By Gary M. White, MD
A brown "mustache" on the upper lip of a young woman.
Melasma is a very common darkening of the skin of the face in woman.
Melasma appears as symmetric brown patches on the face of a woman. Involvement of the middle forehead, cheek, upper lip and tracking along the zygoma is typical. There usually is patchy, stippled areas of normal skin tone throughout the hyperpigmentation. Sun exposure predisposes to melasma as do female hormones, e.g., oral contraceptives or pregnancy. Still, many women not on these are affected, particularly those of Hispanic descent.
According to a review of studies involving topical therapy for lightening melasma [JAAD 2014;70:369-73), the best is triple combination therapy (e.g., Tri-Luma), then 4% hydroquinone, then azelaic acid, and then 2% hydroquinone. Any therapy should be given 3-4 months to have an effect and be combined with daily morning sunscreen. A handout is available.
Visible light can aggravate melasma and thus the patient must apply a physical block sunscreen, e.g., tinted, containing zinc oxide [JAAD J Am Acad Dermatol; 2015 Jan 01:72;189-190] the moment they wake up and reapply several times per day. In another study, adding iron oxide to sunscreen to block visible light did mildly improve efficacy of 4% hydroquinone [Photodermatol Photoimmunol Photomed. 2014;30:35-42].
Tri-Luma cream (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) is applied once daily for melasma. It should be applied QHS and SPF 30 or higher sunscreen applied in the AM.
4% hydroquinone is by prescription; 2% is OTC. It is applied BID to the dark areas. This is second line therapy and the combination of hydroquinone, steroid and retinoid is preferred.
Azelaic acid may be used as a second line agent to maintain lightening of melasma.
An OTC product, Elure, contains lignin peroxidase and has been shown to be better than placebo at skin lightening and approximately equivalent in efficacy to hydroquinone when used BID [JAAD 2015;72;105]. Sixty patients were studied with a split face design. Cohort 1: Elure vs. placebo. Cohort 2: Elure vs. 4% hydroquinone.
Serial glycolic acid peel with triple combination bleach does better than triple combination bleaching agent alone according to one expert.
Response is, as of this writing, variable. For example, one study of fifty patients with melasma who underwent 15 weeks of weekly treatments, using a Q-switched Nd:YAG laser at 1064 nm with an 8-mm spot size, and a fluence of 2.8 J/cm(2), found an average improvement of 50-74% [J Dermatolog Treat. 2014;25:212-7].
Tranexamic acid is a synthetic derivative of the amino acid lysine and is used to reduce blood loss in menorrhagia or after major surgical procedures by virtue of its plasmin inhibiting action. Oral tranexamic acid (TA) (e.g., 250 mg twice daily after food) may be an effective adjunct for refractory melasma [JAAD 2016;June ahead of print]. Careful screening for personal and familial risk factors for thromboembolism should be done before initiation.
Melasma and a solar lentigo.
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