The first step in the treatment and prevention of melasma is to avoid the exacerbating factors. Exposures to sunlight, oral contraceptive pills, hormone replacement medication, and perfumes in the cosmetic preparations are known to trigger the hyperpigmentation.
Melasma treatment
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Melasma during pregnancy may clear spontaneously without treatment after childbirth. Melasma due to hormone treatments, oral contraceptive pills, medications, chemicals, cosmetics and perfumes may resolve gradually after the withdrawal of the triggering factor. Sunscreen usage and sun avoidance are very necessary to achieve the results.
For persistent or chronic melasma, several treatment options like application of hypopigmenting agents, bleaching agents, chemical peels and natural products are available. Procedures like microdermabrasion and laser treatments are also possible. Successful treatment of melasma hyperpigmentation increases the self-confidence and self-esteem in the patients.
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| picture of melasma on face Image by Elord | CC BY-SA 3.0 www.wikidoc.org |
Topical melasma treatment
In the topical treatment of melasma the hypopigmenting agents and/or bleaching agents are applied on the affected area of skin. The excess production of skin pigment is the basic cause of hyperpigmentation. Tyrosinase enzyme converts dopamine to melanin.- Hydroquinone
- Hydroquinone is the hypopigmenting agent of choice and it blocks the enzymatic pathway of tyrosinase in the production of melanin. Hydroquinone in combination with one or more bleaching agents is found to give good results. Hydroquinone creams and its combinations are available in 2% or 4% strength and the later strength is available on a prescription. In some patients hydroquinone creams can cause skin irritation and worsen the hyperpigmentation.
- Kligman formula
- Kligman formula was developed by Dr. Albert Kligman, a famous dermatologist in US. The patented original formulation contained 2 to 5 percent hydroquinone, 0.05 to 1.0 percent retinoic acid and 0.1 percent dexamethasone. The formulation is found to be very effective against melasma. Many effective triple cream modifications are now available with the pharmacists.
- Tri-Luma
- Tri-Luma® Cream is a brand of triple-combination topical cream which is claimed to be FDA-approved melasma treatment. Tri-Luma contains 0.01% fluocinolone acetonide, 0.05% tretinoin and 4% hydroquinone. The fluocinolone acetonide is a mild corticosteroid helpful in reducing inflammation. The tretinoin is a exfoliating and bleaching agent bringing about cell turnover and exfoliation. The hydroquinone is the depigmenting agent which interrupts enzymatic process leading the melanin synthesis.
- Retinoids
- Tretinoin (all-trans retinoic acid or retinoic acid) is the carboxylic acid form of vitamin A. Retinoic acid promotes loss of pigment by increased turnover of epidermis. It also reduces the tyrosinase activity. However the effects take longer time to become apparent. The melasma treatment with retinoic acid may cause side effects like inflammation, erythema, burning and sore sensation, dry skin and scaling. Some patients may have hyperpigmentation.
- Steroids
- Topical corticosteroids, such as hydrocortisone are skin lightening agents, which can lighten the skin as well as reduce inflammation. But such lightening is highly reversible on exposure to sunlight. The topical corticosteroids may inhibit the melanogenesis. In some patients corticosteroid monotherapy has caused skin irritation, inflammation and dermatitis.
Depigmentation agents and chemical peels
Apart from the hydroquinone, retinoids and corticosteroids there are many other depigmentation agents and chemicals which are effective in the control of melasma.- Azelaic acid
- Azelaic acid occurs naturally. Azelaic acid is a nonphenolic, nine-carbon dicarboxylic acid. It inhibits tyrosinase, DNA synthesis and mitochondrial enzymes. Azelaic acid reduces the free radicals and has cytotoxic effects toward abnormal melanocytes. Azelaic acid does not cause depigmentation of normal skin. Azelaic acid is safe for longterm use and it can be used even during pregnancy.
- Kojic acid
- Kojic acid (5-hydroxy-2-hydroxymethyl-4-pyrone) is derived from certain species of fungi. Kojic acid is an antioxidant and inhibits tyrosinase production. Kojic acid formulations can cause irritation and contact dermatitis. Hence these formulations may be tried only when the firstline formulations are ineffective.
- Glycolic acid
- Glycolic acid is a skin lightening agent which promotes epidermal turnover and desquamation. it also has inhibitory effects on the tyrosinase and reduces the melanogenesis. In some patients skin irritation is caused by the application of glycolic acid.
- Ascorbic acid
- Ascorbic acid is a potent antioxidant. 25% L-ascorbic acid is known to inhibit melanin pigment production. However it is highly unstable as a topical cream. It requires appropriate binding agents for efficacy. It is almost devoid of ill effects.
