Developing best practices to treat melasma in skin of color promotes standardized care

Key takeaways:

• Melasma particularly affects women and populations with skin of color.
• FDA-approved fixed-dose triple-combination cream is considered the first-line treatment for melasma.

A review of treatments for melasma — including daily practices, topical treatments and oral options — targeted defining a standard of care for the chronic condition, especially among patients with skin of color, according to a study.

“Melasma affects more than 5 million people in the U.S., with multiple global studies indicating that melasma predominantly affects women and in populations with skin of color,” Seemal R. Desai, MD, of University of Texas Southwestern Medical Center in Dallas and Innovative Dermatology in Plano, Texas, and colleagues wrote. “Melasma typically manifests as symmetrical hyperpigmentation, primarily on sun-exposed areas, with light brown to dark macules and/or patches on the face, particularly on the forehead, cheeks and chin in a centrofacial pattern.”

According to Desai and colleagues, the complexity of melasma pathogenesis often means patients are recalcitrant to treatment and experience recurrence. Finding treatment options for patients, especially patients with skin of color, can be challenging. In this study, the authors outline the best practices for treating melasma, particularly among patients with skin of color.

Communication

Informing patients that melasma is a condition that can be managed, but not cured, is important, Desai and colleagues wrote. Physicians should explain the pathogenesis and complexities of the condition to patients and stress that treatment and prevention of melasma is a long-term commitment. Maintaining those expectations will help the doctor-patient relationship and treatment process, according to the study.

Photoprotection and skin care

Patients with melasma, especially those with skin of color, need to understand the importance of following sun protection strategies, such as applying sunscreen, wearing broad brimmed hats and avoiding the sun. Emphasizing the necessity of these practices will help in melasma treatment, according to the study.

Further, the use of ultraviolet (UV) and visible-light broad-spectrum sunscreen — particularly iron oxide-containing sunscreens — is crucial during melasma prevention and treatment, Desai and colleagues wrote. Studies show that using these sunscreens in conjunction with a topical treatment led to greater decreases in melanin content, blocking UV radiation and reducing disease severity and flares.

Gentle cleansers and moisturizers are also important steps for patients to take before utilizing therapeutic interventions. Studies have shown that barrier disruptions in the skin leave the skin prone to hyperpigmentation from melasma. These solutions assist in the restoration of the skin barrier by increasing moisture levels and preventing an environment where hyperpigmentation can occur, according to the study.

Skin-lightening agents

Hydroquinone, a popular skin-lightening agent, may help reduce the overproduction of melanin that plagues those with melasma. However, physicians should be wary that hydroquinone is accompanied by safety concerns such as skin rashes, facial swelling and ochronosis, the study authors wrote.

The FDA issued a warning letter in 2022 to companies selling over-the-counter skin-lightening products containing hydroquinone due to their lack of recognition for safety and efficacy. Only one hydroquinone-containing prescription — a fixed-dose triple combination cream — is approved by the FDA.

Topical treatments

The FDA-approved fixed-dose triple-combination cream for melasma contains 4% hydroquinone, 0.05% tretinoin and 0.01% fluocinolone acetonide. It is considered the first-line treatment for melasma and can be used up to 8 weeks for short-term treatment.

A 12-month study also showed that the combination can be used for long-term treatment, with 90% of participants experiencing complete or near complete melasma clearance by the end of the study; however, 2.5% discontinued due to adverse events.

Desai and colleagues agree that the triple-combination treatment is more efficacious than individual monotherapies and dual-therapy combinations. Nevertheless, physicians may opt to use compounded therapies containing hydroquinone, corticosteroids, retinoids and azelaic acid. However, as monotherapies, these active ingredients have been known to cause adverse events such as irritant dermatitis, acne, exogenous ochronosis and more.

Oral treatments

While topical treatments are preferred for melasma, oral medications are available for patients that are unresponsive or sensitive to topicals. One such oral treatment is tranexamic acid, a plasmin inhibitor that decreases melanin synthesis.

Tranexamic acid has been shown to be a good treatment option specifically for vascular melasma, according to the study. When used with triple-combination cream, studies indicate that tranexamic acid’s efficacy increases.

Patients with thromboembolic risk should not use this oral medication, Desai and colleagues wrote, cautioning that physicians should take care in screening patients before prescribing. Further, this therapy is not currently approved by the FDA for melasma.

Conclusion

“Treatment can be challenging, especially in the moderately to severely affected patient,” Desai and colleagues concluded. “Careful consideration is required as we determine the optimal treatment regimen for our patients with melasma, particularly those patients with skin of color.”