Keys to Treatment:
Melasma can be a lifelong condition. Long-term topical therapy and strict sun protection are often necessary, and some dark spots may never completely go away.
Melasma due to pregnancy usually goes away within one year after delivery – it is often not beneficial to treat dark spots during pregnancy because they may go away on their own!
In other cases, many treatment options are possible:
Hydroquinone
Hydroquinone is a topical medication that works by blocking the final conversion of melanin precursors to melanin in the melanocytes. It accomplishes this by blocking an enzyme, tyrosinase, that is involved in this final step. Hydroquinone is typically used 2 times a day for at least three months. Usually people notice improvement after 5 to 7 weeks. Higher concentrations of hydroquinone (like 4%) may be more effective but can also cause more side effects such as skin irritation or color changes in the surrounding, normal skin. Hydroquinone should be used only as directed by your dermatologist. It may work better in combination with sunscreen and other topical treatments.
Azelaic Acid
Azelaic acid is another topical medication that works the same way as hydroquinone; by blocking the final conversion in the making of melanin. Some studies have shown that 20% azelaic acid may be as effective or more effective than 4% or 2% hydroquinone respectively, but with fewer side effects. Possible side effects of azelaic acid use are itching, redness, and burning.
Kojic Acid
Kojic acid also stops the enzyme (tyrosinase) from making melanin. Side effects may include contact dermatitis and redness.
Please note that bleaching gels can have side effects and should only be used as directed by your dermatologist.
© 2001-2009,Dermatlas
This otherwise healthy young woman developed skin irritation after applying a bleaching cream to dark spots on her cheeks and nose. In most cases, side effects can be prevented with careful treatment and observation for signs of skin irritation.
Retinoids
Topical retinoids, or tretinoins, decrease many steps in the production of melanin. Tretinoin helps increase epidermal turnover, thus causing faster loss of dark skin pigment. It may take a longer time before a patient starts to notice an effect with retinoic acid treatment – skin lightening can take up to 24 weeks.
Topical Steroids
When topical steroids are applied to normal skin for an extended period of time, there can be resultant skin lightening. This side effect can be used to its advantage in conditions where the skin has extra pigmentation, like melasma. Topical steroids are usually used in combination with other topical melasma treatments (like the above agents) rather than alone. Side effects may include irritation, dermatitis, atrophy, telangiectasia, and increased hair growth. **You should never use topical steroids to lighten your skin without clear instructions and careful supervision from your dermatologist.
Your dermatologist will prescribe the appropriate melasma treatment for your skin type. Sometimes, a combination of topical treatments is necessary to see the most improvement. A new combination of tretinoin 0.05%, hydroquinone 4.0%, and fluocinolone acetonide 0.01% (a mid-strength topical steroid) may be more effective depending on the patient’s individual response.
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© 2001-2009,Dermatlas
This 35-year-old man developed melasma after many years of working on a farm and having been exposed to large amounts of sunlight. His melasma improved with daily, year-round use of SPF 30 sunscreen and a topical combination treatment containing tretinoin, hydroquinone, and fluocinolone acetonide.
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© 2001-2009,Dermatlas
This 30-year-old woman developed melasma during her pregnancy. Although it resolved after delivery, it did not completely go away. She improved with daily, year-round use of SPF 30 sunscreen, topical hydroquinone, and tretinoin cream.
Other topical treatment options that your dermatologist may recommend include some of the following: glycolic acid, mequinol, arbutin, N-acetyl-4-S-cysteaminylphenol (NCAP), ascorbic acid, niacinamide, liquorice products, and/or flavonoids. These should only be used as directed.
Chemical peels and laser therapy may be used in resistant cases of melasma depending on the ability of a patient’s skin to tolerate the procedure. Other new and experimental agents are in development.
If you are concerned that you may have melasma, it may be helpful to see your dermatologist for treatment recommendations. Sometimes, melasma can be the result of other hormone changes and should be evaluated by a physician. Covering cosmetics and skin tone matched concealers may help decrease the appearance of dark spots. It is always beneficial to wear sunscreen when going outdoors. The American Academy of Dermatology recommends choosing a water-resistant sunscreen with broad protection of UVA & UVB rays and a Sun Protection Factor (SPF) of at least 30 for application on a year-round basis. Sunscreen is especially helpful to block some of the UV light from causing the dark spots of melasma. While melasma may often be a life-long condition, in many cases, dark spots can be reduced with appropriate and effective treatment along with cosmetic cover-up.
References:
(1) Goldstein BG, Goldstein AO, Dellavalle RP, et al. Melasma. UpToDate: www.uptodate.com.
(2) Bandyopadhyay D. Topical Treatment of Melasma. Indian J Dermatol 2009;54(4):303-9.
(3) © 2001-2009,Dermatlas