Melasma in a typical location.

MELASMA

Melasma is a very common darkening of the skin of the face in woman. It presents as symmetric brown patches, particularly on the cheeks and upper lip.

• Sun exposure as well visible light from indoor lighting trigger melasma.
• Female hormones (e.g., endogenous, oral contraceptives, pregnancy) are the other key drivers of melasma.
• Melasma provides natural sun protection and there is some evidence that patients with melasma are less likely to develop melanoma.
• There is a four-fold increase of thyroid disease in melasma patients.

Treatment

• Tinted, physical block sunscreen containing iron oxide immediately upon wakening and several times a day is key. The inclusion of iron oxide is key as it blocks visible light which is important
• Combination bleaching creams e.g., Tri-Luma (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%)
• Laser usually in combination with the above.
• Tranexamic Acid
• Polypodium Leucotomos extract

Sun protection is paramount in the treatment of melasma, combined with various topical creams, a pill chemical peels and/or laser.

Sunscreen

Visible light is an important trigger of melasma and thus a physical block sunscreen, e.g., tinted, containing iron oxide applied immediately upon awakening and several times per day is recommended.

Combination Topical Creams

Tri-Luma cream the only FDA-approved topical treatment for the short-term management of moderate to severe melasma of the face. It is applied once daily to the affected areas.

Various pharmacies compound various combinations of hydroquinone, a steroid, tretinoin, Kojic acid, etc. and sell them (by prescription) at a substantially lower price than Tri Luma. Although the separate ingredients may been shown beneficial for melasma in clinical studies, any particular combination may not. Thus, the scientific evidence underpinning their use is not as strong as that with Tri Luma.

Tranexamic Acid

Tranexamic acid is a synthetic derivative of the amino acid lysine and is FDA-approved for the treatment of cyclic heavy menstrual bleeding. It is only availabie by prescription and is NOT FDA-approved for melasma. In a double-blind study, oral tranexamic acid 250 mg twice daily after food reduced the melasma severity score by 49% at 3 months compared 18% for placebo. Usual doses are typically 500 to 1500 mg daily in 2 to 3 divided doses. Careful screening for personal and familial risk factors for thromboembolism (DVT, PE, Stroke, MI) should be done before initiation although there is little evidence for any increased risk of thromboembolic events at this dose. Few side effects are seen in clinical use.

Other Treatments

Chemical peels and laser are commonly used.

Polypodium Leucotomos extract

In a study published in the American Journal of Clinical and Aesthetic Dermatology, 33 Asian women with melasma aged 25 and 55 years were divided into two study groups, one treated with hydroquinone 4% and SPF 50 sunscreen and the other with hydroquinone 4%, SPF 50 sunscreen and oral Fernblock®. After 60 days, the use of Fernblock® oral combined with hydroquinone 4% and sunscreen 50 SPF gave significantly better reduction in the extentension and severity of melasma than hydroquinone 4% and sunscreen 50 SPF alone. See Heliocare.

Melasma of the cheek in a Hispanic woman.

RegionalDerm

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