What is the recommended treatment for melasma?

Treatment for Melasma

The most effective first-line treatment for melasma is triple combination cream containing hydroquinone, tretinoin, and corticosteroid, combined with strict sun protection using broad-spectrum SPF 70 or higher sunscreen. 1, 2

Understanding Melasma

Melasma is a chronic, acquired pigmentary disorder characterized by symmetrical hyperpigmented patches primarily affecting sun-exposed areas of the face. It predominantly affects women and individuals with darker skin types (Fitzpatrick IV-VI). The condition significantly impacts quality of life due to its disfiguring appearance.

Key Pathophysiological Factors:

• Excessive melanogenesis
• Photoaging
• Increased mast cells and vascularization
• Basement membrane damage
• Genetic predisposition 3

Treatment Algorithm

Step 1: First-Line Therapy

• Triple combination cream (4% hydroquinone + 0.05% tretinoin + 0.01% fluocinolone acetonide)

  • Apply once daily at night for up to 6 months
  • Most effective treatment with highest level of evidence 2
  • Monitor for side effects: erythema, irritation, telangiectasia

• Alternative: Hydroquinone 4% monotherapy

  • Apply twice daily for up to 6 months if triple therapy not tolerated
  • Can be safely used for up to 6 months 1

Step 2: Sun Protection (Mandatory)

• Broad-spectrum SPF 70+ sunscreen applied every 2 hours when outdoors
• Physical sun protection (wide-brimmed hats, sun-protective clothing)
• Sun avoidance, especially during peak hours (10 AM - 4 PM) 1

Step 3: Adjunctive Therapies

• For moderate to severe cases resistant to topical therapy:

  • Oral tranexamic acid (250 mg twice daily)
  • Promising for recurrent melasma 2
  • Requires monitoring for thromboembolic risk

• For cases with minimal improvement after 8-12 weeks:

  • Chemical peels (glycolic acid, salicylic acid)
  • Schedule 3-4 sessions spaced one month apart 1

Step 4: Maintenance Therapy

• Continue sun protection indefinitely
• Consider maintenance with hydroquinone-free agents:
  • 5% ascorbic acid (vitamin C) - fewer side effects than hydroquinone 4
  • Azelaic acid 15-20%
  • Kojic acid 2-4%
  • Maintenance treatments every 6-12 months 1

Special Considerations

For Pregnant/Lactating Women:

• Avoid hydroquinone and retinoids
• Safe alternatives:
  • Azelaic acid
  • Vitamin C
  • Glycolic acid peels (low concentration)

For Sensitive Skin:

• Start with lower concentrations
• Apply every other day initially
• Consider 5% ascorbic acid which has fewer side effects (6.2% vs 68.7% with hydroquinone) 4

Common Pitfalls to Avoid

1. Inadequate sun protection - The most common reason for treatment failure and recurrence
2. Overuse of hydroquinone - Can lead to exogenous ochronosis with prolonged use beyond 6 months
3. Aggressive treatments - High-concentration peels or laser treatments can worsen hyperpigmentation
4. Discontinuing treatment too early - Melasma requires long-term management
5. Ignoring hormonal factors - Consider addressing hormonal triggers (oral contraceptives, hormone replacement)

Treatment Monitoring

• Evaluate response every 4-6 weeks using standardized photography
• Assess using Melasma Area and Severity Index (MASI) score
• Adjust treatment if no improvement after 8-12 weeks
• Consider melasma a chronic condition requiring ongoing management 5, 6

Remember that melasma is a chronic, relapsing condition that requires persistent management. Even with optimal treatment, recurrence rates are high, especially with sun exposure.