Melasma Treatment takes committment.
I'm fortunate in that I've never had melasma. I realized just how hard it was to treat when a micro-needling pen sales rep told me that she had melasma. It was startling to me because there wasn't even 1 dark spot on her face! When I talked to her more, she explained that she'd gotten her melasma under control with micro-needling. It was a revelation for me. It was my "Aha!" moment - when I realized all the possibilities that micro-needling had to offer. But I'll go into more detail on micro-needling as a treatment for melasma later.
A Little Bit About Melasma:
Melasma is a difficult condition to treat partly because it is so persistent. That said, progress is being made. Following are some of the best products available for melasma treatment. Each has clinical testing to back it. My hope is that some combination of them will help your melasma.
So let's get started!
Your melasma will take daily care - and it may get worse at times - even when you're doing everything right. Hormones continuously trigger these dark spots. So you'll get the best result if you delay treatment until after:
- you've stopped breastfeeding
- you're no longer pregnant
- your contraceptives have changed
Learn more in our blog post, Can medications cause dark spots? Not sure what melasma is? Read our blog posts, 6 Melasma Triggers + 6 Ways to Avoid Them and What are hypo and hyperpigmentation? Why do some people get color changes with skin treatments?
Melasma takes years to develop. So you should expect your dark spots to fade slowly also - especially if you don't take every chance to protect your skin from sun exposure.
All wavelengths of sunlight - including the light we can see - can jumpstart melasma. Dr. Lance Setterfield explains in his book, The Concise Guide to Dermal Needling, that the light that comes into your eyes triggers pigment formation. This means that, even if you wear sunscreen and cover up, pigment formation can still happen. It also means that wearing sunglasses will help prevent new dark spots.
Because there isn't a good way to remove pigment from deep in the dermis (the 2nd layer of skin), it takes longer to fade than pigment in the epidermis (top layer of skin). Dermal / deep pigment comes from the top layer of the skin (the epidermis), so if you can stop / slow the epidermis from making pigment for long periods, the dermal pigment will slowly fade.
You can keep your melasma from getting worse by wearing sunscreen, sunglasses and a wide-brimmed hat every day.
As I mentioned above, superficial pigment in the top layer of skin (epidermis) is easier to treat than deeper dermal pigment. Unfortunately, melasma usually has both. Daily care with a variety of skin care products and ingredients will help to keep pigment from forming and improve its appearance. It will also give you a better outcome more quickly.
But, shutting off the pigment cells is only the first step in controlling melasma.
"Pigment takes a long time to diminish because it has taken decades to accumulate and show. Treatments like Fraxel or IPL may mop up the "puddle of pigment," but when skin is viewed under the black light, remnants are clearly visible in the deep layers of the skin. Unfortunately, it does not take much sun stimulation to make the puddle visible again on the surface of the skin. Three hours of unprotected sun exposure can undo a year's worth of hard work."
The first / most recommended line of treatment is a topical combination hydroquinone cream, avoiding sun, and NO estrogen exposure. The BEST treatment is what works for you. You may need to experiment with several different treatments to determine the best combination for your melasma.
Hydroquinone has been used for years in melasma treatment. It's still used alone or combined with other products. HQ blocks a critical step in the formation of melanin. It lightens the skin, essentially by bleaching the pigment where it is applied. Low strength formulations are available without a prescription.
A drawback of hydroquinone is that it will bleach any skin that it touches - so it should only be used as a spot treatment. If applied outside of the pigmented area, HQ will lighten that area too - causing a halo effect. Halos are not easily reversed, even after you have stopped using HQ.
Hydroquinone formulations (3% or more HQ) are available from a dermatologist. Generally, the stronger the formulation, the better it works - but stronger formulations have more adverse effects, especially when used long term. Some of the possible side effects are skin irritation, light sensitivity with a secondary reaction that causes more skin darkening, and irreversible ochronosis. (Before you ask, onchronosis is a rare disease with speckles of dark brown or black spots sprinkled symmetrically over the face, neck, and other sun-exposed areas.) To learn more about light sensitivity reactions, read Phototoxic Reactions Versus Photoallergic Reactions by the Skin Cancer Foundation.
In an effort to minimize side effects, dermatologists commonly cycle hydroquinone. In other words, they prescribe hydroquinone products for 4 months, stop for 4 months, then start again for 4 months, and so on. During off months, a HQ-free skin brightener is recommended.
Lower concentrations of HQ are available at drugstores. BUT they may get a poor response.
