What are the treatment options for melasma?

Treatment Options for Melasma

The most effective treatment approach for melasma combines topical therapies, sun protection, and potentially advanced procedures like autologous platelet concentrates (APCs), with hydroquinone being the first-line topical agent for gradual bleaching of hyperpigmented skin. 1, 2

First-Line Treatments

Topical Therapies

• Hydroquinone 4% is FDA-indicated for the gradual bleaching of hyperpigmented skin conditions including melasma 1
• Tretinoin can be used alone or in combination with hydroquinone 2, 3
• Corticosteroids are often combined with hydroquinone and tretinoin in triple combination formulations 2, 3
• Azelaic acid serves as an alternative lightening agent for those who cannot tolerate hydroquinone 3
• Tranexamic acid in topical form shows efficacy, though less than oral administration 4

Sun Protection

• Strict sun protection with broad-spectrum sunscreen is essential and considered the foundation of any melasma treatment regimen 2, 5
• Patients should be counseled to avoid other damaging habits such as smoking 2

Second-Line Treatments

Oral Medications

• Oral tranexamic acid (typically 250mg twice daily) has demonstrated 25% reduction in MASI scores after 8 weeks of treatment 4
• Oral tranexamic acid should be considered for cases unresponsive to topical therapies after approximately 12 weeks 6
• Patients must be carefully screened for contraindications and thromboembolic risk factors before starting oral tranexamic acid 6

Procedural Treatments

• Chemical peels serve as a good adjunct to topical therapies 3
• Autologous platelet concentrates (APCs) including platelet-rich plasma (PRP) have shown promising results in treating melasma 2
• PRP injections have demonstrated significant improvement in melasma within 6 weeks of treatment as measured by mMASI scores 2
• Microneedling may be more effective than intradermal PRP injections for melasma treatment 2
• Laser treatments can be considered but results are variable 3, 7

Treatment Algorithm

1. Initial Approach:

   • Start with strict sun protection and topical therapies 2, 5
   • First-line: Hydroquinone 4% cream 1
   • Consider triple combination (hydroquinone + tretinoin + corticosteroid) for enhanced efficacy 3

2. For Resistant Cases (after 8-12 weeks of topical treatment):

   • Consider oral tranexamic acid 250mg twice daily 4, 6
   • Add procedural treatments like chemical peels 3

3. Advanced Options:

   • PRP/APC treatments (typically three treatments with minimum 21-day intervals) 2
   • Maintenance treatments every 6 months may be required 2

Important Considerations

• Melasma should be managed as a chronic condition requiring regular follow-ups 2
• Treatment efficacy is commonly measured using the Melasma Area and Severity Index (MASI) or modified MASI (mMASI) 2
• Modified Kligman's regimen (containing hydroquinone, tretinoin, and corticosteroid) has shown superior efficacy with 30% reduction in MASI scores compared to oral tranexamic acid (25%) and topical tranexamic acid (5%) 4
• Despite its superior efficacy, modified Kligman's regimen has potential side effects with long-term usage 4
• Nanotechnology-based topical formulations are emerging as promising delivery systems that may enhance penetration while limiting systemic absorption 7

Common Pitfalls and Caveats

• Melasma is highly resistant to treatment and has a high recurrence rate 5
• Hyperpigmentation treatment alone is often ineffective unless combined with regenerative methods and strict photoprotection 5
• Long-term use of hydroquinone may lead to ochronosis and other side effects 3
• Patient education about the chronic nature of melasma and realistic expectations is crucial for treatment adherence 5
• Genetic factors and hormonal influences may limit treatment success in some patients 2, 5