Last week in Part One of our melasma chat, we discussed many things including what other conditions can look like melasma and why it occurs. In this blog, we will put melasma under the microscope and delve into the details of treatment options for this really challenging pigment problem. Dr. Michelle Rodrigues from Chroma Dermatology will guide us through our questions. Read on to learn more.

What is the best treatment approach for melasma?

There are a variety of treatments available and there is no “one size fits all approach” to melasma. A treatment plan needs to be based on a patient’s age, the location of the melasma, the depth of the pigment in the skin, the duration melasma has been around for, treatments someone may have previously and any underlying medical issues they may have. We also have to define what the expectations are for an individual patient and what results they are likely to see with various treatment options and combinations.

What creams are available to treat melasma?

There are over the counter preparations like hydroquinone in a 2% formula that can be bought over the counter without a script which can help patients who have very mild melasma. This should only really be used for 8-12 weeks maximum if a dermatologist is not involved in the treatment planning and reviews.

Higher concentrations of hydroquinone require a script from a doctor and there are also combination creams available for patients too, which contain other ingredients like tretinoin. While some of these ingredients cause skin redness and irritation (like tretinoin and kojic acid), preparations should be carefully tailored to a patient’s skin type, texture and the type of melasma the patient has.

The most important ‘cream’ however, is sunscreen. Protection from the damaging effects of ultraviolet A, B and visible light is a key component of melasma and should not be
underestimated.

What physical skin treatments are available to treat melasma?

There are physical therapies available to assist melasma in the form of chemical peels, and energy-based devices like laser. However, I would reserve these sorts of laser energy-based treatments for those who have not responded to various creams and cream combinations. Even when state-of-the-art picosecond technology (PicoSure) is used, despite it being the safest and most widely studied device showing results and minimal side effects, there is still a small risk of darkening and worsening of the melasma. This should be used with caution and only ever with an experienced dermatologist guiding therapy and the laser settings to be used in combination with prescription medication.

Are there other treatments available for melasma?

There are tablets that modulate the blood vessel response of the skin and can lighten areas of melasma. The medication is called tranexamic acid. I have been using this treatment for about nine years now. When I first lectured about this treatment to other dermatologists in early 2014 and right through to 2017, there was a lot of worry about this treatment due to its potential side effects and I had lots of questions about this new treatment. It’s understandable I guess.

Over the last eight years, it has proven successful in certain subtypes of melasma in certain patient groups, but the risks are important to consider as there are some patients that are not suitable for this treatment. The main issue is the very small theoretical risk of blood clots in arteries and veins. Furthermore, during the COVID-19 pandemic, this medication should ideally be avoided because of the risk of the coronavirus itself causing blood clotting issues in some people. This really should be discussed in detail with your dermatologist who specialises in melasma.

How is treatment different for melasma in people with skin of colour?

In patients with Caucasian skin, the melasma is easily seen and we can quite quickly determine if it is in the top or second layer of the skin. In patients with skin of colour, determining the depth of pigmentation is a lot more challenging and requires the eye of a dermatologist who has expertise in pigment disorders and expertise in skin of colour. Sometimes we require the help of a Woods lamp, which is a tool that enables us to see the difference between affected and unaffected skin a little more clearly.

We must also understand that melasma in those with skin of colour is affected by visible light which is not the case in those with lighter skin types. This means excessive light coming through windows, mobile phones and computer screens can affect melanocytes (pigment cells) in those with skin of colour. So, some types of Chinese skin through to African skin types may be affected by visible light.

There are also treatments which need to be tailored to people with darker skin types. It might be appropriate to tell a patient with Caucasian skin that they could use makeup or cosmetic camouflage to cover a dark area. They might be slightly more bronze as a result of that, but they often do not mind. Patients with skin of colour may find it very difficult to cover melasma because they would have to use very dark cosmetics to cover it.

Another example would be the use of retinoids. I find this fantastic for most patients that have Caucasian skin, but for those that have Chinese and Indian skin, it can be extremely irritating and cause lots of redness, irritation and dryness which can cause rashes like eczema. And this even occurs when patients adequately moisturise and use moisturisers along with their retinoids.

What is the biggest breakthrough in the treatment of melasma during your career thus far?

When I commenced dermatology about 15 years ago, we really only had basic creams available for melasma. One of the biggest breakthroughs has been the use of tranexamic acid for some types of melasma.

This is a really interesting molecule that’s been available through our gynaecology colleagues for excessive menstrual bleeding. Our Japanese colleagues accidentally found this to be helpful in patients with certain types of melasma and in certain situations just before 2010.

This research was only published in English in 2011. So, this is when it became known in some parts of the English-speaking part of Asia. In mid 2013, I was talking with a trusted colleague in Singapore about Tranexamic acid tablet and I decided (after further investigation of my own), that I too was going to try this treatment for the appropriate patient group who had tried and failed other treatments.

It was from 2013 I began treating some patients with this medication. I reported on this in a lecture to my dermatology colleagues in Australia in 2014 at our dermatology conference and understandably, it was met with a lot of anxiety and questions.

In 2014, I decided to collaborate with a colleague and mentor of mine in the USA. I spoke with him at length about the medication, the type of patient I was using this on and the dose and treatment scheduling. We then established a randomized, double blinded, placebo controlled trial to assess the success and effectiveness of this tranexamic acid for the treatment of melasma. The study was meant to be multicenter, meaning between the USA and Australia, but for funding reasons the American arm went ahead before our arm in Australia. I am very pleased to report that the results from our study mirrored my clinical experience.

Late last year, the Journal of the American Academy of Dermatology (which is a very highly reputable journal) called our study on Tranexamic acid, one of the breakthrough treatments and game changers for the decade. I think this illustrates that dermatologists worldwide have seen this as a breakthrough on a global scale and I am humbled to have been a part of that story.

What is the most important piece of advice you can give someone who has melasma?

Melasma is a chronic and recurrent condition. Anyone that tells you that they can remove this completely with a lotion or potion or laser treatments, probably does not really understand the nature of melasma. However, there are effective ways of getting it under control. I would encourage you to see a dermatologist who is a melasma expert about this.

Get yourself a broad-spectrum SPF 50+ sunscreen that blocks ultra-violet light A, B and visible light and make sure you wear it every day. And make sure to reapply it if you are swimming or sweating. Even when the sun is not shining and the temperatures are not high, sunscreen needs to be applied! Re-application during the day is important too. Do not forget your upper lip and below your eyelids.

Want to know more about melasma from dermatologists in Melbourne who specialise in melasma?

For more information on melasma check out our other blogs on laser treatment in melasma and melasma diagnosis and pathogenesis

The information contained in this blog post is intended as a guide only and should not substitute seeking medical attention. Please see your healthcare provider for more information on suitability of products, treatments or procedures.

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