Hydroquinone has been banned in some countries over concerns of an increased cancer risk. However, it's important to say that no association has been found in the 50+ year history of the use of HQ. To date, all concerns regarding HQ’s potential toxic effect are considered speculation.
Over-the-counter and prescription strength hydroquinone are not considered safe for pregnant and breast-feeding women.
Retin-A and Retinol, also called Retinoids
Topical retinoids are a form of vitamin A. Retinoids speed up cell turnover, which speeds up the removal of dark skin cells. They decrease the number of melanocytes, the cells that make pigment and cause skin darkening. They also increase penetration of other products. Retinoids work more slowly than HQ. You'll see improvement after about 6 months - or more.
The major side effect of retinoids is mild skin irritation (redness and flaking), especially when higher concentrations are used.
Retinol is an great alternative to Retinoic acid (the prescription form of vitamin A called Retin-A) because it is much less irritating.
A stabilized pure retinol at 0.5% will give faster results than a retinol complex. (A retinol complex is a blend of different strengths of retinol.)
If you use a retinol blended with calming and soothing ingredients, it will cause much less irritation.
Retinoids should always be used at night because the sun makes vitamin A inactive.
Oral retinoids are a bad idea for pregnant women or women attempting to become pregnant because they can cause birth defects. Experts advise against using topical retinoids while pregnant or breastfeeding also - just to be safe.
Combinations of Retinoids With HQ and Topical Steroids
Topical retinoids increase the effectiveness of other products, so retinoids are combined with HQ and topical steroids. Currently, the FDA has only approved a triple-combination cream known as Tri-Luma for melasma treatment. It contains 4% hydroquinone / 0.05% tretinoin / and 0.01% fluocinolone acetonide (a steroid that reduces skin inflammation and relieves itching). Strong steroids are ideal in this cream because a side effect of their use is reversible hypopigmentation (skin lightening).
Studies of the combination cream versus topical HQ alone found that the combination cream is faster and more effective. One 2010 study found that the triple-combination cream is safe and effective when used intermittently or continuously for up to 24 weeks.
Azelaic acid works similarly to HQ, but targets only the problematic melanocytes. It doesn't lighten normal colored skin, so there's no halo effect like with HQ.
Studies of patients with melasma have shown that topical 20% azelaic acid worked better than 2% hydroquinone and was as effective as 4% hydroquinone, without the undesirable side effects.
Studies have also shown that tretinoin (prescription strength Retin-A) increases the effect of azelaic acid. In fact, Azelaic acid with tretinoin caused more skin lightening after three months than azelaic acid alone, and a higher proportion of excellent responders at the end of treatment.
The biggest adverse effect from azelaic acid is skin irritation. No reactions have been reported from exposure to UV light.
*20% azelaic acid is only available by prescription.
Kojic acid is naturally found in soy and mushrooms. It decreases the number of melanosomes and dendrites. (Melanin / pigment is made in the melanosomes then sent to the top layer of skin cells (keratinocytes) via long arm-like structures called dendrites.) It is a potent antioxidant.
Dr. S. Larry Schlesinger, MD, FACS, says, "I have been treating Melasma for several years with a cream that I invented with a compounding pharmacy in Hawaii. Although we put hydroquinone as an ingredient in our cream, the key ingredient is Kojic acid. I believe Kojic acid is a much better specific treatment for Melasma as it does not give you the halo effect often seen with hydroquinone since it specifically targets the mask
Kojic acid has a high rate of contact sensitivity, both initially and with continued use. Use products with this ingredient exactly as directed - and watch for a developing skin allergy/sensitivity. Discontinue use if you notice a red rash, bumps, itching, pain, blisters or dry, red patches of skin.
In a study published by the American Dermatologic Society, women were treated on half of the face with a gel containing 2% kojic acid / 10% glycolic acid / 2% hydroquinone. The other half was treated with 10% glycolic acid / 2% hydroquinone. All patients showed improvement on both sides, but the side treated with kojic acid showed more improvement. Over half the melasma cleared in 60% of the patients receiving kojic acid compared to 47.5% for the gel without kojic acid. In 2 patients there was complete clearance of melasma with the kojic acid. Side effects were redness, stinging, and exfoliation on both sides of the face that faded by week 3.
Conclusion: Addition of kojic acid to a gel containing 10% glycolic acid / 2% hydroquinone improves melasma.
