Dermatologic 'minefield': Resistant melasma requires ongoing maintenance

Key Points

"In the San Diego area, I suspect almost one-fourth of women over age 35 have some melasma. It's a very common condition," says E. Victor Ross, M.D., director of the Laser and Cosmetic Dermatology Unit at Scripps Clinic, San Diego.

Like vitiligo, Dr. Ross says, "Melasma is a minefield to treat."

Typical treatments for patients with early melasma begin with effective sunblocks.

Additionally, he says hydroquinone creams remain popular for early melasma. Combination creams typically join hydroquinone with tretinoin and hydrocortisone cream, Dr. Ross says.

"We also try to get women off birth control pills or other hormonal therapy - that's the other key ingredient to treatment," he says

If women are on any kind of hormone replacement or birth control pills, he says, these treatments basically cause the body to produce more melanocyte-stimulating hormone.

Aggressive options

Should conservative treatments fail, more aggressive options include a wide array of lasers.

"Some of them work some of the time," Dr. Ross says, "but none of them work all the time, which is really the problem."

With Q-switched Nd:YAG lasers, physicians can use a total of six to eight treatments, spaced one to two weeks apart, he says.

"That regimen works reasonably well to improve the pigmentation temporarily," Dr. Ross says. "But 50 to 80 percent of patients experience melasma relapses within two to three months."

Visible light technologies, on the other hand, include intense pulsed light (IPL) and long-pulsed KTP lasers.

"Those two modalities have been used frequently for melasma. Sometimes, it gets better; sometimes, it gets worse," Dr. Ross says.

Usually, these light sources produce temporary remissions at best, he adds.

Similarly, he says very light laser peels that allow patients to heal in a day or two also produce temporary improvement.

Accordingly, no matter what modality one uses to treat melasma, "Key parts of the long-term strategy are sun avoidance, good (opaque) sunblock, hydroquinone and cessation of any estrogen therapy.

"Physicians must use these strategies for maintenance, no matter what else they do," Dr. Ross says.