Of all hyperpigmentation issues, melasma is one of the most persistent and difficult to treat. While many hyperpigmentation issues happen in the epidermis, melasma runs much deeper and is impacted by many other factors.

Manifesting as clusters or islands of brown-grey pigment, melasma is generally hormonally induced (pregnancy, contraceptives, thyroid) triggered by light (any light, especially UV), heat (infrared saunas, steamy kitchens, the gym included) and pollution (yep, pollution). These hyperpigmentation islands tend to mirror each other on both sides of the face (most commonly, upper lip, chin, brows, cheeks, forehead), but also can appear on the neck and forearms. Further, melasma usually affects women (only about 10% of men are affected) and those with darker or golden undertone skin types.

There actually is no “cure” for melasma. Those annoying melanocytes always will be active below the surface like submerged volcanic islands. Hardly a hopeless situation though, as clarity on the surface can be achieved and maintained with patience and strict compliance with recommended treatments and products. Your reward for your efforts not only will be clear and even skin, but also, seriously youthful looking skin. Win/Win!

Melasma treatment is primarily product and peel driven. As mentioned above, heat and light are triggers, so lasers must be used with extreme caution and must only be performed by highly experienced medical pros. As a matter of fact, you may have melasma and not even know it – that is, until an inexperienced technician performs an IPL to even your seemingly sun damaged skin, jetting you one-way to the hyperpigmentation islands without sunscreen.

How can melasma be treated?

Treating melasma starts with avoiding the sun as much as possible and using sunscreen 365 days a year, rain or shine. To hopefully to hit this sunscreen point home, recent studies show any visible light can impact melasma, especially low-spectrum blue light (another reason to reduce screen/phone time). By the way, if your makeup or face lotion has sunscreen, consider that “bonus sunscreen”; always use a separate sunscreen. If you are going to be outside for any length of time, wide brimmed hats and sunglasses are strongly encouraged.

Worried about Vitamin D? Take a supplement and consume more foods high in Vitamin D. 

Next on the list, pigment suppressing ingredients:

• Hydroquinone (HQ) – HQ has been standard therapy for decades. HQ suppresses melanin production and bleaches pretty much any skin surface to which it is applied. To be potent enough to treat melasma, prescription strength is necessary.

IMPORTANT NOTE: HQ must be cycled with other pigment suppressants. In other words, DO NOT use HQ products year-round without giving your skin a break. Without a break, severe rebounding of melasma or ochronosis can develop.   

• Retinoic Acid (RA)  – RA is a vitamin A-based topical medication (Tazarotene, Retin-A, Tazorac, Tretinoin) – RA speeds cell turnover (including pigmented cells), decreases melanocytes and serves as an anchor for topical medications, drawing them deeper into the skin (why we usually prescribe a compounded formula of tretinoin and HQ).

IMPORTANT NOTE: DO NOT use retinoids if pregnant or breastfeeding. Use only at night because UV renders retinoids inactive.

Btw, retinoids are the most prescribed topical medications for aging issues and acne.

• Azelaic Acid – Azelaic acid targets only hyperpigmented areas with no lightening effect on normal skin tone. Further, when 20% azelaic acid is combined with retinoic acid, it works as well as 4% HQ + RA without the side effects:

Azelaic acid with tretinoin caused more skin lightening after three months than azelaic acid alone, and a higher proportion of excellent responders at the end of treatment. 

• Kojic Acid
• Arbutin
• Liquorice Root
• Glutathione
• Lactic Acid
• Glycolic Acid
• Vitamin C and other antioxidants – Stability, potency and delivery/penetration is critical to the effectiveness of all products, but particularly to vitamin C in the skin. There is an enormous difference between efficacy of products with vitamin C. The most effective and most stable vitamin C / antioxidant products are physician grade ones such as those from Vivier, Epionce and Skinbetter.

IMPORTANT: Avoid combining vitamin C and retinoic acid because efficacy of both is diminished when mixed. Use RA at night. Use vitamin C in the morning.

• Oral Tranexamic Acid (by prescription only) – Oral tranexamic acid is not recommended for anyone with clotting disorders, or anyone who has had a stroke, possible deep vein thrombosis or pulmonary embolism. 
• Heliocare – this oral supplement offers extra protection against free radicals, especially those caused by visible light sources that damage skin.

Procedures

• Chemical Peels – Chemical peels are the second line of treatment for melasma. Only gentle and superficial peels should be used to treat melasma. Stronger acid concentrations of most acids can worsen melasma.

List of most common and effective peels: Glycolic Acid, Lactic Acid, Trichloroacetic Acid (TCA), Salicylic Acid + Mandelic Acid, Jessner’s

IMPORTANT: Pre-treatment prep with products (see above list) is required before chemical peels or lasers.

• SkinPen – SkinPen is the first FDA-approved medical microneedling device. Skinpen provides an effective physical method of enhancing penetration of topical ingredients (HQ, tranexamic acid, etc.) without causing heat on the skin. Of course, too much trauma will worsen the condition, so again, experience is required.

• Lasers – While laser therapy is not the first choice or second, or even the third when treating melasma (heat and light are primary triggers), low-frequency Q-Switched laser combined with Laser Genesis, or a fractionated erbium laser such as Pixel by Alma Lasers can be used in highly experienced hands to reduce the appearance of melasma.

Hopefully, it is a bit more clear to all that a delicate balance is required when treating melasma. As for the precious but impatient ones, you must stop insisting on stronger treatments. Over-treatment is a bad thing and will worsen the situation. Also, you can’t scrub it off; scrubbing and friction makes melasma worse. Having a recurrence since joining a hot yoga class? Heat makes melasma worse. 

Melasma may be tempermental, but you don’t have to be. Patience, a continuous regimen of pigment suppressing products and sunscreen, and regular professional peels will clear melasma, forcing these hyperpigmentation islands to subside and keeping them submerged.