Multimodal therapy: Is more better?

Miami - While an evidence base is lacking to demonstrate benefits of combination treatment for melasma using topical plus procedural modalities, available data are generally positive and conceptually there is good rationale for using this multimodal approach, says Marta I. Rendon, M.D., associate clinical professor of dermatology, University of Miami School of Medicine, Miami

Concepts behind multimodality

"With those goals in mind and based on its composition and demonstrated safety profile, the fixed triple combination cream might also be considered the most suitable agent for using together with procedural therapies," Dr. Rendon says.

Dr. Rendon recently undertook a literature review to identify published reports describing the use of combination topical and procedural therapy for pigmentary disorders, including melasma. She identified a limited number of controlled studies, some using a split-face design and a few case series describing the use of various topical products pre- and/or postprocedural therapy with superficial and medium-depth chemical peels, intense pulsed light therapy (IPL) and laser treatment.

Literature review sparse data

The majority of the published reports have involved use of chemical peels that were performed using trichloroacetic acid (TCA) 30 percent to 35 percent, glycolic acid 20 percent to 70 percent or Jessner's solution as the peeling agent and various topical products that involved hydroquinone or tretinoin alone or in combination with a corticosteroid or glycolic acid.

Outcome assessments in the published studies included subjective evaluations by the investigators (e.g., MASI scores, Munsell color chart gradings) as well as objective measurements (e.g., mexameter analysis). Significant benefits were noted for the use of tretinoin to accelerate healing after TCA peeling and for various topical combination regimens to hasten the onset to and magnitude of melasma clearing.

There were just a few reports in the literature describing combination treatments involving procedures other than chemical peels. In her review, Dr. Rendon identified papers reporting application of tretinoin/hydroquinone/hydrocortisone prior to laser treatment with single passes of both the CO₂ and Q-switched alexandrite laser as well as a study evaluating IPL therapy combined with hydroquinone 4 percent in patients with refractory melasma.

In practical application

In her practice, Dr. Rendon has had favorable experience treating challenging melasma patients with a dual or triple combination approach consisting of topical therapy with the fixed triple combination cream plus microdermabrasion with or without glycolic acid peels.

She also uses IPL occasionally and the Q-switched Nd:YAG laser in a patient with very recalcitrant melasma. However, she cautions that laser treatment for melasma should be undertaken very cautiously, taking into account skin type and the risk for PIH.

Areas for more research

In addition to the need for further controlled studies to evaluate the efficacy and safety of combination topical and procedural therapy for the treatment of melasma, well-designed clinical trials are needed to determine what constitutes optimal timing for initiating topical therapy.

Literature and anecdotal reports indicate there is wide variation in clinical practice.