and is usually hormonally-linked or can be caused by pregnancy or long-term use of oral birth control pills. Sun exposure dramatically worsens melasma pigmentation. While melasma is a benign condition, many people seek treatment for it because it often appears as areas of pigmentation on the face.
It can be difficult to treat and can reoccur because it is genetically and hormonally-linked. Due to this, melasma treatment is not as straightforward as treatment of some other types of pigmentation. Melasma requires a multi-pronged approach as the pigmentation can appear in various layers of the skin and is often present alongside other types of pigmentation as well. Because this condition has genetic and hormonal links and is heavily influenced by sun exposure, managing it is a long term process and reasonable expectations for outcomes must be set. The goal is often to reduce pigmentation, NOT 100% guarantee that all pigmentation is gone.
Daily use of broad-spectrum SPF is a MUST when treating melasma. Arguably, this is the MOST important step one can take to prevent worsening of pigmentation from sun exposure. UV radiation stimulates melanocytes to produce melanin in the skin, which is what causes tanned skin, freckles, and other types of sun-induced pigmentation. For those prone to melasma, sun exposure can markedly worsen melasma pigmentation. Using sufficient sunblock and reapplying as directed is extremely important for managing melasma pigmentation. Tinted sunscreens colored with iron oxide are also beneficial, as the iron oxide allows for even more UV protection. At least a quarter of a teaspoon of SPF should be used for the face and neck daily; at least one reapplication mid-day is encouraged. Full body application necessitates 1 oz of SPF, which is the equivalent of a shot glass.
For short hand, using two – three fingers’ worth of sunscreen is a good approximation for the face and neck. Sunscreen must be reapplied according to package directions or immediately after swimming. 20 minutes of unprotected sun exposure can set back months of careful treatment. Brimmed hats, UPF clothing, and sunglasses are also good measures to protect against UV exposure.
Topical Pigment-Lightening Products
Using topical products with lightening agents is a very important part of treatment of melasma. Skincare can be applied up to twice daily, so pigment-lightening topicals are a vital part of managing melasma pigmentation. In general, topical pigmentation products inhibit tyrosinase, a major enzyme in melanogenesis, which is the process by which melanin forms in the skin. Most lightening products are indicated for PM use only and must be used in conjunction with SPF in the AM.
Topical prescription strength hydroquinone is the gold standard for treating stubborn melasma pigmentation. Hydroquinone can be quite irritating to the skin and use must be cycled on and off every few months. Excessive use can lead resistance and to ochronosis, blue-black/gray-blue discoloration of the skin. When using hydroquinone products, use should be monitored by a health professional and last no more than 3-5 months per use cycle. Other tyrosinase inhibitors can be alternated with off cycles of hydroquinone – products with ingredients such as arbutin, retinoids, AHAs like glycolic acid, licorice root, azelaic acid, or kojic acid. Brightening products with ingredients like vitamin C, antioxidants, or tranexamic acid can also be used to improve results.
Some form of lightening or brightening topical must be committed to long-term (in the order of months) in order for best results and to pre-treat skin before considering any adjunctive treatments, such as lasers or peels.
Nano, pico, and thulium lasers can all be used to treat melasma pigmentation. While it is tempting to undergo strong laser treatments, excessive heat exposure and incorrect laser settings can actually worsen pigmentation. Pretreating with SPF and pigment-inhibiting topicals for a minimum of 4-6 weeks will ensure best results. Several laser “toning” sessions may be necessary as an initial course of treatment, with more intermittent sessions afterward for pigmentation maintenance. Microneedling is generally not recommended as a course of action to treatment melasma, as the needles can inadvertently puncture the basement membrane of the skin and cause pigmentation to sink even deeper in the skin.
Chemical peels are another method to treat pigmentation. Extremely deep peels are not recommended as they can cause rebound pigmentation. Light to medium chemical peels can be a great method for reducing superficial and medium depth pigmentation. This is because they do not run the risk of overheating the skin as laser treatments can. One downside of chemical peels is that they can often come with downtime for several days post-treatment while peeling occurs.
Along the same vein, but perhaps gentler than chemical peels, are facials that include some use of AHAs or other lightening products.
Oral Tranexamic Acid
Oral tranexamic acid is a prescription medication that has dramatically improved melasma treatment outcomes. While also available topically, it is more effective when taken by mouth for a course of several months. Certain medications and conditions are contraindications for tranexamic acid, which is why it is not considered a first line of treatment for standard melasma protocols. These include but are not limited to hormone replacement therapy, hormonal medications, and pregnancy or breastfeeding. Patients’ medical history and medication usage must be evaluated by a medical doctor prior to beginning a prescription course of oral tranexamic acid. For more resistant cases of melasma, supplementation of this medication in addition to previously-mentioned methods may prove effective.
Mixed-modality treatments will offer the best results overall. Because melasma pigmentation is affected by genetics, hormones, as well as lifestyle (e.g. hormonal changes, stress, and sun exposure), no one single method should be used to achieve reduction in pigmentation. For a regimen that is tailored to your skins’ specific needs, please contact DSC for a free consultation!
DSC Laser & Skin Care Center
889 S. San Gabriel Blvd. San Gabriel, CA 91776