What are the treatment options for managing melasma?

Management of Melasma

The most effective treatment for melasma is a 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 (Fitzpatrick scale)

• Identify underlying causes (UV exposure, hormonal influences)

• Assess depth of pigmentation using Wood's lamp examination:

  • Epidermal (enhances under Wood's lamp)
  • Dermal (no enhancement)
  • Mixed (partial enhancement)
  • Indeterminate

• Use Melasma Area and Severity Index (MASI) to measure extent and monitor treatment response 1

First-Line Treatment Options

Topical Treatments

1. Triple Combination Therapy

   • 4% hydroquinone + 0.05% tretinoin + 0.01% fluocinolone acetonide
   • Apply once daily
   • Most effective option with 77-94% clearance rates 2
   • Monitor for skin irritation, erythema, and dryness

2. Hydroquinone Monotherapy

   • 4% concentration
   • Apply twice daily for 8-12 weeks
   • Limit use to 6 months to prevent ochronosis (blue-black discoloration) 3, 4
   • Test for skin sensitivity before use 3

3. Alternative Topical Agents (for hydroquinone-intolerant patients)

   • Azelaic acid (15-20%)
   • Kojic acid
   • Non-hydroquinone formulations containing:
     • Tranexamic acid
     • Vitamin C
     • Niacinamide
     • Arbutin 1, 4

Second-Line Treatment Options

Oral Therapy

• Tranexamic acid (250 mg twice daily)
• For moderate to severe cases resistant to topical therapy
• Monitor for thromboembolic risk 1, 4

Procedural Treatments

1. Chemical Peels

   • Consider after 8-12 weeks of unsuccessful topical therapy
   • Options: glycolic acid, salicylic acid
   • 3-4 sessions spaced one month apart 1

2. Platelet-Rich Plasma (PRP)

   • Intradermal injections
   • Protocol: once monthly for 3-5 sessions
   • Shown to be more effective than intradermal tranexamic acid 1

3. Laser and Light Therapy

   • Use with caution, especially in darker skin types
   • Risk of post-inflammatory hyperpigmentation
   • Consider only for resistant cases 1, 4

Essential Adjunctive Measures

Sun Protection

• Mandatory broad-spectrum SPF 70 or higher
• Most common reason for treatment failure is inadequate sun protection
• Continue indefinitely, even after clearing 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 1

Treatment Algorithm

1. Start with:

   • Triple combination cream (first choice)
   • OR Hydroquinone 4% (if triple combination unavailable)
   • PLUS strict sun protection

2. If inadequate response after 8-12 weeks:

   • Add or switch to alternative topical agents
   • Consider chemical peels or PRP

3. For resistant cases:

   • Consider oral tranexamic acid
   • Evaluate for procedural interventions

Cautions and Pitfalls

• Hydroquinone has carcinogenesis concerns and is restricted in many countries 1
• Prolonged hydroquinone use beyond 6 months can cause ochronosis 1, 3
• Aggressive treatments (high-concentration peels or lasers) can worsen hyperpigmentation 1
• Discontinuing treatment too early leads to recurrence 1, 5
• Melasma is chronic and often requires maintenance therapy 5, 4