Physicians see it regularly—symmetrical patches of excess pigmentation across the nose and/or on the cheeks, chin and forehead. Sometimes called the “mask of pregnancy,” melasma is more common among women but is also seen in men. Causes include a complex combination of genetic and hormonal influences that are not yet fully understood, and treatment is challenging.
Melasma can be categorized according to location patterns and depth of pigment in the skin. The three typical patterns are centrofacial, involving the cheeks, forehead, upper lip, nose and chin; malar, involving the cheeks and nose; and mandibular, involving the lower sides of the face.
While physicians currently employ a wide array of treatments ranging from sunscreens and daily topical lighteners to controlled skin peels and laser or light-based procedures, reliable, consistent, long-term clearance of melasma remains among their most difficult challenges.
Epidermal vs. Dermal
The depth of the melasma pigment can be epidermal (more superficial) or dermal (deeper); however, the majority of cases involve pigment in both skin layers. Determining the depth of pigment deposits can be difficult.
Determining the type of melasma and depth of excess melanin deposits is important in providing the most effective treatments and advising a patient on the most likely prognosis. In the epidermal form, characterized by brown color, melanin is found in the basal and suprabasal layers. In dermal melasma, which appears more blue-gray, melanin is found in the superficial and deep perivascular melanosomes. The epidermal form is easier to treat and more amenable to topical therapy, while dermal or mixed melasma is more resistant to treatment. Dr. Parsons is able to treat both superficial and deep melasma with our Sciton BBL Intense Pulsed Light device. https://www.renovemedspa.org/photorejuvination
First-line treatments involve sun protection and some combination of topical skin lighteners and chemical or mechanical peels. Experts recommend a broad-spectrum sunscreen that protects from both UVA and UVB rays and is water-resistant with an SPF of at least 30. It is important that the sunscreen has zinc oxide and/or titanium oxide, to block the UVA and UVB rays. Experts also recommend sunscreens that block blue light. Only a select few sunscreens block blue light. Wide-brimmed hats and other protective clothing are recommended during extended periods in the sun.
“I recommend tinted sunscreens containing iron oxide such as ZO Skin Health Triple Protection Sunscreen + Primer with natural melanin and iron oxide to block visible light, antioxidants, and zinc and titanium oxide SPF 30,” says Dr. Michelle Parsons. “Iron oxide not only provides a tint but also blocks visible light, which worsens melasma.”
Patients should also minimize UV exposure while in a car. “Patients may not think they spend a lot of time outside, but even incidental UV exposure—through car windows, home windows, for example—can worsen melasma. UVA rays in particular contribute to skin darkening through windows,” says Eric F. Bernstein, MD, of the Main Line Center for Laser Surgery in Ardmore, Pennsylvania. “Having photoprotective film professionally applied to car windows to block UVA rays can be a big help.”
Clear window films such as Llumar and Solar Gard block 99% of UVA and don’t hinder night vision. Car windshields already contain a layer of clear plastic mandated to help prevent broken glass from flying through the air after an impact, but it is not designed to block UVA.
In addition to photoprotection, Dr. Parsons recommends topical therapy. “Effective melasma treatment includes removal of the excess melanin in the epidermis and dermis as well as suppression of further melanogenesis. Without these two steps, there is high risk for relapse,” she says. “The gold standard for first-line melasma treatment is strict photoprotection and topical therapy, using either hydroquinone 4% cream, tretinoin or triple combination creams.”
Triple combination creams, such as Tri-Luma (Galderma), which is FDA-approved for treating melasma, include a combination of hydroquinone, tretinoin and a topical steroid.
“Our first-line treatments include 4% hydroquinone, as well as azelaic acid and kojic acid in combination with tretinoin, and broad spectrum sunscreen. For very stubborn melasma I will add topical Cyspera https://www.cyspera.com/, a very potent anti-oxidant, and topical tranexamic acid, especially for hormonally related melasma” says Dr. Parsons. “Patient satisfaction depends on the severity of the condition, but a high percentage of newly diagnosed epidermal melasma patients get satisfactory results. Patients with dermal melasma will need a lot more patience.”
Pregnant patients should first consult their obstetricians regarding which products they can safely use. “We cannot utilize tretinoin, hydroquinone, Cyspera or tranexamic acid during pregnancy. Most pregnant women with melasma can use AHAs versus retinoids during pregnancy and chemical-free, non-nanoparticle physical sun blockers,” says Dr. Parsons.
For many patients, first-line treatments are not satisfactory, but experts don’t always agree as to the best, most effective option for persistent cases.
“For persistent melasma, we continue first-line topical treatments and add physical therapies, such as peels and microneedling which does not cause chemical injury to the epidermis, thereby increasing clearance rates and reducing the risk of hyperpigmentation,” says Dr. Parsons. “When all other modalities have failed, I will recommend intense pulsed light (IPL) treatments, depending on the chronicity of the condition, previous treatments and skin type. Current evidence from randomized studies suggests that low-fluence QS Nd:YAG and IPL provide the most effective results. Fraxel CO2 lasers have been shown to be not effective for treating melasma.”
“I will also treat selected patients with oral pills such as tranexamic acid after I take a thorough medical history. Oral pills are not for everyone. They should not be given to certain patients, including those with clotting problems, and can cause side effects.”
IPL shows better results in primarily epidermal melasma and with Fitzpatrick skin types 1 to 3, while the QS Nd:YAG has broader efficacy in treating both dermal and epidermal melasma, “When these devices are combined with effective photoprotection and topical lightening creams, the improvement in melasma is significantly better, and risk of relapse lower than when using any of the devices or topical therapies as monotherapy. After laser therapy, it is important to counsel patients to continue using photoprotection and a topical lightening agent to reduce recurrence risk.”
But whichever light or laser source is employed, results require multiple treatments, and hyperpigmentation is likely to recur.
If you would like to be evaluated to see if you are a good candidate for melasma treatment, call the office for a complimentary consultation with Dr. Michelle Parsons.