Melasma Diagnosis and Management: An Evidence-Based Approach

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By Rahul Pandey

Even though the summer sun is a welcome break from the long year we have all had, it is also a hard time for people with melasma. Melasma often shows up for the first time or gets worse in people who already have it because of the heat and spending more time outside.

On May 25, dermatologist Mona Sadeghpour, MD, founder of the SkinMed Institute in Lone Tree, Colorado, spoke about “Stepping out of the Shadow: An Evidence-Based Approach to the Diagnosis and Management of Melasma” at the Face & Body with MedEsthetics virtual event.


Melasma happens when the body makes more pigment than it can get rid of. This is caused by overactive melanocytes and, in some cases, more blood vessels. But, Dr. Sadeghpour said, not all dark spots are melasma.

Melasma shows up in one of three different patterns of darkening: centrofacial, which affects the middle of the face, forehead, and upper lip (this is the most common pattern), malar, or mandibular (least common).

Melasma is less likely if the patient’s skin is red and swollen. Dr. Sadeghpour said, “Inflammation is not usually a sign of melasma.” “This could be another skin disorder.”

Get a good medical and family history from people with melasma who don’t have inflammation or a pattern they recognize. Treatment resistance is more likely if there is a history of it in the family.

Use a Wood’s lamp to figure out where pigments should go. The Wood’s lamp will help melasma on the skin’s surface, but it won’t help melasma on the skin’s surface. Deeper dermal pigment will look a little lighter (lighter brown or bluish with poorly circumscribed borders). The color of the epidermis is darker, and the edges are clear.

First Line Treatment

Always start with treatment on the outside of the skin and strict sun protection. This is the best way to treat someone. Hydroquinone (HQ) at 4% twice a day is the first line of treatment. Dr. Sadeghpour said, “It’s important to use it twice a day, not once a day.” Sun protection is also important. She recommends a tinted sunscreen with iron oxides that block visible light. This is because visible light can make melasma worse, especially in people with darker skin.

She also said that retinoids (tretinoin, 0.5% or 1%), with sun protection, are a “wonderful choice.” So you can buy this medicine on Buy Tretinoin Cream. She recommends azelaic acid 20% on the skin twice a day for pregnant women who can’t use HQ or retinoids.

Creams with HQ, retinoids, and steroids, like Tri-Luma Cream 15gm, have been shown to be effective, but she doesn’t use them as her first line of treatment because tretinoin can cause enough irritation to cause PIH. In addition, steroids can aggravate acne in people who already have it.

So, she only gives them to people who don’t pass HQ by 4%.

“People with sensitive skin should be really careful with the triple combination,” she said.

You also need to figure out what could go wrong and try to fix it if you can. Melasma is more likely to happen if:

  • Fitzpatrick Skin type III-IV
  • Exposure to UV radiation
  • Exposure to visible light, especially in skin of color patients
  • Family history of melasma
  • Pregnancy
  • Exogenous hormones (oral contraceptives and hormone replacement therapy)
  • Heat, which causes vasodilation and inflammation that can exacerbate melasma
  • Endocrine disorders (thyroid, adrenals, etc.)

If the patient is taking an oral contraceptive, try to get them to switch to one that exposes them to fewer hormones.

Second and Third Line Treatments

If a patient has been using topical treatments for three to four months and hasn’t seen much improvement, they may want to try oral tranexamic acid, peels, or lasers along with topical treatments and sun protection.

Dr. Sadeghpour gives oral tranexamic acid (TA) to people who haven’t gotten better with topical treatments and who have “really deep” pigment in their skin. “I tell my patients to take one 650-mg tablet once a day,” she said. “It will take a few weeks before they start to feel better, and there is a chance that they will get sick again if they stop taking it.”

Before using oral TA, patients must be checked for thromboembolic disorders and a family history of stroke or heart disease. Also, find out if they are taking an oral contraceptive, which can make blood clots more likely.

Lasers and peels are not the first treatments that doctors use. But they can be used along with topical treatments for people who have tried everything else.

The strongest evidence shows that glycolic acid can help with melasma. “But it’s never been compared to topicals,” Dr. Sadeghpour said. “In my practice, I never use peels because they can irritate the skin and make melasma worse.” “But glycolic acid can help melasma if it is used by a skilled peeler.”

She starts with topical therapy with her patients and then looks at them again in three to four months. “If we’ve tried everything we can with topicals, I’ll look at laser treatments that are slow, steady, gentle, low-energy, and low-density,” she said.