Toronto dermatologist Dr. Michelle Levy writes about common skin problems, controversies and developments, and provides science-based answers to common questions in our dermatology blog.
Melasma is a common cause of increased pigmentation that most commonly occurs on the face. Melasma can be frustrating, and in some cases is challenging to treat. Thankfully, several options exist, and most cases of melasma can be improved if not cleared.
What is melasma?
Melasma is a common skin condition in which people develop blotchy brown patches, most commonly on the face. it is most common in women, and is more common in those with darker skin.
What causes melasma?
The exact cause of melasma is unknown, but it is thought that sunlight (ultraviolet radiation) and female hormones both play important roles. Melasma is frequently triggered by sun exposure, and by exposure to hormones such as during pregnancy or with the use of birth control pills. Thyroid problems also have the potential to worsen melasma.
How is melasma treated?
In some people melasma resolves on its own when the skin is exposed to less sunlight (in some people it fades every winter and recurs in the spring), or after pregnancy when hormone levels fall. In others, it stubbornly persists, and may get worse with subsequent pregnancies and with more sun exposure.
Sun protection is of the utmost importance in those with melasma. People who have this skin condition need to use a broad-spectrum sunscreen with a high SPF value every single day, including in the winter. The best sunscreens for people with melasma are physical sunscreens that contain the ingredient zinc oxide, with or without titanium dioxide. Tinted sunscreens may work better than non-tinted sunscreens. Use a hat with a wide brim and avoid exposure to direct sunlight on the areas affected by melasma as best you can.
Lightening creams are the mainstay of treatment of melasma. Lightening creams that contain hydroquinone, a chemical that blocks the skin's ability to make pigment (melanin), are felt to be the most effective. Creams containing hydroquinone are available over-the-counter in Canada in concentrations of 2-4% (in the US concentrations above 2% are by prescription). Dermatologists will often prescribe combination creams that contain hydroquinone, a mild cortisone, and tretinoin (a vitamin A derivative), as these have been shown to be more effective than hydroquinone alone.
Are there risks associated with using hydroquinone?
While hydroquinone has been safely used by dermatologists around the world for over 50 years, there are potential side effects associated with its use. Hydroquinone can be irritating to the skin (it is often combined with a mild cortisone to minimize this), and can uncommonly cause allergic reactions. Very rarely, prolonged use of hydroquinone can lead to a condition known as exogenous ochronosis, in which the skin develops a bluish discolouration. It should also be noted that hydroquinone should not be used by pregnant or nursing women. A full discussion of the use of hydroquinone, including the risks and benefits of this ingredient can be found here.
Under no circumstances should you buy a bleaching cream that has been imported into the country from abroad and is not sold at a reputable pharmacy. There have been cases reported in which imported bleaching creams were found to contain very high levels of hydroquinone, strong cortisones or mercury. Exposures to such creams can lead to unwanted or even dangerous side effects.
When should I expect to see results if I'm using a bleaching cream?
Results usually start to become apparent after two months of use and it often takes four to six months to achieve a good result.
Are there lightening creams that do not contain hydroquonine?
Over the past few years, a number of lightening creams that use ingredients other than hydroquinone have emerged on the market. Compounds which have been found to have skin lightening effects include retinol, niacinamide, kojic acid, azaleic acid, arbutin, licorice extract, soy, and vitamin C. These are generally not not felt to be as effective as creams that contain hydroquinone, but are an option for those with mild melasma, or for those who are concerned about using hydroquinone. Several commercial products available combine several of these lightening ingredients in an effort to provide more noticeable improvement. Examples include Skin Medica's Lytera, Derma E Skin Lighten Natural Fade & Age Spot Cream, and Obagi's Skin Brightening Complex.
In my practice, I frequently use non-hydroquinone products for "maintenance" to prevent recurrences of melasma, or will alternate their use with a hydrquinone-containing cream in 3-6 month cycles to improve response and minimize the risk of side effects.
Chemical peels for melasma
Chemical peels can be helpful in treating melasma. Glycolic acid peels are most commonly used, although trichloroacetic acid (TCA) peels may also be effective. Typically, dermatologists will start with lower concentrations and will increase if tolerated, as higher concentrations (50-60% glycolic acid) are felt to be more beneficial. Both types of peels have the potential to cause hyperpigmentation (skin darkening that results from inflammation), especially in individuals with skin of colour, and should only be performed by qualified individuals. For more information on chemical peels see our post on this topic.
Laser treatments for melasma
A number of lasers have been used for the treatment of melasma with variable success. Certain fractionated laser resurfacing or treatments with a Q-switched laser may benefit those with melasma, but results are unpredictable and lasers can actually make melasma worse in some cases. The Clear and Brilliant Laser is a type of fractionated laser resurfacing that has been reported to be beneficial in melasma and may be safer in skin of colour.
Laser treatments for melasma should be done very carefully, and should only be done by those with expertise in performing these procedures. Recurrences of melasma are common after treatment and this should be taken into account given that these procedures tend to be costly.
Other Treatments for Melasma
Small case series have reported improvement in melasma with microneedling, a procedure in which tiny needles are passed into the top of the skin. Done properly, microneedling is safe in darker skin types and is usually less costly than laser treatments. Tranexamic acid is a medication that is usually used to treat excess bleeding, but has recently been reported to be beneficial in difficult-to-treat melasma. Like all systemic medications, this medication carries risks and the treatment of melasma is an off-label use of this drug.
Summary of the Treatment of Melasma
1. Use a broad-spectrum sunscreen every single day. Look for one that has a high concentration of zinc oxide. Wear a hat and avoid the mid-day sun.
2. Consider using a lightening cream that contains hydroquinone. Become familiar with the risks and benefits of using these creams. For mild melasma, an over-the-counter product may suffice. Prescription combination creams may be more effective, particularly for more severe cases of melasma. Limit the use of hydroquinone-containing products to 4-6 months at a time to minimize the risk of side effects.
3. Consider using a vitamin C serum each morning under your sunscreen. Vitamin C has been shown to lighten skin modestly and both vitamins C and E protect from sun damage. Examples include Skinceuticals' C E Ferrulic and Neo Strata's Skin Brightener.
4. Glycolic acid peels may be helpful in melasma. Higher concentrations may be needed and these should be done under the supervision of a dermatologist.
5. Lasers have had variable results in melasma. They can be helpful but also have the potential to worsen this problem. Laser treatments should be considered only if other therapies have failed and should be done very carefully by those with expertise in this area.
6. Microneedling has been reportedly beneficial in a small number of patients with melasma. An oral medication called tranexamic acid has been used with some success if very resistant cases.
7. Be gentle with your skin. Skin irritation can make melasma worse. Use gentle, fragrance-free skin care products. Do not wax your face as this can trigger melasma.
8. If you noticed onset of melasma after starting a birth control pill, consider switching to a non-hormonal form of contraception.
9. Consider camouflage make-up. Examples include Vichy's Dermablend and Cover FX. These can camouflage the discolouration and also provide further sun protection.
10. See a dermatologist! If over-the-counter treatments and sun protection do not improve your melasma within 3-4 months, visit a skin expert for a professional opinion.