What is the recommended supportive treatment for melasma?

Supportive Treatment for Melasma

The most effective supportive treatment for melasma includes strict sun protection with broad-spectrum SPF 70 or higher sunscreen, combined with topical agents such as hydroquinone 4% or triple combination cream (hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01%). 1, 2, 3

First-Line Treatments

Sun Protection

• Mandatory use of broad-spectrum sunscreen (SPF 70+) daily
• Protective clothing when outdoors
• Sun avoidance, especially during peak hours
• Note: Inadequate sun protection is the most common reason for treatment failure 1

Topical Treatments

1. Hydroquinone 4% cream

   • FDA-approved for gradual bleaching of hyperpigmented skin conditions including melasma 2
   • Apply once or twice daily for 8-12 weeks
   • Requires skin sensitivity testing before use
   • Should not be used continuously beyond 6 months due to risk of ochronosis 1

2. Triple combination cream (preferred option)

   • Contains 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide
   • 77-94% of patients achieve clear or almost clear skin 3
   • Apply once daily in the evening
   • More effective than monotherapy 4

Second-Line and Adjunctive Treatments

Alternative Topical Agents

• Niacinamide 4% - Showed good to excellent improvement in 44% of patients compared to 55% with hydroquinone, with fewer side effects (18% vs 29%) 5
• Azelaic acid (15-20%) - Less irritating alternative with similar efficacy to hydroquinone 1
• Kojic acid - Natural alternative with fewer side effects 1
• Tranexamic acid - Promising topical agent for resistant cases 1, 6

Oral Therapy

• Tranexamic acid (250 mg twice daily)
  • For moderate to severe cases resistant to topical therapy
  • Requires monitoring for thromboembolic risk
  • Emerging as an effective systemic treatment 1, 4

Procedural Interventions

• Chemical peels

  • Consider after 8-12 weeks of unsuccessful topical therapy
  • Typically 3-4 sessions spaced one month apart
  • Glycolic acid or salicylic acid peels are commonly used 1

• Platelet-Rich Plasma (PRP) therapy

  • Recent evidence shows PRP intradermal injections are effective for melasma
  • Can be used alone or in combination with tranexamic acid
  • Significantly better results seen with intradermal PRP than intradermal tranexamic acid 7
  • Treatment protocol: once a month for three to five sessions

Monitoring and Follow-up

• Evaluate response every 4-6 weeks using standardized photography
• Use Melasma Area and Severity Index (MASI) score to assess improvement
• Adjust treatment if no improvement after 8-12 weeks 1
• Continue strict sun protection indefinitely, even after clearing

Common Pitfalls and Caveats

1. Neglecting sun protection - Even minimal sun exposure can sustain melanocytic activity and reverse treatment benefits 1, 2

2. Prolonged hydroquinone use - Can lead to ochronosis (blue-black discoloration) with use beyond 6 months 1

3. Ignoring hormonal factors - Oral contraceptives or hormone replacement therapy can impact treatment outcomes 1

4. Discontinuing treatment too early - Melasma is chronic and requires long-term management to prevent recurrence 6

5. Aggressive treatments - High-concentration peels or laser treatments can worsen hyperpigmentation, especially in darker skin types 1

6. Unrealistic expectations - Patients should understand that melasma treatment is long-term and complete resolution may not be possible 6

7. Hydroquinone safety concerns - Some studies have demonstrated carcinogenic potential in animals, though human risk remains unknown 2