What are the treatment options for managing melasma?

Management of Melasma

The most effective treatment for melasma is triple combination cream containing 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide, with 77-94% of patients achieving clear or almost clear skin. 1, 2

Diagnosis and Assessment

• Determine skin phototype using Fitzpatrick scale
• Identify depth of pigmentation (epidermal vs. dermal) using Wood's lamp examination
• Classify melasma as epidermal, dermal, mixed, or indeterminate
• Use Melasma Area and Severity Index (MASI) to measure extent and monitor treatment response

First-Line Treatment Options

Topical Therapies

1. Triple Combination Cream

   • 4% hydroquinone + 0.05% tretinoin + 0.01% fluocinolone acetonide
   • Apply once daily for 8 weeks
   • Most effective first-line therapy with 77-94% clearance rates 2
   • Monitor for skin irritation and erythema

2. Hydroquinone Monotherapy

   • 4% hydroquinone cream
   • Apply twice daily for 8-12 weeks
   • Effective for epidermal melasma
   • Caution: Do not use continuously beyond 6 months due to risk of ochronosis (blue-black discoloration) 1, 3
   • Test for skin sensitivity before full application 3

3. Non-Hydroquinone Alternatives

   • Azelaic acid (15-20%)
   • Kojic acid
   • Formulations with tranexamic acid, vitamin C, arbutin, or niacinamide
   • Consider for patients with hydroquinone sensitivity or during maintenance phases

Second-Line Treatment Options

Oral Therapy

• Tranexamic acid (250 mg twice daily)
• For moderate to severe cases resistant to topical therapy
• Caution: Screen for thromboembolic risk factors before initiating 1

Procedural Interventions

1. Chemical Peels

   • Glycolic acid or salicylic acid peels
   • Consider after 8-12 weeks of unsuccessful topical therapy
   • 3-4 sessions spaced one month apart 1
   • Higher risk of post-inflammatory hyperpigmentation in darker skin types

2. Advanced Procedures

   • Platelet-rich plasma (PRP) intradermal injections
   • Protocol: Once monthly for 3-5 sessions 1
   • Microneedling
   • Laser therapy (use with extreme caution in darker skin types)

Critical Adjunctive Measures

Sun Protection (Mandatory)

• Broad-spectrum SPF 70 or higher sunscreen
• Reapply every 2 hours when outdoors
• Use protective clothing and wide-brimmed hats
• Note: Inadequate sun protection is the most common reason for treatment failure 1

Treatment Monitoring

• Evaluate response every 4-6 weeks using standardized photography
• Assess using MASI score
• Adjust treatment if no improvement after 8-12 weeks
• Continue strict sun protection indefinitely, even after clearing

Treatment Algorithm

1. Start with: Triple combination cream + strict sun protection
2. If inadequate response after 8-12 weeks: Consider chemical peels or switch to alternative topicals
3. For resistant cases: Add oral tranexamic acid or consider procedural interventions
4. Maintenance phase: Intermittent hydroquinone use for recurrences, non-hydroquinone alternatives, and continued sun protection

Important Considerations

• Hydroquinone has been associated with carcinogenesis concerns, though this remains debated 1
• Aggressive treatments can worsen hyperpigmentation, especially in darker skin types
• Treatment is typically long-term with potential for recurrence
• Patient education about realistic expectations and importance of sun protection is crucial for successful outcomes 4, 5