What is the treatment for melasma?

The most common melasma therapies include 2% hydroquinone (HQ) creams like the over-the-counter products Esoterica and Porcelana and prescription-strength 4% creams like Obagi Clear, Tri-Luma, NeoCutis Blanche, and 4% hydroquinone. Certain sunscreens also contain 4% hydroquinone, such as Glytone Clarifying Skin Bleaching Sunvanish SPF 23 and Obagi's Sunfader sunscreen. Products with HQ concentrations above 2% sometimes require a prescription or are dispensed through physician's practices. Clinical studies show that creams containing 2% HQ can be effective in lightening the skin and are less irritating than higher concentrations of HQ for melasma. These creams are usually applied to the brown patches twice a day. Sunscreen should be applied over the hydroquinone cream every morning. There are treatments for all types of melasma, but the epidermal type responds better to treatment than the others because the pigment is closer to the skin surface.

Melasma may clear spontaneously without treatment. 

Other times, it may clear with sunscreen usage and sun avoidance. For some people, the discoloration with melasma may disappear following pregnancy or if birth control pills and hormone therapy are discontinued.

In order to treat melasma, combination or specially formulated creams with hydroquinone, a phenolic hypopigmenting agent, azelaic acid, and retinoic acid (tretinoin), nonphenolic bleaching agents, and/or kojic acid may be prescribed. For severe cases of melasma, creams with a higher concentration of HQ or combining HQ with other ingredients such as tretinoin, corticosteroids, or glycolic acid may be effective in lightening the skin.

Azelaic acid 15%-20% (Azelex, Finacea)

Retinoic acid 0.025%-0.1% (tretinoin)

Tazarotene 0.5%-0.1% (Tazorac cream or gel)

Adapalene 0.1%-0.3% (Differin gel)

Kojic acid

Lactic acid lotions 12% (Lac-Hydrin or Am-Lactin)

Glycolic acid 10%-20% creams (Citrix cream, NeoStrata)

Glycolic acid peels 10%-70%

Other proprietary ingredients and mixtures of ingredients as in Elure, Lumixyl, and SkinMedica's Lytera products

Possible side effects of melasma treatments include temporary skin irritation. People who use HQ treatment in very high concentrations for prolonged periods (usually several months to years) are at risk of developing a side effect called exogenous ochronosis. In this condition, the skin actually darkens while the bleaching agent is used. Hydroquinone-induced ochronosis is a permanent skin discoloration that is thought to result from use of hydroquinone concentrations above 4%. Although ochronosis is fairly uncommon in the U.S., it is more common in areas like Africa where hydroquinone concentrations upward of 10%-20% may be used to treat skin discoloration like melasma. Regardless of the potential side effects, HQ remains the most widely used and successful fading cream for treating melasma worldwide. HQ should be discontinued at the first signs of ochronosis.

What melasma treatments can I have at my doctor's office?

In conjunction with home cream applications, in-office treatments include chemical peels (chemical exfoliation), microdermabrasion (mechanical exfoliation), and laser therapy. These additional treatments may be useful for some cases of melasma, although the beneficial effects are not very impressive.

Many types and strengths of chemical peels are available for different skin types. The type of peel should be tailored for each individual and selected by the physician. In treating melasma, 30%-70% glycolic acid peels are very common. Various combinations, including a mix of 10% glycolic acid and 2% HQ, can be used to treat melasma.

Microdermabrasion utilizes vacuum suction and an abrasive material like fine diamond chips or aluminum oxide crystals to exfoliate the top layers of the skin. The vacuum pressure is adjusted depending on the sensitivity and tolerance of the skin. Typical microdermabrasion sessions can last anywhere from a few minutes to one hour. Minimal to no recovery time is needed after microdermabrasion. Microdermabrasion techniques can improve melasma, but dramatic results are not generally seen or expected after one or two treatments. Multiple treatments in combination with sunscreen and other creams yield best results.

There is no guarantee that melasma will be improved with these procedures. In some cases, if treatments are too harsh or abrasive, melasma can be induced or worsen. Additionally, these procedures are almost always considered cosmetic and may not be covered by medical insurance providers.

Do lasers work for melasma?

Lasers may be used in melasma, but they generally produce only temporary results. Laser therapy is not the primary choice to treat melasma as studies reveal little to no improvement in the hyperpigmentation for most patients. Lasers may actually worsen some types of melasma and should be used with caution. Multiple laser treatments may be necessary to see results, as treatments are most effective when they are repeated.

To ensure that treatment doesn't fail, people must minimize sun exposure. People who treat their melasma report a better quality of life because they feel better about themselves. As with any treatment, people should consult their physician. Pregnant women or mothers breastfeeding may need to wait to treat melasma. Many melasma creams need to be discontinued in pregnancy and breastfeeding because of possible risks to the developing fetus and newborn. These people may consider cosmetics to temporarily conceal the skin discoloration.

How does hydroquinone work in melasma?

Researchers believe that the hydroxyphenolic chemical (HQ) blocks a step in a specific enzymatic pathway that involves tyrosinase. Tyrosinase is the enzyme that converts dopamine to melanin. Melanin gives skin its color.

Are there non-hydroquinone alternative treatments for melasma?

Azelaic acid is a non-hydroquinone cream that can be used to treat melasma. Studies have reported that 15%-20% azelaic acid was very effective and safe in melasma, although the overall results are significantly less impressive than 4% hydroquinone. There are no major complications reported with azelaic acid. Possible minor side effects include itching (pruritus), redness (erythema), scaling (dry patches), and a temporary burning sensation that tends to improve after 14-30 days of use.

Tretinoin cream (Retin A, Renova, Retin A Micro) is a non-hydroquinone cream used to treat melasma. Most often, tretinoin is used in combination with other creams like azelaic acid or hydroquinone. Mild localized side effects are fairly common and include peeling, dry skin, and irritation. Overall, melasma may respond slower to treatment with tretinoin alone than with hydroquinone.

Other retinoid creams include tazaratone and adapelene. These are prescription creams used much like tretinoin (Retin A).