Melasma or brown pigmentation on the face is a common concern for young women and for some men. It most often affects those with darker skin tones but can occur in all skin types. The known risk factors are sun exposure, pregnancy, thyroid disease, birth control pills and hormone replacement pills.
Hydroquinone, which blocks the production of melanin ( the brown pigment in the skin) is the most prescribed treatment. Hydroquinone cream or liquid can be applied in combination with topical vitamin A and a topical steroid to enhance the results. Research studies show improvement in pigmentation in 35%-65% of participants within 3 months. Recently, there has been concern raised about the long term safety of hydroquinone. Studies in rodents show evidence of carcinogenity, but that has not been proven in human studies. As a result of these concerns, new topical agents and treatments with lasers or peels have gained in popularity.
Skin lightening agents with non-prescription, herbal ingredients, such as kojic acid, arbutin 1% and azaleic acid 20% are beneficial in clearing melasma. These agents can be used alone, in combination, or with hydroquinone depending on the severity of melasma. The herbal skin lighteners have a safety advantage and can be used during pregnancy.
Chemical peels are often used as an adjunct to speed up pigment reduction. Glycolic acid peels work by thinning the top layer of the skin to enhance penetration of the topical agents and by breaking up the pigment in the deeper layers. For best results a series of 6-10 treatments at 2-4 week intervals is needed. Salicylic acid and and Jessner’s solution ( a combination of salicylic acid, lactic acid and resorcinol) are peeling agents with comparable results. All of these peels are mild and have no signficant “downtime”. Trichloracetic acid or TCA is a peeling agent that penetrates the skin more deeply and provides the best results. Healing time for this peel is 4-5 days. In concentrations of 15-20% it is safe for most skin types.
Light and laser treatments have been used for melasma with varied results. The Intense Pulsed Light or IPL is effective for light skinned patients but can cause worsening of melasma in patients with darker skin tones. The fractional erbium laser, or Fraxel laser, has has also been used in combination with topical therapy for melasma. When compared with topical therapy alone , some studies have shown improvement in the laser treated group vs. the home treatment group. However, depending on skin type, some patients in the laser treated group experienced darkening of melasma.
Based on the latest information, I recommend a conservative treatment plan for patients suffering from melasma:
- Try a topical program of hydroquinone with tretinoin or a combination of herbal skin lighteners for a minimum of 3-4 weeks.
- If improvement is insufficient, try a series of 4-6 light peels with glycolic acid, salicylic acid , Jessner’s or one of the newer combination peels such as Vitalize Peel.
- If improvement is insufficient or if there is time urgency, TCA peel is a good option. Home products should be used before and one week after the peel for optimal results.
- IPL is an option only for fair skinned patients. In my experience the TCA peel provides better results
- Fraxel laser , used with very gentle settings, is an alternative if all else has failed. It must be used in combination with home use products for best results.
For anyone with chronic melasma, fanatic sun protection is a key element of the program. And, consideration must be given to stopping oral contraceptives or hormone replacement if they are being used and the melasma is refractory to treatment.