Melasma is a complex pigmentary disorder that can be frustrating for patients due to its chronicity and high risk for relapse. Sunscreen is the best option for preventing melasma. However, topical and oral agents can help improve pigmentary changes.
In an interview with The Dermatologist, Seemal R. Desai, MD, FAAD, discussed prescription and cosmeceutical topical options and exciting new developments in melasma.
Dr Desai is the president and medical director for Innovative Dermatology, PA in Dallas, Texas, and a clinical assistant professor of dermatology at the University of Texas, Southwestern. In addition, he is the Immediate Past President of the Skin of Color Society and serves on the American Academy of Dermatology Board of Directors.
The Dermatologist: Which are some topical and oral agents for melasma?
Dr Desai: Some topical options for melasma include hydroquinone, tranexamic acid, azelaic acid, vitamin C, niacinamide, and soy-based products. Hydroquinone is still our gold standard workhorse in topical skin lightening, but there are newer topical melasma treatments. One option is tranexamic acid, which is available in 2% or 3% concentrations either compounded or in cosmeceutical formulations. Topical cosmeceuticals, such as niacinamide and vitamin C, have become very important in our therapeutic fight against hyperpigmentation. Soy is making a comeback as well because it is a natural, reversible, depigmenting agent. It has been studied a lot in different cosmeceutical forms in Asia.
All of these therapies, however, are not used a monotherapy but in combination with other treatment modalities. Most therapies for melasma require tailoring the approach to using one of the treatments in the morning and one at night. For example, a patient may need to apply a cosmeceutical along with sunscreen in the morning and apply a hydroquinone bleaching agent at night. After using hydroquinone for 8 to 12 weeks, the patient can stop using it and maintain improvement with one of the following off-label, non-hydroquinone options, such as azelaic acid or tranexamic acid.
Clinicians will need to keep patients on these therapies long term because melasma relapses frequently. If the relapse is bad, then patients can restart hydroquinone. This is a rotational approach to treatment, where hydroquinone takes care of the hard part and once it is under control, other topical agents can be used. That is how I like to think about melasma treatment.
Another important aspect is that hydroquinone is not something patients should use long term. It should only be used for a short duration because of the risk of long-term toxicity. Although it is rare, patients can develop exogenous ochronosis, which is the worst-case scenario with long-term hydroquinone use. On the other hand, azelaic acid is very effective and a nice second-line topical agent that works well for patients with hyperpigmentation. In addition, a variety of cosmeceuticals that contain soy, niacinamide, and/or vitamin C are usually available in serums and can be used in combination with prescriptive agents or procedures. Patients really like natural or botanical-based cosmeceutical options and are pleased when they are offered this option because this is certainly an unmet need from a nonprescriptive perspective.
The Dermatologist: Are there any new therapies that you are excited about? What areas of melasma still requires further research to improve treatment options for patients?
Dr Desai: There is a topical tranexamic acid combined with a retinol and vitamin C that is coming out soon, which I am excited about. Also, there is a new topical tranexamic acid, which is already on the market, that is in a serum formulation and contains hepes, an exfoliator of the skin that does similar things as retinol without the irritation profile.
A lot more research needs to be done in melasma, particular on the pathogenesis. We need to continue to tease out and really understand why the pigment is so chronic and if there is a way to prevent the pigment from going deeper down into the dermis.
In addition, there needs to be more research on post inflammatory hyperpigmentation (PIH). We know that PIH happens after trauma and irritation to the skin, but we need to figure out why that happens and if there is anything we can do from a mechanism perspective to help prevent it.
The Dermatologist: What other key takeaways would you like to add?
Dr Desai: The most important thing to remind patients who suffer from melasma that, no matter what, sunscreen use is of paramount importance. Patients have got to use sunscreen, even if it is not sunny outside and even if they are indoors partially during the day. They need to apply a base layer of sunscreen SPF 30 or higher in addition to other topical therapies they use. I usually recommend a physical block over a chemical blocker because I find those work a little better at protecting melasma-prone skin.
Dermatologists also need to understand that melasma is not just a cosmetic disease. It should be considered a chronic medical skin disease because there are several different causes, such as abnormal vascularity, dysregulation in mast cells, and hormonal influences on the skin.
Treating melasma, and other pigmentary disorders, is an important part of what we do as dermatologists. We will need to be aware of these presentations among patients with skin of color as the prevalence is going to rise as the skin of color population increases in the United States.