This compound has revolutionised melasma management. This tablet modifies feeding vessels to the pigment cells in your skin. It works by modifying a receptor called VEGF 1.

Oral tablets are best, however creams can be marginally effective. This is a prescription only medication. Without t.acid, the prognosis of dramatically improving melasma drops significantly.

Creams form the second tier of melasma management, the first tier is sun protection. My go to skin lightening agent is hydroquinone, in concentrations ranging from 2 to 8%. This compound has to be used in a rotational manner for safety reasons. My nurses & therapist will guide you accordingly.

Other skin care ingredients I use include-

• Arbutin: Both alpha & beta compounds
• Kojic Acid: Ranging from 0.1 to 1.8%
• Citric Acid: An AHA
• Glycolic & lactic acids: AHAs that exfoliate pigment
• Retinol: Vitamin A cream
• Retinoic Acid: Stronger vitamin A
• Ascorbic Acid: Vitamin C, concentrations ranging from 1 to 20%
• Cystemine: A pigment inhibitor from Europe
• Licorice root: Natural pigment inhibitor
• Botanicals: Bearberry, soy, flavenoids, cranberries

The aim of laser is not to heat up melanocytes (pigment producing cells), but to decrease the transfer of pigment from these cells to the skin. This is a gentle treatment process and takes 5-6 sessions before results can be seen.

My melasma laser of choice is the Q Switch laser. A treatment program consists of 5 sessions spaced 2-4 weeks apart. There is no downtime following Q Switch laser. If you respond to this trial of laser, you can continue on the program. Another laser is called a Pico laser. This laser can give slightly faster results than Q switch nano lasers. 4-5 sessions are conducted 2-3 weeks apart.

for resistant cases of melasma, I also use low density non-ablative fractional lasers, including fractional 1927 Thulium. Fraxel is my third laser choice (way down the line). This form of laser resurfacing should only be used on patients who fail pico or nano lasers. Fractional lasers such as CO2 and Erbium have been reported to improve melasma, however most of these studies are from Korea and Japan- areas where the UV index is much lower than in Brisbane. I never treat melasma with ablative lasers.

This is one of the most common reasons for melasma to worsen. Despite education of beauticians and cosmetic GPs, IPL is still performed on melasma. In 90% of cases this treatment will worsen melasma. Some cases of epidermal melasma can respond to IPL, but only if the pigment producing cells are kept at bay before treatment.

Why IPL worsens melasma is because of the excessive heating of skin with this treatment. IPL stands for intense pulse light. This light is converted to heat energy that in turns stimulates excessive pigmentation.

I Do employ both the Cosmelan & Dermamelan peel for melasma. These peels are termed ‘novel peels’ with proprietary skin care ingredients.

Peels have several advantages over lasers, including faster results. The flip side is that downtime ranges from 4 to 9 days. Peels are also more costly than lasers.

Preselection of patients are essential prior to the use of both Cosmelan & Dermamelan peels. To see if you are a good candidate, book an appointment with my clinical team @cliniccutis.

This treatment is probably worse than IPL, reason being pigment in the upper layers of skin gets pushed deeper into the dermal layers, converting superficial to deep pigmentation.

The logic behind microneedling is to repair the damaged basement membrane as well as providing epidermal & dermal drug delivery (t.acid most frequently). Highly illogical as the initial injury results in pigment dropout. Topicals can be delivered to the epidermis (where pigment cells are) with good formulations of skin care ingredients.

Microneedling (with or without PRP) induced or worsened melasma is one of the harder ‘rebound’ cases to treat, often requiring 4-8 months of therapy to improve.

Pico lasers are the second line laser of choice in some melasma patients. They should only be used in conjunction with medical therapy. Pico is most useful in mixed pigment including melasma, sun spots, freckles & age warts. Pico is especially useful in darker skin types, including ethnic & Asian skin.

There are many papers on the treatment of melasma with Fraxel laser. I use this treatment as third line lasers for resistant melasma.

Fraxel is another frequent cause of melasma fare ups. Used conservatively, it can improve melasma in a minority of patients.

1. 1. Not everyone will improve with Fraxel laser. If you have pure sun damage and sun spots, Fraxel is our treatment of choice, but if you exhibit melasma, Fraxel has a chance of making it worse.
2. 2. All patients who undergo Fraxel MUST be on a fading agent such hydroquinone. This will reduce the chance of rebound. Ideally patients should be on t.acid.
3. 3. All other treatments are far more cost effective than Fraxel. For melasma you may need up to 4-5 Fraxel treatments. We don’t encourage patients spending upwards of 4-5 thousand dollars for results that are not guaranteed.
4. 4. Fraxel has a downtime of 3-5 days, other treatments do not.

In summary, Fraxel is an excellent method for treating sun pigmentation, sun spots, and freckles, however I do not endorse this treatment for melasma.

This patient responded well to Fraxel laser.

The natural history of melasma is to recur over time. Part of our treatment program is to reduce or prevent recurrence with the use of creams and sun protection. Developing a melasma prevention regime that you undertake at home is important.

There are many agents that contain fading agents that do not contain HQ. These can be used longterm or as rotational therapy alternating with hydroquinone.

HQ free topicals include Kojic acid, azelaic acids, ascorbic, citric, glycolic, mandelic, lactic, salicylic & retinoic acids. Botanicals such as bearberry, cranberry, soy, & liquorice root extracts.

Melasma treatments are more affordable than you think.

As a guide-

• Q switch laser toning from $150 per session ($690 for 5)
• Picosure or Picoway Picofacial laser $240-490 per session
• Fraxel or LaseMD laser from $740 per session (4 for 3 package, see below)

I do not recommend Fraxel Laser as an initial treatment for melasma, as other treatments carry less risk. Fraxel laser starts from $740 per session

* Package deal of 4 Fraxel lasers at $2990