By Dr. Mike McGuiness
Of all the conditions we treat in dermatology, melasma is among the most intriguing and frustrating to me. Much is known about melasma, but it remains quite difficult to treat successfully. It affects 40-50% of women and a smaller percentage of men, so, overall, the number of people afflicted is quite large. The pathophysiology and etiology of melasma are not to be a significant part of this discussion, as it is detailed elsewhere. Nor will the treatment options be exhaustively outlined, as there are many that do not work, and others not proven. There is one potential treatment we are beginning to study, which we hold very high hopes for in the future.
Melasma is classically thought of as a facial condition, but similar conditions are found on the neck, chest, back, and arms. The MOST important factor in melasma is exposure to ultraviolet radiation ( UV ), from sun or tanning beds. As there is no “safe” amount of exposure to UV that will not do damage to the skin and increase your risk of skin cancer, there is no small amount of UV exposure that will not lead to causing or worsening melasma, or making it much more difficult to treat; none. UV exposure must be completely avoided as much as possible, year round, or melasma treatment will be fruitless. We have seen good results after months and months of melasma treatment obliterated with an hour or two of inadvertent UV exposure. I can not emphasize this enough. The details of what complete sun avoidance entails can be found in an article to be released in the near future. It is a considerable undertaking.
There does seem to be an inflammatory component to many cases of melasma, meaning there are increased numbers and sizes of small blood vessels. Any activity that simply warms or increases blood flow to the skin will often lead to more discoloration that is more difficult to treat. These include being in the sun, exercise, alcohol use, certain medications, etc.
Hormonal fluctuations during pregnancy, hormonal means of birth control (pills, IUD, subcutaneous implants), and other hormonal replacement therapy are well know contributors to the onset, perpetuation and difficulty treating melasma. Avoiding these issues to the extent possible is very important for optimizing melasma treatment.
In addition to the above measures, any of the following would be helpful. In fact, multiple modalities used simultaneously, are usually more effective. One must be careful not to overtreat and develop skin irritation or inflammation, for this will worsen the melasma. This is not an exhaustive list of further treatments, but it is a gathering of mostly proven therapies.
Other topical treatments that comprise the backbone of melasma treatment include daily use of hydroquinone, kojic acid, retinoids, azelaic acid, corticosteroids and vitamin C products. With strict avoidance of UV exposure, hormonal fluctuations, and vascular insults, the addition of several of the above topical treatments may lead to improvement in the appearance of melasma, after several months. Maintaining this improvement takes a lifelong commitment to the program. As stated, even a brief solar indiscretion can undo many months of work.
Laser treatments have long been used to treat melasma, usually with little success. Major problems with this modality, are that the degree of heat and tissue damage generated by the high laser energy, often worsen the melasma. There has been some success with using what is called a Q-switched laser at very low energies, low treatment density, and few passes. An advantage of the Q-switched laser is that it has a very short pulse width, and with the proper settings, can target pigment in the skin with little thermal damage induced, which as stated earlier, can worsen melasma.
The newest lasers are called picosecond lasers, and they have a much shorter pulse width than the Q-switched lasers. Theoretically, if the proper wavelength is selected, and low energy and density used, the super short pulse of the picosecond laser might cause even less collateral damage while still targeting and destroying the unwanted skin pigment. The most promising of these picosecond lasers is the Enlighten by Cutera. We have started treating people with melasma, with the Enlighten, who have been refractory to the usual measures. We welcome hearing from individuals interested in being considered for treatment with the Enlighten laser, who have been resistant to other treatments.
I hope that someday we will be able to treat melasma, confident that our efforts will lead to a high rate of success. Until then, successful treatment of melasma remains complex, and a long-term commitment, with little room for non-compliance.
If you are interested in exploring melasma treatment options, request an appointment with our cosmetic dermatology experts at our Plano, Prosper, Flower Mound, Lakewood, Richardson, Murphy, and Anna locations.