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Chapter 70: Melasma

Orlando Martinez Luna; Amit G. Pandya

MELASMA

Therapeutic Approach

Melasma is a common pigmentary disease caused by overactive melanocytes producing excessive melanin in the epidermis, which often migrates to the dermis. This leads to symmetric hyperpigmented macules and patches on sun-exposed areas of the face and sometimes the extensor arms. Types of melasma include centrofacial, malar, and mandibular, as well as epidermal, dermal, and mixed. Treatment is often difficult and recurrence rates are high. Initial management should focus on avoiding triggers: solar radiation and exogenous hormones. Choice of therapeutic strategies should be based on melasma type and severity. See Table 70-1.

Table 70-1Melasma Treatment Table
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Table 70-1 Melasma Treatment Table
MEDICATION NAME INDICATIONb MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Broad-spectrum sunscreens/tinted sunscreens All melasma patients UV light blocker + visible light blocker SPF = 50 formulations; apply daily Skin irritation None IB1,2
Triple combination cream (TCC)a First-line: EP, MI Tyrosinase inhibition, anti-inflammatory HQ 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%; apply QD Contraindicated in pregnancy; skin irritation, erythema, burning, pruritis, skin atrophy None IB3-6
Hydroquinone (HQ) First-line: EP, MI Tyrosinase inhibition 2%-4% cream; apply BID Contraindicated in pregnancy; skin irritation, erythema, burning, pruritis, ochronosis None IB6,7
Azelaic acid First-line (alternative): EP, MI Tyrosinase inhibition 10%-20% cream; apply BID Skin irritation, erythema, pruritis None IB8,9
Retinoids First-line (alternative): EP, MI Reduction in melanosome transfer, keratolytic Tretinoin 0.1% cream, adapalene 0.1% gel, isotretinoin 0.05 % gel; apply BID Contraindicated in pregnancy; skin irritation, erythema, pruritis None IB10-13
Tranexamic acid First-line (alternative): EP, MI Plasmin inhibition 2%-5% cream; applied BID Skin irritation None 1A14,15
Rucinol serum First-line (alternative): EP, MI Tyrosinase and TRP-1 inhibitor 0.3% serum; apply BID Skin irritation, burning, pruritis, blepharoplasty None IB16
Kojic acid First-line (alternative): EP, MI Tyrosinase inhibition 2% cream; apply QD Skin irritation, erythema, pruritis None IB17
Cysteamine First-line (alternative): EP, MI Tyrosinase inhibitor, peroxidase inhibitor 5% cream; apply QD Skin irritation, erythema, dryness None IB18,19
Licorice root extracts First-line (alternative): EP, MX Tyrosinase inhibition 2%-4% liquiritin cream; apply QD Skin irritation None IB20
Niacinamide First-line (alternative): EP, MI Reduction in melanosome transfer, antioxidant 4% cream; apply QD Skin irritation, erythema, pruritis None IB21,22
Ascorbic acid First-line (alternative): EP, MI Tyrosinase inhibitor 5% cream; apply QD Skin irritation None IB23
Systemic Therapy
Tranexamic acid Second-line: EP, MI, DE Plasmin inhibition 250 mg BID-TID for 12 wk Contraindicated in patients with hx of thromboembolic disease; menstrual changes, headache, arthralgias None IA15,24-26
Procyanidin + vitamins A, C, and E Second-line: EP, MI, DE Antioxidant 24 mg procyanidin, 6 mg β-carotene, 60 mg ascorbic acid, and 15 IU of D-α-tocopherol acetate BID None None IB27
Procedural Therapy
Chemical peels Second-line: EP, MI, ...

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