From the Guidelines
Melasma in skin of color is distinct due to its persistence, resistance to treatment, and higher risk of post-inflammatory hyperpigmentation, necessitating cautious treatment approaches. In darker skin, melasma appears as brown to gray-brown patches rather than the light to medium brown patches seen in lighter skin, as noted in a study on autologous platelet concentrates in esthetic medicine 1. The distribution pattern may also differ, with a higher prevalence of the dermal and mixed types of melasma in darker skin, where pigment is deposited deeper in the skin. This deeper pigmentation makes treatment more challenging and increases the risk of post-inflammatory hyperpigmentation following aggressive treatments.
Some key characteristics of melasma in skin of color include:
- Higher melanocyte activity and melanin production, making it more persistent and resistant to treatment
- Deeper pigmentation, increasing the risk of post-inflammatory hyperpigmentation
- Higher prevalence of dermal and mixed types of melasma
- Greater challenge in finding suitable sunscreen formulations that don't leave a white cast on darker skin
Treatment approaches for melasma in skin of color typically involve:
- Gentle topical agents like hydroquinone 2-4%, kojic acid, azelaic acid, or tranexamic acid
- Physical sunscreen containing zinc oxide or titanium dioxide
- Longer treatment duration and maintenance therapy to prevent recurrence
- Caution with procedures like chemical peels and lasers due to the higher risk of post-inflammatory hyperpigmentation, and should be performed by practitioners experienced with treating diverse skin types, as discussed in the context of autologous platelet concentrates in esthetic medicine 1.
From the Research
Characteristics of Melasma in Skin of Color
- Melasma is a chronic hypermelanosis of the skin that affects approximately 1% of the global population, predominantly affects women, and is more prevalent in skin of color 2
- It is a common driver for patients with skin of color to seek out a dermatologist for treatment, and ensuring the right approach for these patients is important because some treatments may be associated with adverse side effects 2
- Melasma and postinflammatory hyperpigmentation (PIH) are the most common forms of dyschromia in patients with skin of color, and both are associated with a high psychological burden of disease 3
Treatment Considerations
- Successful treatment of melasma in skin of color is contingent upon a correct diagnosis, patient education, and a carefully considered therapeutic approach, which is often multimodal in design 3
- Topical hydroquinone is a mainstay of treatment for melasma, but there are alternatives that have emerged as of late that have shown varying degrees of promise, both in terms of safety and efficacy 3
- Triple combination cream (hydroquinone, tretinoin, and corticosteroid) remains the most effective treatment for melasma, as well as hydroquinone alone 4
- Oral tranexamic acid is a promising new treatment for moderate and severe recurrent melasma 4
Challenges and Limitations
- Melasma can be challenging to treat, particularly in patients with skin of color, due to the chronicity of the disease and established psychosocial and emotional impacts 2
- The current evidence on the treatment of melasma is limited by heterogeneity of study design, small sample size, and lack of long-term follow-up, highlighting the need for larger, more rigorous studies in the treatment of this recalcitrant disorder 4