Many of my patients, particularly women aged 20 to 50, are concerned about the same thing – a “mask” of mottled skin on the tops of the cheeks and temples. This common (and benign) condition is called melasma, a Greek derivation meaning “dark pigmentation of the skin.” Melasma can happen to anybody, but it is more common among darker-skinned people and those who tan easily.
Ninety percent of cases occur in women because female hormones are a major contributing factor. As a result, it may start or worsen during pregnancy or with the use of birth control pills. While the discoloration usually appears on the face, it can also develop on the neck and forearms. Aside from hormonal causes, melasma is also triggered by sun exposure.
Melasma occurs in 3 forms – epidermal (at the top layer of skin), dermal (at the second layer), or mixed. Epidermal melasma is easier to treat than dermal melasma, which often doesn’t respond or reappears after treatment.
My patients want to learn more about treatments for melasma because the condition is so highly visible. Before discussing treatment options, I first need to minimize hormonal or sun exposure that is aggravating the condition.
If my patient is on birth control pills or other hormonal therapies, I recommend stopping the medication with her doctor’s approval. Sometimes that’s enough to reverse the case. If my patient is pregnant, I recommend waiting it out. The condition is not harmful, and we would not want to start a course of treatment during pregnancy. Quite often, pregnancy-related melasma resolves on its own over time.
Treatment for melasma requires a strict regimen of high-SPF sunblock protection, protective clothing such as wide-brimmed hats, sun avoidance, and using an ultraviolet coating on car windows to reduce UVA exposure. I know staying in the shade or indoors during peak sun hours may be tough, particularly for those who are very active, but keep in mind that sun exposure makes melasma worse.
One good strategy is to layer sun protection, starting with a sun-protective cleanser, followed by a high-SPF sunblock, followed by make-up with built-in SPF. Give each layer a few minutes to absorb before applying the next. When treating melasma, more sun protection is better.
For initial treatment, the most commonly prescribed therapy is topically applied hydroquinone cream, or a combination cream that also includes a topical steroid, or tretinoin, such as Tri-Luma® cream. While highly effective (70%), this therapy is limited to a treatment span of 6 months, may irritate the skin, and the condition may reappear when the treatment stops. I often recommend Tri-Luma from April through September to coincide with, and counteract, increased sun exposure. Side effects may include irritation and steroidal acne, which subsides when the treatment is stopped.
Over-the-counter hydroquinone products are a lower potency, so they usually don’t work as well as prescription creams. Mild cases may respond to new soy creams, like the Aveeno® Positively Radiant® product line, which include natural light-reflecting minerals that subtly even skin tone.
For patients with stubborn or recurring cases, fractional laser resurfacing is often the best option, and about two-thirds of patients find it cures their condition. But results are not guaranteed, treatment is expensive (up to $1,000 per session), and it usually requires multiple sessions to achieve results. There is “downtime” for healing, and there is a risk of temporary hyperpigmentation, which may appear to make the melasma worse. Laser treatment is riskier for those with darker skin tones. As an additional note, during and after laser treatment regimens, patients must diligently avoid sun exposure.
Other less commonly used options in my practice include PhotoFacial™, which uses intense pulsed light (IPL) to “zap” the pigmentation. The advantage of such treatment is that it is nonablative – that is, it does not damage the skin during treatment. While this treatment can work well for skin damaged caused by the sun, it is not recommended for those with darker skin tones.