Ascorbic Acid (Vitamin C)
L-ascorbic acid (vitamin C) can be man made or found naturally in citrus fruits. L-Ascorbic acid is an antioxidant that prevents the formation of free-radicals and absorption of UV radiation. It prevents melanin from forming. Learn more by reading our post, Vitamins C and E for Skin.
Sixteen women with melasma used 5% ascorbic acid cream on one side of the face and 4% hydroquinone cream on the other side each night for 16 weeks. Sunscreen was applied daily. They were checked each month by colorimetry, photography, and color slides. Each patient's subjective evaluation was taken into account. The best subjective improvement was observed on the hydroquinone side with 93% good and excellent results, compared with 62.5% on the ascorbic acid side; however, colorimetric (an instrument that compares the colors of both sides of the face) measures showed no statistical differences. Side-effects were MUCH higher with hydroquinone at 68.7% vs. 6.2% with ascorbic acid / vitamin C.
Conclusion: Although hydroquinone showed a better subjective response, ascorbic acid/vitamin C should be used in melasma treatment because it has so few side-effects. It can be used alone or in combination with other products.
Niacinamide, Also Known as Vitamin B3 or Niacin
Studies have shown that niacinamide can be effective for melasma. Melanocytes, cells deep within the skin, create melanosomes which contain the pigment that gives skin color. When melanosomes are released, they move into the keratinocytes, the cells in the top layer of skin.
Researchers showed in a study by Hakozaki et al that niacinamide inhbits the transfer of the melanosomes to the surrounding keratinocytes by up to 68%. By stopping melanosome transfer, pigmented spots are reduced, skin is lightened, and a more even skin tone is created.
Tanno et al showed that niacinamide significantly decreased hyperpigmentation and increased skin lightness after 4 weeks.
A study comparing HQ to niacinamide treatment for melasma got good to excellent improvement with niacinamide in 44% of patients, compared to 55% with HQ. Lightening from niacinamide was seen in the 2nd month of use. Side effects were noted in 29% of the HQ patients and only 18% of the niacinamide patients. It could also be used for longer periods than HQ.
Conclusion: Niacinamide works well in a corrective moisturizer to decrease hyperpigmentation and increase skin lightness. It has the added benefit of clearing and tightening skin, while reducing wrinkles. It is an excellent ingredient for a daily skin care regimen - particularly in cases of dry and/or sensitive skin. To learn more, read our blog post about Niacinamide.
This antioxidant occurs naturally in fruits. It regulates melanin production and fades discoloration.
In a 2013 study published in the Journal of Drugs in Dermatology, a product with both ellagic acid and salicylic acid was as effective as a 4% hydroquinone product. More studies have confirmed these findings. A study by H. Shimogaki. et al in 2000, found that Ellagic Acid suppressed melanin production without injuring cells. A 2013 study published in the Journal of Cosmetic Dermatology compared a formulation of hydroxyphenoxy propionic acid / ellagic acid / yeast extract / salicylic acid applied twice daily with nightly application of prescription 4% hydroquinone / 0.025% tretinoin cream. People in the study had significant difficulty tolerating the HQ cream. Both products had comparable results in their ability to even skin tone, fade and shrink spot size, and improve overall pigmentation.
Another study done in Brazil tested the effectiveness of ellagic acid / hydroxyphenoxy propionic acid / yeast extract / salicylic acid on people with melasma. There was statistically significant improvement after 90 days of treatment. Subjects said they had improved quality of life at the end of the study with no adverse events. Click here to see a photo of one subject's improvement.
Tranexamic Acid (TA)
Tranexamic acid is a medication that prevents bleeding by blocking the breakdown of blood clots. Doctors use it to treat heavy menstrual bleeding in women. It's also used to stop bleeding during surgery and in accidental injuries.
Scientists don't know exactly how it works, but they think that TA used orally, topically, or by injection inhibits ultraviolet (UV)-induced plasmin activity in the keratinocytes of skin. (The keratinocytes form the top layer of your skin and they regulate how much melanin your skin makes. Melanin gives your skin its color.)
Most of the studies have been done in Asia. Several have shown TA is effective for melasma.
There was a randomized, double blind, placebo study of oral tranexamic acid (that's a really high quality study). 39 people with moderate - severe melasma used sunscreen and took 250 mg of TA or placebo capsules twice each day for 3 months. Then for another 3 months, they used only sunscreen. The results were measured using the modified Melasma Area and Severity Index (mMASI) score. The higher the score, the worse the melasma.
- 44 patients were enrolled and 39 completed the study.
- At 3 months, there was a 49% reduction in mMASI score in the TA group vs. 18% in the control group.
