Melasma At A Glance
- Best Results2-10 treatments
- Treatment Recovery0-7 days
- Procedure Time5 min
- Skin SpecialistDermal therapist, nurse
- Duration of ResultsMonths to years
- AnaestheticNil Required
- Back to WorkImmediately
Melasma is a unique form of hormonal pigmentation that is mostly seen in women. Melasma can be improved by up to 80% with a combination of prescription creams, sunblock, gentle chemical peels & special lasers.
FactsFacts on melasma treatment
- The cause of melasma is a mix of genetics, UV exposure & hormones
- This is a special form of pigmentation that presents on the upper lip, around the eyes, & forehead area
- Melasma is often patchy, & motley in appearance
- Lasers can improve melasma
- The degree of improvement will depend on the depth of pigmentation
- IPL should not be used to treat melasma
- Microneedling often makes melasma worse
- The majority of melasma can be improved with a combination of SPF, tablets, creams & laser
What is melasma?
Melasma is also known as hormonal pigmentation or cholasma. It presents as patchy pigmentation on the forehead, under the eyes & upper lip.
Melasma is caused by a combination of genes, UV rays, and hormones. It is more common in pregnancy & may occur after taking the birth control pill.
Why is melama vital to diagnose? It is because melasma is a unique form of pigmentation. Unlike other types of pigmentation, melasma has to be treated in a special way or treatments can worsen pigmentation.
Patchy pigmentation and upper lip darkening are signs of melasma. Never undertake IPL for this form of pigmentation.
What is the best treatment for melasma?
The optimal treatment will depend on the type of melasma you have. The majority of patients will have mixed melasma– this means your pigmentation lies on the surface as well as deeper in the dermal layers of your skin. The best method of treating this form of melasma is with a combination of creams, tablets & laser.
- Sun protection and sunscreen forms the basis of treatment. If you are sun exposed for 20 minutes without sun block, all the work you may have accomplished to fade your melasma will be undone.
- Creams- we use a mixture of fading creams, including bleaching agents, Vitamin A, as well as Vitamin C creams.
- Peels- our favourite peels include AHA or glycolic, VITA peels, or lactic acid peels. TCA at very low concentration can also be used.
- Lasers- I employ both nano, pico & thulium lasers. Never undertake IPL, as this often makes melasma worse.
Why is sun protection essential in the management of melasma?
Without good sun protection, even the best lasers & creams will have no chance of improving melasma. This is because the pigment cells are super sensitive to UV, visible light & infrared light sources.
A high factor SPF 50+ sunscreen is best. As a daily sunscreen I like La Roche Posay 50+ Anthelios or Invisible Zinc. For outdoor activity, Sunsense or Cancer Council makes great sunscreen.
Sunscreens only form one part of sun protection- sun avoidance and a broad brimmed hat is essential.
The correct way to use sunscreen in melasma patients is as follows-
- Two types of sunscreen. Daily & activity.
- Use twice a day.
- Use 2 finger lengths.
What can I try at home before seeing a dermatologist?
Sun protection will give you the biggest improvement by far. Once you get this right you can try the following before seeing a dermatologist.
Fading creams: Try this combination- Azelaic acid 10-20% in the am. Superfade 2% Hydroquinone in the evening. You do not require a prescription of these creams.
The combination of correct sunscreen use & bleaching creams can reduce pigment by up to 30-50%. For further improvement, book a consult with my team of therapists & nurses @cliniccutis.
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What is tranexamic acid & why is it so important in treating melasma?
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.
What are the pigment inhibitors that I employ to treat melasma?
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
What lasers do I use to treat melasma?
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.
Why did my melasma get worse after IPL treatment?
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.
What is the Cosmelan peel for melasma?
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.
Can microneedling or microneedling PRP be used to treat melasma?
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.
Can Pico lasers treat melasma?
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.
Can Fraxel be used to treat melasma?
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. 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 this treatment for melasma.
This patient responded well to Fraxel laser.
Will melasma return if I stop treatments?
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.
What are Hydroquinone free topicals & how do I use this in my melasma treatment regime?
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.
How much do melasma treatments cost?
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
Davin’s View on Melasma Management
This is one of the hardest skin condition to treat. Despite continue education to the cosmetic industry, including beautician and cosmetic GPs, hundreds of cases of IPL & Pico lasers are performed for melasma pigment. The vast majority of cases will worsen. Melasma MUST be treated medically, with lasers as adjunctive therapy.
Treating this condition is a marathon & not a sprint. The most successful treatments are gentle, over a period of weeks to months.
Not all melasma can be treated or improved. Deep melasma or dermal melasma will not improve with creams or peels. Fortunately the majority of cases are ‘mixed’, namely superficial and deep, and hence the majority of cases can be improved. The key to treating this condition is with a mixture of tablets to reduce vascular input, appropriate lasers in the correct settings, & also creams that ‘turns off’ the pigment producing cells.
If laser is performed, it has to be gentle and not agitate melanocytes, or melasma will worsen- the laser of choice is Q switch laser. I tend not to use Fraxel for this condition because of the fact that some cases can worsen with this treatment. In some cases I use the LaseMD Thulium 1927 laser with topical therapy such as t.acid.
New lasers such as Picoway & Picosure has shown great promise in the treatment of resistant melasma & sun induced pigmentation.
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