Melasma. You know it when you see it: those irregularly shaped brown patches on the cheeks that inevitably darken in the summer months and fade in the winter. This can be a very challenging and painful condition because there is no cure to date. Fortunately, our board-certified dermatologists at SkinCare Physicians have developed an approach that allows us to control melasma even if we can’t cure it. Dr. Mitalee Christman, who has conducted extensive research* on the topic, reveals what causes melasma, how it’s diagnosed, and our treatment plans.
Understanding and diagnosing melasma
We know that melasma tends to affect women with deeper skin tones, but it can also affect men. Female hormones, sun exposure and heat tend to aggravate the condition.
A trained eye is necessary to distinguish melasma from other skin conditions that can cause dark spots on the face, such as freckles or post-inflammatory hyperpigmentation. The pigment in melasma tends to form lacy irregular borders, favoring the cheeks, forehead and upper lip. Occasionally, we also see it from the face. During your visit to SkinCare Physicians, we may use a special light called a Wood lamp to determine the depth of the melasma, which will then inform your treatment options. We will also take standardized clinical photographs at each visit to monitor response to each treatment.
The best results await
Unfortunately, melasma is a chronic condition and has no known cure to date. By its very nature, it tends to be repetitive, which can be very frustrating. Some treatments work better than others, so expect the condition to wax and wane. The goal of our treatment plans is to help melasma change gently and infrequently, rather than fluctuating dramatically. I tell my patients that they will know their condition is under control when they find they are wearing less makeup over time.
A rotation of melasma treatments
All treatments have side effects that prevent long-term use, so we often use a rotation of treatments to control melasma while minimizing the risk of side effects. This means that patients come to the clinic three times a year for evaluation and a change in their treatment.
Topical drugs:
We will often prescribe hydroquinone, a powerful bleaching agent, sometimes in combination with other ingredients such as retinoids, corticosteroids or kojic acid, at a local pharmacy. These compounds help reduce melanin production and fade dark patches over time. Importantly, hydroquinone cannot be used for more than 8 to 12 weeks, so it is always used alternately with other treatments.
Oral tranexamic acid tablets:
For moderate or severe melasma that is very painful, we may introduce the idea of taking tranexamic acid pills for a few months a year. This drug is commonly used to treat heavy menstrual bleeding, but is increasingly being used off-label to treat melasma with impressive results. We believe it works by targeting vascular factors in melasma-affected skin. The pills are very well tolerated with the most common side effects being bloating, headaches and lighter periods. There is an extremely rare risk of blood clots, so the drug is only offered after a thorough examination to those deemed to be at low risk.
Chemical peeling:
Our estheticians at SkinCare Aesthetics can use chemical peels that contain alpha hydroxy acids (AHAs), such as glycolic or lactic acid, to gently exfoliate the skin. Chemical peels help lighten patches of melasma and promote the growth of new, evenly pigmented skin. They can be repeated every 2-4 weeks for best results.
Laser treatment:
Unfortunately, lasers are not the magic wand that many wish for for this condition: even mild lasers can heat the skin and cause melasma flare-ups, so we are very cautious about recommending them. Some doctors offer lasers only when the patient has been clinically monitored for many months – this time helps us understand how irritable or malleable the melasma is. Once the melasma is well controlled and if the patient’s skin would benefit from the collagen stimulating capabilities of our lasers, we can recommend a low energy, low density, non-ablative fractional laser treatment called ‘Fraxel Quick Recovery’ or FQR, often in combination. with topical treatments and oral tranexamic acid pills. The temporary improvement provided by this approach can be very rewarding.
Strict sun protection:
Even the best treatment regimen can be undone by sloppy sun care. All year round, but especially in the sunniest months, we recommend wearing wide-brimmed hats, UPF clothingand one broad spectrum tinted sunscreen with SPF 50. Tint is important because the iron oxides in tinted products block visible light, which we know worsens melasma. The Weather app on your phone can help you identify peak times (UV index > 3) and during these times, it’s wise to seek shade and limit sun exposure. ONE Polypodium leucotomos dietary supplement (eg Litmus) and a UV face shield (eg Bluestone Sunshields) can be a useful addition to tropical vacations or days at the beach.
Dealing with melasma can be difficult, but our team at SkinCare Physicians is ready to help patients regain their confidence. By accurately diagnosing this condition and using evidence-based treatments, we can turn melasma from a significant mental burden to a minor, easily managed nuisance. If you think you have melasma, contact us to schedule a consultation. We look forward to seeing you at the clinic.
bibliographical references
- Del Rosario E, Florez-Pollack S, Zapata L Jr, et al. Randomized, placebo-controlled, double-blind study of oral tranexamic acid in the treatment of moderate to severe melasma. J Am Acad Dermatol. 2018? 78 (2): 363-369. doi:10.1016/j.jaad.2017.09.053
- * Kamal K, Heitmiller K, Christman M. Lasers, lights and compounds for melasma in aesthetics. Clin Dermatol. 2022;40(3):249-255. doi:10.1016/j.clindermatol.2021.11.006
- * Pomerantz H, Christman MP, Bloom BS, et al. Dynamic optical coherence tomography of cutaneous blood vessels in melasma and vascular response to oral tranexamic acid. Lasers Surg Med. 2021;53(6):861-864. doi:10.1002/lsm.23345
- Relke N, Chornenki NLJ, Sholzberg M. Tranexamic acid evidence and controversies: An illustrated review. Res Pract Thromb
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