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. Cutis Dermatology treats over 80 melasma patients per week using a combination of prescription creams, sunblock, chemical peels & special lasers. Our success rate is over 85%. Our nurses are capable of providing advanced treatments & cosmeceuticals to quickly, safely & cost effectively reduce pigmentation in as little as 10 days.
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
- Special lasers can improve melasma within a week or two
- The majority of melasma can be improved with a combination of SPF, tablets, creams & laser
- Resistant melasma can be treated with Picoway, Picosure Pro & fractional Hybrid lasers
- Fraxel HD is a good treatment for pigmentation, however Fraxel should not be used to treat primary cases of melasma
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 melasma vital to diagnose?
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.
Patchy pigmentation and upper lip darkening are signs of melasma.
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 & lasers.
- 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. Novel peels such as Dermamelan or Cosmelan can give FAST results, however they have 4-9 days of downtime.
- Tablets include VEGF-1 modulators
- 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.
Why do some Brisbane Skin clinics treat melasma with Fraxel?
Because Fraxel carrier more profit to the provider, as each treatment ranges from $890 to $1690 per session. I do use Fraxel for resistant melasma, however as first line therapy, I prefer precision Q Switch lasers as they are more effective, have less side effects & cost 1/5 that of Fraxel.
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 at Cutis Dermatology.
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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. 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.
What are other peels that can treat melasma?
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.
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.
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.
What is the Cosmelan peel for melasma?
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.
Can microneedling 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). 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.
Can Pico lasers treat melasma?
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.
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 a frequent cause of melasma fare ups. Used conservatively, it can improve melasma in a minority of patients.
- 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.
- 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.
- 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.
- 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.
Will melasma return if I stop treatments?
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.
Why do I spend the most amount of time understanding your sun protection?
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.
Why is melasma different in Asian patients?
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.
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 $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
What is the Hybrid laser by Alma & when do I use it to treat melasma?
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)
When are vascular lasers used to treat melasma?
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).
The melasma check list; why isn’t your pigment getting better?
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.
Davin’s View on Melasma Management
This is one of the hardest skin condition to treat. There is an expression in dermatology that melasma will humble even the most experienced dermatologist. My teams hit rate is about 85%, by definition we can improve the MASI or melasma area severity index by 50% or more in over 85% of cases.
The 15% failure rate? Combination of recalcitrant disease, deep dermal melasma, poor photo protection- compliance or contraindication to topicals (sensitive skin) or medical C/I to oral t.acid.
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 or peels as adjunctive therapy.
Treating melasma 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 the pigment cells known as melanocytes, or melasma will worsen. My 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. For deep melasma I also employ the 1570 Hybrid laser to help exfoliate pigment in the dermal layer. This is called the ‘melanin-shuffle’ theory.
New lasers such as Picoway & Picosure Pro has shown great promise in the treatment of melasma & sun induced pigmentation. These lasers are most useful to treat Asian or ethnic patients who have combination pigment, including Hori, freckles, sun spots, macular seb keratosis & generalised dyschromia.
The aim of melasma treatments is to find the correct formulation for each patient & to treat them with rotational therapy. The duration of each treatment cycle is individualised.
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