Evidence-Based Treatment for Melasma: Expert Opinion and a Review

Abstract

IntroductionMelasma is one of the most common pigmentary disorders seen by dermatologists and often occurs among women with darker complexion (Fitzpatrick skin type IV–VI). Even though melasma is a widely recognized cause of significant cosmetic disfigurement worldwide and in India, there is a lack of systematic and clinically usable treatment algorithms and guidelines for melasma management. The present article outlines the epidemiology of melasma, reviews the various treatment options along with their mode of action, underscores the diagnostic dilemmas and quantification of illness, and weighs the evidence of currently available therapies.MethodsA panel of eminent dermatologists was created and their expert opinion was sought to address lacunae in information to arrive at a working algorithm for optimizing outcome in Indian patients. A thorough literature search from recognized medical databases preceded the panel discussions. The discussions and consensus from the panel discussions were drafted and refined as evidence-based treatment for melasma. The deployment of this algorithm is expected to act as a basis for guiding and refining therapy in the future.ResultsIt is recommended that photoprotection and modified Kligman’s formula can be used as a first-line therapy for up to 12 weeks. In most patients, maintenance therapy will be necessary with non-hydroquinone (HQ) products or fixed triple combination intermittently, twice a week or less often. Concomitant camouflage should be offered to the patient at any stage during therapy. Monthly follow-ups are recommended to assess the compliance, tolerance, and efficacy of therapy.ConclusionThe key therapy recommended is fluorinated steroid containing 2–4% HQ-based triple combination for first line, with additional selective peels if required in second line. Lasers are a last resort.Electronic supplementary materialThe online version of this article (doi:10.1007/s13555-014-0064-z) contains supplementary material, which is available to authorized users.

Treatment of Melasma Using a Novel 1,927 nm Fractional Thulium Laser: A Retrospective Analysis of 68 Korean Patients

“…Pigment reduction is achieved by using chemicals that interfere with various steps of the melanogenesis pathways via: (i) the retardation of abnromal melanocyte activity; (ii) the inhibition of melanosome formation and melanin synthesis; and (iii) the enhancement of melanosome degradation. 21 Topical application of depigmenting agents, sometimes along with superficial chemical peels, is usually the first-line treatment. Laser and light therapies represent potentially promising options for patients who are refractory to other modalities.…”

“…Because laser and light therapy frequently carry a significant risk of worsening the disease, a thorough understanding of the risks and benefits of each treatment option is crucial. 21 Lasers and light sources have been evaluated in the treatment of melasma with varied results. 14,16,21 The basic mechanism of action of laser and light-based treatment for the treatment of pigmentary disorders employs photothermal, photomechanical, or ablative effects.…”

“…21 Lasers and light sources have been evaluated in the treatment of melasma with varied results. 14,16,21 The basic mechanism of action of laser and light-based treatment for the treatment of pigmentary disorders employs photothermal, photomechanical, or ablative effects. The principle of photothermolysis dictates that the target molecule, the chromophore, should preferentially absorb the delivered wavelength of light, and that the light energy must be delivered over a period of time to damage the target while limiting collateral damage to adjacent structures.…”

“…16 Regarding melasma treatment, typical devices that rely on this principle include the low fluence 1,064 nm and 694 nm Q-switched lasers, which have been reported to have moderate clinical efficacy with minimal downtime and less side effects. 10,12,16,21 Use of a long-pulsed laser with a pigment-selective wavelength has also been tried. 15 Pigment non-specific fractional lasers have also been used to treat melasma.…”

“…This tendency has also been described in previous trials. [18][19][20] Considering that most melasma treatment modalities are related with slow clinical response and long-term, repeated applications, 8,10,14,21 the quick therapeutic onset of the 1,927 nm fractional laser resurfacing can be a strong advantage in the treatment of melasma. This implies that early clinical improvement of melasma can first be achieved by ablative fractional laser resurfacing and other treatment modalities can be applied after it for maintenance.…”