Melasma and It's Management: Keypoints
- In South East Asia, melasma accounts for 0.25 to 4% of patients seen in dermatology institutes, with peak incidence in those aged 30 to 44 years.1
- One simple survey suggests that the prevalence of melasma is as high as 40% in females and 20% in males in Asian patients.1
- Melasma predominantly affects Fitzpatrick skin phototypes III and IV and often lasts for many years after pregnancy.2
Clinical & Pathological Features2
- The centrofacial pattern of melasma is the most common.
- While a Wood lamp examination was previously thought to accurately predict epidermal versus dermal pigment deposition, recent studies have shown that dermal melanin deposition is common and may be underrecognized.
- Melasma may be caused by the presence of more biologically active melanocytes in the affected skin, rather than an increase in melanocytes.
- The high incidence of melasma among family members suggests a genetic component.
- Sun exposure is a commonly reported exacerbating factor, likely because of the UV-induced upregulation of melanocytestimulating cytokines.
- While melasma is known to occur with hormonal changes, clinical evidence to date does not clearly associate serum hormone levels to melasma.
- For women who note the onset of melasma after beginning a course of an oral contraceptive, the medication should be stopped if possible.
Sunscreens & Camouflage3
- Ultraviolet and visible light can induce melanin formation.
- The regular use of broad spectrum sunscreen is effective both in preventing melasma and in enhancing the efficacy of other topical therapies once melasma has developed.
- Camouflage makeup can be an important component of melasma treatment.
- Hydroquinone, a tyrosinase inhibitor, has been extensively researched and found to be very effective in treating disorders of hyperpigmentation.
- While controversy exists regarding the use of hydroquinone, a review of the literature indicates that hydroquinone is safe as a topical agent for melasma.
- Tretinoin is an effective treatment for melasma but often causes irritation and usually requires months to show improvement as monotherapy.
- Adapalene may be an alternative retinoid in patients who cannot tolerate tretinoin.
- A combination of hydroquinone, a retinoid, and a topical steroid appears to be highly effective for the treatment of melasma.3
- This triple combination takes advantage of the additive and synergistic effects of the three components.4,5
- Combination of Hydroquinone, Tretinoin and Fluocinolone acetonide strongly inhibits the production of melanin without the destruction of melanocytes.6
- Tretinoin is a known steroid antagonist and is capable of counteracting steroid-suppressed wound healing.5
- Tretinoin-induced irritation may facilitate epidermal penetration of hydroquinone and also prevent its oxidation.5
- Tretinoin overrides the atrophy-promoting and anti-mitotic effect of the corticosteroid.5
- Fluocinolone acetonide appears to antagonize the thinning effect of tretinoin on the stratum corneum and reduces retinoid-induced irritation.5
- Glycolic acid may be the most efficacious alpha hydroxyl peeling agent for melasma, but it should be used cautiously.
- Glycolic acid peels should be used in conjunction with a depigmenting agent for maximal benefit and to minimize the risk of postinflammatory hyperpigmentation.
- Salicylic acid peels appear to be of minimal benefit in the treatment of melasma.
Laser & Light Therapies3
- Q-switched ruby lasers and erbium:yttriumaluminum-garnet lasers have been shown to worsen melasma.
- The combination of carbon dioxide laser with Q-switched Alexandrite laser does not appear to be beneficial for melasma and carries a significant risk of worsening hyperpigmentation in darker-skinned patients.
- Fractional resurfacing is approved by the FDA for the treatment of melasma and has been shown to have some benefit; however, additional controlled trials are needed to evaluate its efficacy for melasma.
- Intense pulsed light therapy may provide modest benefit as an adjunctive therapy for refractory patients.
- Copper bromide lasers may be of benefit for melasma, especially in patients with a visible vascular component, but require further study.
- Sivayathorn A. Melasma in Orientals. Clin Drug Invest 1995; 10 (Suppl 2):24-40
- Sheth VM, Pandya AG. Melasma: a comprehensive update: part I. J Am Acad Dermatol 2011; 65:689-697
- Sheth VM, Pandya AG. Melasma: a comprehensive update: part II. J Am Acad Dermatol 2011; 65:699-714
- Rendon MI. Utilizing combination therapy to optimize melasma outcomes. J Drugs Dermatol. 2004 Sep-Oct; 3(5 Suppl):S27-34
- Menter A. Rationale for the use of topical corticosteroids in melasma. J Drugs Dermatol. 2004 Mar-Apr; 3(2):169-74.
- Gupta AK, Gover MD, Nouri K, Taylor S. The treatment of melasma: a review of clinical trials. J Am Acad Dermatol 2006; 55:1048-65
- Cestari T, Arellano I, Hexsel D, Ortonne JP; Latin American Pigmentary Disorders Academy. Melasma in Latin America: options for therapy and treatment algorithm. J Eur Acad Dermatol Venereol. 2009 Jul; 23(7):760-72
- Chan R, Park KC, Lee MH, Lee ES, Chang SE, Leow YH, Tay YK, Legarda-Montinola F, Tsai RY, Tsai TH, Shek S, Kerrouche N, Thomas G, Verallo-Rowell V. A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate-to-severe melasma. Br J Dermatol 2008; 159:697-703
- Grimes P, Kelly AP, Torok H, Willis I. Community-based trial of a triple-combination agent for the treatment of facial melasma. Cutis 2006; 77:177-84