Melasma treatment has changed: Dermatologist explains the latest creams, lasers and therapies that actually work

For many years, melasma has frequently been treated with the use of a tube of cream. Creams containing hydroquinone, different forms of retinoids, and steroids have been used as an initial treatment for those difficult brown or gray patches that will appear on the cheeks, forehead, nose, and upper lip as a result of factors such as exposure to the sun, hormonal changes, genetic predisposition, and pregnancy. However, even the fact that some patients witnessed some improvement during the treatment, pigmentation often returned once treatment has been completed.

Melasma affects millions, especially women

According to Dr. Ajay Rana, Founder & Director, Institute of Laser & Aesthetic Medicine, "Melasma is a very widespread condition. The incidence of melasma equals about 1% in the case of the adult population, but it can be as high as 30-40% in so-called risk groups. Approximately 90% of all patients suffering from melasma are women aged 20 to 50. Today, the field of dermatology has undergone thorough changes."

The new generation of topical ingredients

Topical therapies remain significant in treating melasma but the options available now are far more sophisticated than before. The new brightening agents like Thiamidol and 2-MNG have mechanisms of action that are different from those of hydroquinone. The results of clinical trials indicate that the new compounds provide similar results but with much milder side effects and can therefore be used in maintenance treatment.One more compound, Malassezin, has shown promising results in regulating the production of melanin and reducing skin oxidative stress. As melasma is a chronic and recurring disease, dermatologists prefer milder formulations nowadays.

Laser and light-based therapies

The development of laser and light technologies represents one of the biggest steps forward in the fight against melasma. Contemporary low-fluence picosecond lasers are capable of emitting short pulses of energy that break up the excess pigment with minimal thermal effect on surrounding structures, thus diminishing the risk of post-inflammatory hyperpigmentation, which has posed a problem for the use of laser procedures, notably in patients with Indian skin.

Fractional laser technology is used in combination with topical therapy for better penetration of topical drugs and the effectiveness of both methods. Unlike classical laser procedures, modern techniques are generally less invasive and require a short recovery period after surgery. When used correctly in combination with pharmacotherapy, laser therapy can result in a significant improvement of skin pigmentation and decrease the chances of recurrence.

Newer-generation chemical peels

Chemical peels have changed a lot too. Instead of using one acid in a big amount, new combination peels use different active ingredients in small amounts. This allows effective pigmentation treatment with much less aggressiveness, which is especially important for people with darker skin that is more prone to post-inflammatory hyperpigmentation. Chemical peels are used not only as separate treatments but now it is also common to include them into the treatment plans that provide other procedures and topical medications. They are performed with the help of multiple small treatment stages and provide effects instead of negative consequences.

Microneedling and regenerative therapies

In the past, microneedling was primarily used to encourage collagen production. These days, though, this procedure is often combined with specially formulated serums, growth factors, and exosome-based products that help reduce inflammation, repair the skin barrier, and manage skin color changes during healing. The use of this method looks to resolve one of the main issues behind melasma, namely, inflammation in the skin. The aim is for these treatments to make the skin an overall healthier environment rather than just help reduce current pigmentation. While investigations into the use of exosome-based products continue, initial evidence suggests their utility in future protocols for managing melasma.

Oral treatment options for melasma

Managing melasma today has evolved beyond merely topical or procedural solutions. A new and foremost tool in the fight against this skin condition is systemic Tranexamic Acid (TXA) therapy, prescribed only if medically indicated and under close medical supervision. Studies have confirmed the efficiency of this low-dose solution of TXA, indicating that it can help improve pigmentation in selected patients by up to 70% by reducing abnormal blood vessel activity and inflammatory processes causing melasma. Its effectiveness has been particularly shown in patients not benefitting much from topical creams. However, since this drug is contraindicated for some patients, it should only be administered after proper evaluation by a dermatologist.

Why combination therapy has become the new standard

Possibly the most significant shift in our understanding of melasma is the recognition that it is more than just a pigmentation disorder. Today, it is seen that it consists of many simultaneous processes, genetically-, hormonally-, UV- and light-induced, and follows the course that involves heat exposure, inflammation, changes in vascularity in the skin and impairment of skin barrier. As a result, people have learnt that application of one cream or one procedure often works only to bring temporary results.

Currently, most dermatologists advocate the use of a multi-modal approach to treatment that implies combined topical therapy, procedures in clinics, taking oral medications, when appropriate, and long-term maintenance care, depending on the skin type and the degree of pigmentation of the patient. Such an integrated approach gives a chance not only to achieve better treatment outcomes but also to avoid rebound pigmentation especially in people with dark skin. Rather than searching for instant outcomes, treatment is viewed as a gradual process, with the first step being control of active pigmentation and then moving to maintenance therapy for recurrence.

Sun protection remains essential for melasma treatment

It can be said that although there have been many advances in the treatment of melasma, one thing has remained the same in its handling: sun protection is essential. Using broad-spectrum sunscreen of at least SPF 50 every day still remains the basis for effective treatment of melasma. Dermatologists recommend that patients with melasma use tinted sunscreens that also contain iron oxide, as visible light can aggravate pigmentation.

Clothing that protects the skin as well as wide-brimmed hats, sunglasses and limited exposure to sunlight during peak hours are important for keeping the skin protected. Without protection from the sun, even the best treatments will not yield any results.

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