- Niacinamide
- Niacinamide (nicotinamide) is the active form of vitamin B3. Niacinamide has no action on the tyrosinase enzyme activity. Skin lightening is achieved by its property of blocking the transfer of melanosomes from melanocytes to the keratinocytes. After four weeks of melasma treatment significant results are achieved.
- Topical methimazole
- J.Malek et al have treated two persons having melasma which was not responding to 4% topical hydroquinone (HQ). Application of topical 5% methimazole (MMI) for 8 weeks resulted in near complete clearing of the lesions. As methimazole is an oral anti-thyroid medication, the levels of the thyroid hormones after a 6-week treatment were monitored. It showed no change in serum TSH, free thyroxine, and free triiodothyronine levels as well as no detectable serum MMI levels. Topical application of methimazole appears to be a promising alternative to hydroquinone.
Microdermabrasion for melasma
- In microdermabrasion abrasive materials are used to exfoliate the epidermal layers of the skin. This procedure can improve melasma, but several sittings may be required for good results. In some patients this procedure may induce inflammation and hyperpigmentation. Sunscreen and anti-inflammatory creams must be applied after microdermabrasion.
Laser treatment of melasma
- Treatment with lasers produced mixed results. In some patients melasma had worsened when there was inflammation after the procedure. Many patients required repeated sittings to get visible results. The Fraxel laser (a type of fractional laser) is found to give better results and the Dual 1550/1927 Fraxel laser has been approved by FDA for the treatment of skin pigmentation problems like melasma.
Melasma natural treatment
A number of botanical compounds and their synthetic derivatives have been found to have positive results in lightening the melasma lesions. Some of the natural compounds and their sources are:
- Aloesin (aloe vera),
- cinnamic acid (cassia and ginseng),
- linoleic acid (unsaturated fatty acid),
- orchid extracts,
- epigallocatechin gallate (green tea),
- dioic acid (from oleic acid),
- silymarin (thistle plant),
- genistein (soybeans),
- diadzein (soybeans),
- gentisic acid (Gentian roots) and
- ellagic acid (strawberries, green tea).
- Oral medication in melasma treatment
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Tranexamic acid, a synthetic derivative of the amino acid lysine, is prescribed for treatment and prevention of blood loss, especially during surgery and also in dysfunctional uterine bleeding. It is known to decrease melanogenesis in the melanocytes and provide fast and sustained lightening of melasma lesions. As it has a potential risk of thrombosis, its use is not yet universally recommended for the treatment of melasma.
In a placebo-controlled trial oral proanthocyanidin plus vitamin A, C, and E were administered on patients with bilateral melasma with encouraging results by the end of eight weeks. Pycnogenol, a plant extract containing procyanidins showed a decrease in melasma lesions after 30 days.
- Melasma prevention
- For the successful treatment, resolution and prevention broad spectrum sunscreen with sun protection factor (SPF) of at least 30 and physical light blocking agents like zinc oxide and titanium dioxide is required. Both the UV-A and UV-B spectrum are to be blocked. Melasma tends to be a chronic skin disorder which may be kept in check by avoiding the triggering factors. Melasma treatments fail when adequate sun protection measures and avoidance of excessive sun exposure are lacking.
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References:
1.Rashmi Sarkar, Shikha Chugh, Vijay K Garg. Newer and upcoming therapies for melasma. Indian J Dermatol Venereol Leprol. 2012 Jul-Aug;78(4):417-28.
2.Ball Arefiev KL, Hantash BM. Advances in the treatment of melasma: a review of the recent literature. Dermatol Surg. 2012 Jul;38(7 Pt 1):971-84.
3.Debabrata Bandyopadhyay.Treatment OF melasma. Indian J Dermatol. 2009 Oct-Dec; 54(4): 303–309.
4.Malek, J., Chedraoui, A., Nikolic, D., Barouti, N., Ghosn, S. and Abbas, O. (2013), Successful treatment of hydroquinone-resistant melasma using topical methimazole. Dermatologic Therapy, 26: 69–72. doi: 10.1111/j.1529-8019.2012.01540.x
1.Rashmi Sarkar, Shikha Chugh, Vijay K Garg. Newer and upcoming therapies for melasma. Indian J Dermatol Venereol Leprol. 2012 Jul-Aug;78(4):417-28.
2.Ball Arefiev KL, Hantash BM. Advances in the treatment of melasma: a review of the recent literature. Dermatol Surg. 2012 Jul;38(7 Pt 1):971-84.
3.Debabrata Bandyopadhyay.Treatment OF melasma. Indian J Dermatol. 2009 Oct-Dec; 54(4): 303–309.
4.Malek, J., Chedraoui, A., Nikolic, D., Barouti, N., Ghosn, S. and Abbas, O. (2013), Successful treatment of hydroquinone-resistant melasma using topical methimazole. Dermatologic Therapy, 26: 69–72. doi: 10.1111/j.1529-8019.2012.01540.x
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