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: Tretinoin, 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 Picosure Pro laser.  A treatment program consists of 4 sessions spaced 2-4 weeks apart. There is no downtime following pico. Pigment clearance can be seen in as little as one week.

More on our Picosure Melasma program. 

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. IPL an excellent treatment for generalised pigmentation, however it will worsen melasma in over 90% of cases. Some cases of epidermal melasma can respond to IPL, but only if the pigment producing cells are kept at bay before treatment. 

IPL worsens melasma because of the excessive heating of skin when light is converted to heat energy. This turns stimulates excessive pigmentation. 

Chemical peels are useful in some cases of melasma. TCA & deeper peels are no longer performed, as aggressive peels are associated with rebound melasma.

In order of merit, the peels I use include-

Dermamelan or Cosmelan

These are novel peels that contain pigment inhibitors & exfoliants. 

Pros: One of the fastest ways to temporarily treat melasma.

Cons: Super expensive, works in 65% of cases, over one week recovery.

Glycolic acid peels

Derived from sugar cane & related to lactic, glycolic acid is classed as an alpha hydroxy acids.

Pros: No downtime, also treats sun damage & wrinkles

Cons: Must be performed as a step up program of 5-7 peels.

Retinoic acid peels

Super strength vitamin A; over 200 times as powerful as retinol.

Pros: Also treats sun damage & fine lines.

Cons: May peel for 2-4 days.

I 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 at Cutis Dermatology.

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). This theory is flawed as the initial injury results in pigment dropout. Topicals can be delivered to the epidermis (where pigment cells are) with good formulations of ingredients.

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

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.

We have both the Picoway & the Picosure Pro at our clinics. Picosure is better for treating melasma & Asian skin, whist Picoway is better at treating dark inflammation following trauma or laser burns. 

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

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. 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. 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. 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 Fraxel as the primary treatment for melasma.

The natural history of melasma is recurrence over time. The good news is that melasma will go away on its own- usually in the late 40s to 50s. Asian patients usually have spontaneous fading in the sixth decade of life.

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. 

My team & I will discuss the best rotation treatment for your melasma, namely clinic treatment followed by home routines. 

If you have had a consultation with me, you know how much time I spent asking you about your sun exposure. It takes me 10 times as long understanding your UV exposure than looking at your pigmentation under lighting & magnification. 

I know the answer of ‘I’m always indoors’ or I don’t get any sun. For a small minority of vampires, it’s true, but most patients fail to understand collateral light exposure including-

Driving? The front window can not be tinted, for most there is UVA exposure & for all there is visible light exposure. Drive 30 min. Each way? That’s one hour daily of collateral exposure.

You can see light outside? You have visible light on your skin. The same goes for hanging clothes outside, gardening, exercise, taking the letters in. The list goes on. This is why it is super important to use sunscreen twice a day, regardless of sun exposure. 

Firstly the onset of melasma is later in Asian patients; typically in the late 30s to even early 50s!

Secondly, melasma is often mixed with other forms of pigmentation such as sun spots, freckles, dark circles, as well as dermal pigment such as Hori’s naevus. Each type of pigment requires special lasers & settings, complicating the treatment.

Thirdly, most Asian patients are not great sunscreen users (I know this very well as my relatives don’t use sunscreen). Yes, I know we hardly burn, but sunlight stimulates pigmentation, so sunscreen is a must. 

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 $158 per session ($790 for 5)
• Picosure Pro or Picoway Picofacial laser $490 per session
• Fraxel or LaseMD laser from $740 per session (4 for 3 package, see below)
• Hybrid laser from $290 per session
• Chemical peels from $98

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 

This laser uses 2 wavelengths, the CO2 (which is never used to treat melasma) & the 1570, which is twice a powerful as Fraxel. The Hybrid is used to treat deep resistant dermal melasma. 

It works by employing the melanin shuffle theory, which is ‘drilling deep holes in the skin to allow pigment & pigment cells to be exfoliated through the upper layers of skin.’

This can be successful in some patients. I prefer the Hybrid over 1550 Fraxel Dual because-

• The Hybrid goes deeper (twice as powerful as Fraxel)
• The Hybrid hurts less (inbuilt cooling) 
• The Hybrid cost less than Fraxel (less than one third the cost of Fraxel)

I did try vascular lasers for several years, based upon the theory of vascular inputs accelerating pigment production, hence why tranexamic acid is employed to treat melasma. Bottom line? They don’t work as well as what we expected. 

I only use vascular lasers such as the VBeam, DermaV & others when melasma is associated with rosacea (almost never). 

No. We have a success rate of over 80%. This means despite optional medical therapy & lasers, some patients are just resistant to treatments.

Lower success rate are seen in –

1. Deep dermal melasma
2. Microneedling induced melasma
3. Melasma in darker skin
4. Melasma due to heat or infrared exposure

Sun protection. Are you using enough sunscreen. One 50 ml bottle should last  2-3 weeks. Are you using the correct sunscreen? If you exercise, you should use a water-proof sunscreen.

Other sources of heat: melasma is activated by visible & IR heat. Examples of the former include light behind a window; driving for example. IR heat can come from saunas & cooking.

Compliance of topicals: you need to regularly apply pigment correctors. In some cases your skin maybe too sensitive; especially to retinoids, cysteamine & hydroquinone. Exogenous ochronosis is rare, but your dermatologist can sort that out.

Compliance of other medications: t.acid should be orally taken in the absence of contra-indications.

Settings, wavelengths, equipment use: they all matter. Sure you can use a laser.

Diagnosis: Conditions like Hori or age spots can look like melasma. They are treated very differently.

Truely resistant melasma: in a small percentage of cases, melasma is recalcitrant to medications, lasers, & peels.

I will be seeing select cases of pigmentation in Sydney. For an expression of interest, please contact the clinic in the Eastern Suburbs.

Our Picosure Pro laser is due in early 2024.