Melasma Management Considerations

melasma on facePearls for the common, but vexatious, dermatologic condition of melasma.
Dermatologists walk a tough line in their daily practice lives. We must identify each patient’s true problem, which often (as we know) is not the problem stated on their intake sheet. We then need to examine the site, arrive at a diagnosis, formulate a treatment plan, and predict on how long it will take to respond to therapy: in other words, educate the patient. An incredibly important part of this education is setting reasonable expectations. 


This article represents the accumulated wisdom of more than 50 years of dermatologic practice regarding a common, but vexatious, dermatologic problem—melasma.


It would seem that the diagnosis and treatment of melasma would be straightforward. But not so fast. Sure, it is present on the face for everyone to see. And, of course, virtually every patient with melasma you see in your office has already consulted with, or closely read, Dr. Google, Dr. WebMD, or even Dr. RealSelf.  They have already seen 6 other good dermatologists who have given them at least 8 different regimens, all of which, according to the desperate patient, have failed miserably. They are here to see you, however, because they have heard that you are “the absolute best”, and they want to be cured of this affliction—now.

A knotty and commonly encountered scenario and problem, indeed. Many patients with melasma are angry and psychologically exhausted by their disease, both from psychosocial impacts and multiple doctor visits. Even though insurance companies consider melasma a cosmetic nuisance, we all know it can carry just as much psychological burden as vitiligo. It is always there, looking at them in the mirror, in every selfie taken, at every event, all the time. 

Patients consider medicines and therapies that initially worked, but then stopped doing so, as failures. Your initial patient history should always go into great detail regarding all treatments they have tried before (including those that were self-initiated), what worked, for how long, and what did not. Here are 4 pearls for diagnosing melasma:

• The most important thing when encountering a patient with melasma is to take the time to listen to the patient tell their tale of woe, anger, exasperation, and anxiety. This may be the first time the patient has had someone listen to their entire saga, and it can be very cathartic for them and extremely important in building the trust needed for a good therapeutic result.

• Touch the patient. The more involved and tactile you are in your examination, the more value the patient will perceive in it. Make sure to use loupes and good lighting, and absolutely use both hands to gently move the head back and forth during the examination. Take a look at the arms and hands (almost always overlooked and sometimes involved, especially in men). 

• Use a Wood’s lamp and view all sites under that light. Many debate the utility of a Wood’s lamp during this examination, but we have found over the years that finding pigment that stands out under the light correlates with greater treatment success. You can explain to the patient that their pigment is relatively superficial, and thus more likely to respond to therapy. It also makes the patient feel that you are going the extra mile, doing everything you can to diagnose and make their condition better. 

• Take photographs. Patients never, (and in our experience) ever, accurately remember what they looked like before treatment, and before and after images are invaluable.

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