Melasma is a common, acquired disorder of hyperpigmentation that occurs commonly in women with skin of color. Clinical patterns of disease include centrofacial, malar, mandibular and forearm types. Although the exact pathogenesis remains unknown, exacerbating factors include hormonal contraceptives, pregnancy, and ultraviolet-light exposure.

Drug Strengths Weakness
Ascorbic acid Less cutaneous irritation compared with hydroquinone Rapidly oxidized and highly unstable; not good as monotherapy
Azelaic acic Reasonable response for epidermal melasma Erythema, burning, stinging
Arbutin Less irritation than hydroquinon; may have sustained lightening effects (seen in studies for lentigines) May cause paradoxical hyperpigmentation in concentrations >3%; no studies in melasma
Glycolic acid Inexpensive, available as cream or peel Cutaneous irritation; best in combination with other agents
Hydroquinone Excellent, well-established efficacy Cutaneous erythema, burning, itching, irritation
Kojic acid Licorice extract Less cutaneous irritation compared with retinoids and triple therapy Mixed efficacy in split-face trials; may be best in combination with hydroquinone
extract Good response in epidermal melasma More robust studies needed
Nicotinamide Good response in epidermal melasma Effective for skin lightening More robust studies needed Cutaneous irritation; more studies needed
Retinoids Good effect in melasma; other benefits on fine lines, texture of skin Satisfactory effect in melasma in one Cutatneous irritation, slow (months) to show improvement as monotherapy 'Tolerable' side effects; more studies needed
Rucinol serum Soy12 Modest effect on lentigines No studies on efficacy in melasma

Melasma is a common, acquired disorder of hyperpigmentation that occurs commonly in women with skin of color. Clinical patterns of disease include centrofacial, malar, mandibular and forearm types. Although the exact pathogenesis remains unknown, exacerbating factors include hormonal contraceptives, pregnancy, and ultraviolet-light exposure

Wattanakari9 evaluated weekly low-fluence QS Nd-YAG for five weeks plus 2% hydroquinone nightly versus 2% hydroquinone alone for dermal and mixed melasma. Although excellent improvements were cited, mottled hypopigmentation, rebound hyperpigmentation and confetti-like hypopigmented macules were reported. A total of eight out of 24 subjects were noted to develop the latter problem, with relapse in all patients at Week 12.

Another randomised study8 reviewed three groups of patients. The first was treated with low-fluence QS Nd-YAG, the second with glycolic acid peels fortnightly (35-70% with pre-treatment retinoid priming) for 12 weeks and the third with high-fluence Nd-YAG fornightly.8 Best results were seen with low-fluence Nd-YAG, with high-fluence Nd-YAG causing the most adverse effects. All groups' MASI scores were increased at Week 12, indicating worsening of pigmentation.

Park et al. 10 reported that combination QS Nd-YAG plus 30% glycolic acid peels every two weeks were superior to QS Nd-YAG treatment alone, but some recurrence was noted five months post-treatment. Mild adverse events (erythema, transient burning) were noted but no pigmentary problems were cited.

These and other studies suggest that low-fluence QS Nd-YAG laser may be useful in severe, refractory melasma when patients are carefully selected, risk factors for complications are excluded, and a combination of laser treatment and peels is utilized.11,12 The cost of treatment, inevitable relapse and the increasing side-effect profile with subsequent treatments urges the clinician to use multi-modality treatments and emphasize the need for ongoing photoprotection.

Lasers use in melasma

Laser Strengths Weakness
High fluence Nd-YAG NIL Worsens melasma
Low fluence QS Nd-YAG Modest - good effect on severe, refractory melasma Mottling, hyperpigmentation, confetti hypopigmentation
Intense Pulsed Light Good effect in skin phototype I-III Unpredictable pigmentary side effects in skin phototype IV-VI
Fractional resurfacing and copper bromide lasers Some good effects seen with melasma Further studies required

Oral tranexamic acid (TNA) is a novel treatment in melasma and also deserves some attention. Although traditionally used for bleeding diatheses and menorrhagia, it has been successfully used for the treatment of melasma.13 Although its mechanism of action is not entirely known, decreased tyrosinase activity in melanocytes is one possibility.14 Possible side effects include nausea, vomiting and diarrhea. Thromboembolism, pulmonary embolism and myocardial infarction have rarely been reported.

Cho et al. 13 showed that TNA at a dose of 500 mg/day plus intense pulsed light, and QS Nd-YAG (four treatments) was superior to laser therapy alone. Shin et al. 14 performed a randomized prospective trial, revealing that eight weeks of TNA at a dose of 750 mg/day enhanced the efficacy of low-fluence QS Nd-YAG laser therapy. Further studies are required to more fully evaluate this therapeutic option for melasma.

With the advent of new treatments, including lasers, and more therapeutic options on the horizon, it is an exciting time to be managing pigment disorders. This heralds the inevitable need for ongoing evidence-based research and trials.

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