- Patients with severe melasma improved more than those with moderate melasma.
- 3 months after treatment with oral TA was stopped: the mMASI score in the TA group went down by 26% compared to before they started treatment. There was only a 19% reduction in the placebo group.
- No serious adverse events were noted in either group.
*Oral and injectable tranexamic acid are only available by prescription.
When used topically to lighten dark spots, tranexamic acid is most effective in concentrations of 2 - 5%. Increasing the duration of treatment is more effective than increasing the concentration of TA (which increases irritation). TA was applied to skin 1 - 2 times each day for an average of 8 - 12 weeks.
SkinCeuticals did a 12 week study on 50 women, aged 25 - 60. They were Fitzpatrick skin type I (very light skin, burns easily, often has red hair) to Fitzpatrick IV (olive skin, tans easily, dark brown hair). Each of the women had mild - moderate discoloration, including stubborn dark spots, acne marks, and uneven skin tone. Each woman applied Discoloration Defense to her face twice a day and used sunscreen.
- There was an 81% average improvement in the appearance of dark spots left by acne.
- There was a 60% average improvement in the appearance of stubborn brown patches.
- There was a 59% average improvement in the appearance of skin discoloration.
- Skin tone improved (became more uniformly colored) by an average of 59%.
- Results were seen as quickly as 2 weeks.
- There were no adverse effects.
Some procedures have been shown to help melasma.
If a topical medication does not help your melasma, a procedure might. Some treatments commonly used to treat melasma are chemical peels (such as glycolic acid), microdermabrasion, micro-needling and lasers.
Melasma treatment should only be done by a medical professional.
*Caution is essential because skin treatments can cause inflammation which in turn lead to more dark spots.
Micro-needling has grown exponentially in recent years. This treatment rejuvenates skin - without causing heat damage. Micro-needling is done with a pen or roller covered with tiny needles. The needles range in length and can penetrate the skin up to 2.5 mm.
Micro-needling stimulates collagen production by creating minor trauma to the skin with very few side effects. It's more cost-effective than comparable laser treatments. However, micro-needling will still trigger an inflammatory response - and more pigment formation - if too much trauma is induced. Using a shorter needle length limits the depth of penetration and decreases the risk of new pigment formation.
Learn more about this service on our Medical Micro-Needling page.
Washington DC-based dermatologist Cheryl Burgess, MD, is a big proponent of micro-needling and has seen positive results with darker skin types. “In my experience, there is minimal postinflammatory hyperpigmentation."
Remember, all treatments will have limitations, including micro-needling. Micro-needling does increase the overall health of the skin, including reduction in UV damage, reduction of permanent diffused redness, reduction of pore size, prevention and reversal of wrinkles, etc. It accomplishes these by allowing greater absorption of required cell nutrients and release of growth factors to regulate and optimize skin cell function. Micro-needling is the safest and most affordable treatment for melasma.
To learn more about medical micro-needling for melasma, read our blog posts, What is micro-needling? and Why is a micro-needling pen better than other methods of skin rejuvenation?
Chemical peels can improve epidermal melasma, but choosing the best peel formulation and treatment protocol requires the utmost care. This is because the people who get melasma are usually more sensitive to UV rays and harsh chemicals - which can trigger hyperpigmentation. To learn more, read our blog post, 3 Types of Chemical Peels to Make Your Skin Radiant.
Lasers should be a last resort because the heat that they generate can cause inflammation making melasma worse, especially in people with dark skin.
Using the right skincare products daily is critical to getting a good outcome.
Following are some of the SkinCeuticals products that work well on dark spots and hyperpigmentation.
I recommend the SkinCeuticals cosmeceutical line because all of their products go through rigorous clinical testing, so you know they work.
- PHLORETIN CF - This serum combines 2% phloretin, 10% L-ascorbic acid, and 0.5% ferulic acid. Together, these ingredients provide advanced environmental protection to defend skin against the reactive molecules (including free radicals) known to cause cell damage. Phloretin CF has superior antioxidant capabilities and has been proven to correct existing damage from the inside out.
- Provides advanced environmental protection against UVA and UVB radiation
- Improves the appearance of fine lines and wrinkles
- Phloretin fades dark spots. Vitamin C speeds up cellular turnover to retexture skin.
- Helps prevent cell mutation such as thymine dimers by shielding skin’s DNA
- Once absorbed, this serum can’t be washed or rubbed off. It remains effective for a minimum of 72 hours, making it an excellent addition to sunscreen.
