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WASHINGTON, D.C. (February 6, 2004) -- Imagine wearing a masquerade mask that you could never take off.  Not only would that mask color how you view the world, but it would also affect how other people see you.  Unfortunately, patients with melasma often feel like they are wearing a mask since the brown spots and darkened pigmentation of the condition often cover the face like a disguise.  New therapies are providing dermatologists with options that can help resolve melasma and help patients remove that mask.

Speaking today at the 62^nd Annual Meeting of the American Academy of Dermatology (AAD), dermatologist Valerie D. Callender, MD, Clinical Assistant Professor of Dermatology, Howard University College of Medicine, Washington, D.C., discussed the options available in the treatment of melasma.

Common Condition Among Women

Melasma affects five to six million American women annually; only five percent to 10 percent of patients are male.  Although melasma affects all races, individuals with darker skin, especially women of Hispanic, Caribbean, and Asian origin who live in areas of intense ultraviolet (UV) radiation exhibit a higher incidence.

“In addition to UV exposure, multiple factors can contribute to the development of melasma including pregnancy, hormonal therapy, genetic influences, certain cosmetics, and selected antiepileptic drugs,” said Dr. Callender.  “However, most cases involving men and up to a third of the occurrences in women are not preceded by any other disease.” 

The brown or grayish-brown patches of melasma typically result from increased melanin, the natural substance that gives color to skin and hair.  The spots occur on the cheeks, upper lip, and forehead, and because of the visible nature of the disease, the condition – sometimes called the “mask of pregnancy” – can have a considerable psychological effect on patients.

“Although melasma may resolve itself after pregnancy, that does not diminish the serious psychological effects that it has on a woman’s self esteem during its tenure,” stated Dr. Callender.  “The key to successful management of melasma is for the patient to diligently comply with the treatment regimen provided by their dermatologist, avoid the sun and any skin irritants, and use sunscreen.”

Dermatologists offer multiple medical and supplemental therapies to treat melasma.  They include:

Topical Agents

A variety of both over-the-counter and prescription bleaching creams are available for the treatment of melasma.  The creams do not “bleach” the skin but instead decrease the activity of the melanin, or pigment-producing cells in the skin.  Over-the-counter (OTC) creams contain low concentrations of hydroquinone, the most commonly used depigmenting agent. 

While these OTC creams are effective for mild forms of melasma, a dermatologist may prescribe creams with higher concentrations of hydroquinone.  However, individuals who suspect they may have melasma should schedule an appointment with their dermatologist before they begin any treatment regimen.

“The usefulness of hydroquinone as a depigmenting agent has been apparent for a number of years and is the gold standard of therapy,” said Dr. Callender.  “However, the lengthy time required for satisfactory improvement of melasma – typically a minimum of six months – can be frustrating for patients.”

Tretinoin is another topical cream that has been shown to improve the appearance of melasma, but results can take 24 weeks or more to become visible.  This vitamin A derivative, or retinoid, works by promoting the rapid loss of pigment by increasing skin turnover and easing penetration of bleaching ingredients into the skin.  Tretinoin can cause skin irritation, especially when higher concentrations are used.  In addition, temporary photosensitivity and hyperpigmentation can occur.

“Although not commonly used as a first-line therapy, all retinoids -- adapalene, tretinoin, tazarotene -- are excellent agents to prevent recurrence of melasma and can be used as maintenance therapy,” stated Dr. Callender.

Other topical treatments that have been used with some success are azelaic acid, a naturally occuring acid found in grain, and the popular Japanese bleaching agent kojic acid.  Both treatments are also used in melasma maintenance therapy. 

“Although it can trigger more irritation, studies have found azelaic acid to be superior to 2 percent percent hydroquinone with no significant difference noted between azelaic acid and 4 percent hydroquinone,” commented Dr. Callender.   “Kojic acid is as effective as other therapies and can be used if a patient has difficulty tolerating other first-line therapies.”

Combination Therapy

In the management of melasma, combination therapy is often more successful than single agents.  In one study of 641 moderate to severe melasma patients, the triple combination of the cortisone cream fluocinolone acetonide, hydroquinone, and tretinoin proved better than any dual combinations of the ingredients.  In addition, significant improvement with the triple therapy was noted as early as four weeks with maximum results in eight weeks.

“Long-term safety trials have proved the triple combination therapy is safe even with six to 12 months of use,” Dr. Callender said.  “While topical steroids can have many side effects with long term use, the addition of tretinoin to topical steroids increases the epidermal skin thickness which may help to explain the maintained safety of the treatment.”

Other successful combinations include hydroquinone and glycolic acid in a moisturizing hyaluronic base or hydroquinone and retinol in a microentrapped delivery system such as spherical moisturizing beads that gradually release the treatment into the skin thereby minimizing irritation.

Supplemental Therapy

Superficial and medium-depth chemical peels that use trichloroacetic acid, glycolic acid, or salicylic acid to remove the top layer of skin can reveal new even-colored skin for some melasma patients.  However, peeling agents must be used with caution in darker-pigmented skin because of the greater risk of postinflammatory hyperpigmentation.  Microdermabrasion, a procedure that utilizes microscopic crystals or diamond chips to remove the top layers of skin, is an alternative to chemical peels for those who do not tolerate these procedures well or who have sensitive skin.

Lasers are another treatment option for melasma, although most have demonstrated limited success.  While the er:YAG laser has revealed some improvement in the facial skin of patients with melasma, postinflammatory hyperpigmentation can occur which may require additional treatment.  The Q-switched ruby laser and the argon laser can also be used to treat melasma, but these lasers have not yielded long-term results.

Sun Protection

Because UV radiation is the most influential of all the environmental triggers of melasma, regular use of sunscreens that offer broad-spectrum protection against both UVA and UVB rays is one of the most important interventions in the management of the condition.  “Sunscreen usage is the most important factor for successful treatment of melasma,” stated Dr. Callender. “For maximum protection, dermatologists recommend that patients use a broad-spectrum sunscreen with an SPF of 15 or higher.”

“Melasma can cause patients physical and emotional distress,” said Dr. Callender.  “But a consultation with a dermatologist and a comprehensive treatment regimen can help patients resolve the condition and provide options to avoid recurrence.”

The American Academy of Dermatology, founded in 1938, is the largest, most influential, and most representative of all dermatologic associations.  With a membership of over 14,000 dermatologists worldwide, the Academy is committed to: advancing the diagnosis and medical, surgical, and cosmetic treatment of the skin, hair and nails; advocating high standards in clinical practice, education, and research in dermatology; supporting and enhancing patient care for a lifetime of healthier skin.  For more information, contact the AAD at 1-888-462-DERM or www.aad.org

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