The Inside Scoop on Melasma: A Dermatologist’s Tips & Tricks

Melasma. An annoying and difficult to manage condition. But one which can offer tremendous reward to both the patient and provider when proper expectations are set and education is provided at the outset of an appropriate treatment plan. As a skincare expert, I believe it is my responsibility to ensure my patients understand this pesky condition is just that. A condition much like hypertension or diabetes, albeit one without systemic ramifications. Once diagnosed, we must always continue to take heed and address melasma. I have provided you with some pro-tips.

1. Causes. Always begin with considering the underlying causes which could be promoting melasma and advise the patient to eliminate if at all possible. Hormonal changes such as initiation of, or switches in, oral contraception, as well as menopause, can dramatically influence this condition. Heat, as much as light, can drive this condition, and your patients should be reminded to avoid situations such as hot yoga or hot saunas. Otherwise, we are simply a cat chasing its tail.
   
2. Sunscreen. Just as a house needs a foundation, sun protection is critical in the treatment of melasma. But not just any sunscreen. Chemical sunscreens work by absorption of light, converting to heat, thereby worsening melasma. Physical sunscreens like zinc oxide and titanium dioxide are a must, as they simply reflect light off the skin. No heat will be generated, and these are mandatory, not optional, on a daily basis for the melasma patient. Not only do I recommend daily physical block SPF to my melasma patients, but I recommend layering of physical block SPF. Yes! Two sunscreens layered one on top of the other for the melasma patient. Some manufacturers create sunscreen powders which can be applied over traditional lotion-based sunscreens and these mineral powders are optimal for second-layer application and for re-application.
3. Topical therapy. No longer is hydroquinone the gold standard in care. Instead, tranexamic acid has risen to number one. Many countries have banned hydroquinone, and it is likely the United States will follow suit in the years to come. Hydroquinone is simply a Bandaid for a longstanding condition. Once discontinued the pigmentation only returns. Instead, tranexamic acid targets all five steps in the pathway leading to pigmentation and melasma formation. It is safe, effective, and has many past and current clinical trials which affirm this data. When combined with other topicals, such as retinoids, growth factors, alpha and beta hydroxy acids and anti-oxidants, a reversal in the pigmentation pathway is accelerated. From a cost perspective, topical therapy is an efficient use of patient finances as there is no labor involved other than that of the patient.
4. Procedures. There are many procedures which have been used with varying degrees of success based on the location of the pigmentation—whether superficial or deep within the dermis. Regardless of the location of the pigment, there will never be a “once and done” procedure for a melasma patient. I know it is disappointing to be the bearer of bad news. However, the treatments I have found to work well can be rotated for maximum efficacy.
   
   • Microneedling with or without PRP (platelet-rich plasma). The fact that this procedure does not induce heat, but improves melasma makes it a year-round procedure for all skin types. When PRP is added, outcomes are improved and recovery times are shortened.
   • 1927 wavelength laser. This is an actual laser which means it will target water in the skin. A study in the Journal of Drugs and Dermatology showed these devices to be safe and effective for the treatment of melasma in all skin types year-round. The target of water indicates that predominately superficial pigmentation will be addressed with this type of laser.
   • Picosecond laser. This is a laser that targets actual pigment. Originally finessed to treat pigmentation in the Asian population before making its way to the United States, it was first popularized for its ability to treat tattoos in this country. It has now gained notoriety for its successful for its ability to treat both the superficial and deep pigment of melasma. A picosecond is a trillionth of second, and the human body is unable to mount a heat response based on the rapidity of that pulse time. For melasma patients, this is tantamount to achieving results.
   • Chemical peels. By physically destructing the superficial cells which contain pigment, and forcing new cells to turn over, chemical peels can be an effective way to treat melasma depending on the type of chemical chosen. Self-neutralizing peels such as Jessner’s, can be quite effective when combined with a topical retinol solution for penetration to the deeper dermis.
5. Systemic Therapy. Oral tranexamic acid 250 mg bid has been used to effectively treat melasma as it inhibits tyrosinase, the enzyme responsible for the first step of melanin synthesis. Oral glutathione 500 mg qd is a supplement which has been shown to reduce melasma severity as well when taken over 12 weeks. 

If you are a healthcare provider, check out Dr. Turner’s new website DrEllenTurner.com and sign up for her e-newsletter to receive tips, tricks and updates on injections, devices and life in this incredible but, sometimes overwhelming space we call aesthetic medicine.