- ADVANCED PIGMENT CORRECTOR - A highly effective formula that works in 4 ways. 0.3% Salicylic acid exfoliates existing dark spots and enhances the penetration of other key ingredients. 1% Hydroxyphenoxy propionic acid inhibits melanin production, to prevent new hyperpigmentation. 0.5% Ellagic acid reduces dark spots and discoloration. This product won an Allure Best of Beauty Award in 2015.
- Fades stubborn discoloration
- Enhances resistance to new pigment
- Ideal for all skin types
- Paraben-free and non-comedogenic
- BRIGHTENING UV DEFENSE SPF 30 - A broad spectrum mineral based sunscreen. It reduces excess pigmentation to prevent the occurrence of future brown spots while helping to fade existing discoloration.
- ADVANCED PIGMENT CORRECTOR
- RETINOL 0.5 - SkinCeuticals retinol products help stimulate cell regeneration and build collagen. They diminish the appearance of fine lines, wrinkles, and age spots from both sun damage and genetic aging. Retinol 0.5 contains 0.5% pure retinol.
- Helps reduce appearance of fine lines, wrinkles, age spots, uneven skin tone
- preserves optimal retinol stability and minimizes irritation commonly associated with the use of retinol
- Ensures maximum amount of retinol reaches the target site
Additionally, you might try:
PHYTO + is a hydrating botanical serum made to fade discoloration. It combines 4 ingredients to diminish discoloration and improve the overall health of the skin. These ingredients are delivered to skin via a hyaluronic acid base that calms and improves the appearance of the skin.
- Contains kojic acid to fight dark spots and arbutin glycoside to brighten skin. Both help reduce discoloration
- Contains cucumber and thyme to soothe and calm skin
- Ideal for all skin types
Metacell Renewal B3 includes 5% niacinamide combined with 2.5% tightening tri-peptide concentrate and 15% glycerin. It is a daily, corrective moisturizer that reduces the appearance of sun damage. Metacell clears skin, reduces wrinkles, tightens surface elasticity, and evens skin tone.
- Renews skin by increasing cell turnover
- Reduces the appearance of discoloration and the look of redness
- Hydrates without a tacky feel
Discoloration Defense from SkinCeuticals was made to correct stubborn pigmentation. It's clinically proven to treat post-inflammatory hyperpigmentation (like dark spots from acne) by 80% in 12 weeks. In a SkinCeuticals study, this product improved melasma by 60% in 12 weeks. People start to see results at 2 weeks.
- 3% topical tranexamic acid (stops inflammation, the 1st step of dark spot and stubborn brown patch formation)
- 1% kojic Acid (stops the melanin / dark spot production)
- 5% niacinamide (keeps melanin from moving to the top layers of your skin where it can be seen as dark spots)
- 5% HEPES (exfoliates and speeds cell turnover). Each of these ingredients targets a different step in dark spot formation.
You might like our downloadable list of Melasma Skincare Products to Try - No Doctor Needed! + when to apply them! It's available in our free resource library.
Melasma is a difficult condition and may take months of treatment to see improvement. However, as difficult as melasma is to treat, many people get a good outcome.
Another option is camouflage.
Skin conditions, particularly those that are noticeable, can have a profound effect on everyday life. People with visible skin conditions have higher rates of depression and anxiety - combined with low self-esteem. For these people, makeup is a great way to disguise dark spots. An airbrush cosmetic cover up is great for special occasions. It offers rapid and dramatic results. And there is a makeup specially made to cover skin imperfections. It's called Dermablend, by Loreal and is made for daily use.
Melasma can last for decades. Although it is frustrating for both patients and the medical professionals working to treat it, melasma treatment can be successful. People prone to hyperpigmentation and melasma will always be susceptible to recurrence - so it's important to use products that suppress melanin formation every day. Year-round care with a combination of pigment-inhibiting ingredients, broad-spectrum sunscreen and regular, professionally applied, gentle treatments can make a huge difference.
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You might find these related posts helpful:
Setterfield, L. (2013). The Concise Guide to Dermal Needling: Expanded Medical Edition. Canada: Acacia Dermacare.
The Information provided on our website is not medical advice and should not be viewed as such. By law, only a medical doctor can diagnose or give medical advice. As a registered nurse, my goal is to educate, so I provide information on skin care, skin care products, and skin care treatments. If you have any condition that concerns you, please see a medical doctor. While most skin conditions are benign, some - like melanoma - can be deadly. If there is any doubt, please, please consult your physician. Thank you!
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