Treatments that Work for Melasma Depend on Continuous Multiple Combination Therapies
Most women think of melasma as a temporary condition that appears during pregnancy—or they shrug it off as nothing but age-related brown spots that will disappear with enough whitening cream. But that perspective doesn’t sync with the views expressed by dermatologists, who use words like “vexing,” “recalcitrant,” and “frustrating” to describe melasma. What most women don’t know about the condition is that it’s chronic, frequently recurs, and isn’t easily treated. These patients might not realize it, but they need the health information and treatment guidance that pharmacists can provide.
What Patients Don’t Know about Melasma
One good piece of news about melasma is this: it doesn’t increase your odds of developing melanoma. In fact, women with melasma may have a lower risk of developing skin malignancies.1 On the down side, its resistance to treatment is discouraging and affects patients’ quality of life. The following statistics show the extent of the problem and the patient profile to target for outreach efforts:
- Melasma affects over 5 million people yearly, with prevalence ranging from roughly 9 percent among Latino women in the Southern United States to 40 percent in Asian women.
- People of all races develop melasma, but it’s more common in those with light brown skin.
- Women represent 90 percent of all melasma cases.
Melasma is an acquired hypermelanosis that occurs in areas of the skin exposed to sunlight. It can develop in any sun-exposed area, but it usually appears as symmetrically distributed hyperpigmented macules on the patient’s face. It’s caused by several factors:
- Ultraviolet radiation – Exposure to sunlight is the most significant factor leading to melasma. UV light increases the production of the hormones and cytokines that trigger melanin production. Sunlight also stimulates fibroblasts in the dermal layer that boost melanogenesis.
- Hormones – The role of hormones in melasma is still uncertain, but there’s clearly a relationship: the condition is more common in women and frequently appears during pregnancy (about half of all cases first appear when women are pregnant). Additionally, the keratinocytes in skin affected by melasma have more estrogen receptors than normal skin.
- Genetics – Melasma tends to run in families.2
- Other factors – Mild ovarian or thyroid dysfunction, photosensitizing medications, and some cosmetics may contribute to melasma.
Triple-Combination Therapy and Other Treatments
When it comes to treating melasma, patients must be prepared to make regular visits to the doctor and persist through multiple treatment trials. They’ll have to carefully consider the pros and cons of therapies that could worsen their condition. Patients with melasma must diligently avoid the sun if they want any treatment to succeed—recurrence is virtually guaranteed in those who continue to expose their skin to sunlight. Beyond sun protection, mainstay treatment consists of topical pharmaceuticals. Here’s a rundown of prevention and treatment options:
- Prophylactic management by avoiding sunlight – Patients should regularly apply sunscreen with an SPF of 50 or higher.
- Oral contraceptives – Patients who develop melasma after starting oral contraceptives should stop taking them, and women with a family history of melasma should consider other forms of birth control.
- Triple-combination therapy – This first-line treatment is a topical agent that combines hydroquinone with a steroid and a retinoid such as fluocinolone. In addition to being active ingredients, retinoids increase the permeability of the epidermis so that all the agents are better absorbed into the skin. Compounded formulas that provide the best concentration of active ingredients are preferred.3
- Hydroquinone – Topical hydroquinone inhibits melanin synthesis and interferes with melanocyte viability. It’s often used alone in a cream delivery base. Patients may see results with OTC-strength products but usually need a prescription-strength medication. Any concentration runs the risk of causing skin irritation, phototoxic reactions with secondary post-inflammatory hyperpigmentation, and irreversible exogenous ochronosis.
- Retinoids – Topical retinoids decrease melanocyte activity. The major adverse effect is mild skin irritation, but retinoids are known teratogens, so they shouldn’t be used in women who are pregnant or trying to become pregnant. Studies indicate that adapalene 0.1 percent and tretinoin 0.05 percent produce similar results, but adapalene causes fewer side effects.
- Azelaic acid – A 20 percent cream-based formulation of azelaic acid is an effective alternative to 4 percent hydroquinone and may be better than 2 percent hydroquinone. Azelaic acid targets skin with hyperactive melanocytes, which means it doesn’t lighten skin with normally functioning cells. It may cause mild skin irritation.
- Chemical peels and laser treatments – These therapies may help after other treatments have been tried. Laser toning is never a first-line treatment, and it has a high risk of side effects that include rebound hyperpigmentation. Relapse occurs after treatment stops.4 About a third of patients see their condition worsen from laser therapy, and another third won’t see any results.
Tips for Pharmacist Counseling
When melasma first appears, patients are likely to self-treat with OTC products or do nothing at all because they expect the condition to resolve. At this stage, they need basic information about melasma and a reminder to use sunscreen daily. They should also be strongly encouraged to consult their physician. You’ll improve patient prognosis by keeping these points in mind:
- Early treatment – Patients who get early and aggressive treatment can prevent the hyperpigmentation from going deeper into the dermis, which makes treatment more difficult.5
- Medication review – Most melasma patients get better results from multiple combination therapies, which requires long-term adherence to a variety of medications. Use regular medication reviews to check on the patient’s progress, ask whether they’ve had any adverse effects, and reiterate care basics like using sunscreen. If they’re not using a triple-combination therapy, recommend a compounded option.
- Long-term encouragement: Symptoms may come and go, but patients can have melasma for 10 to 12 years.6 For this reason, dermatologists treat it as a chronic condition, continuing therapy even after lesions resolve. Doctors may use the same treatment but have the patient apply it less frequently, or they may switch to a less potent combination of kojic acid, arbutin, azelaic acid or 2 percent hydroquinone. Pharmacists should continue to encourage patients to stick with their therapy or recommend they talk with their doctors about interim treatment between flare-ups.
Outreach Protocol Helps Ensure Optimal Results
Treating melasma is partly an art because doctors must assess how the disease affects the patient’s psyche and spend time counseling the patient about how to manage an incurable disease, said Chee Leok Goh, M.D. at the 73rd annual meeting of the American Academy of Dermatology. Pharmacists who develop an outreach protocol—such as medication review combined with a plan to connect with patients buying OTC whitening creams—can help patients get early treatment, maintain a positive outlook, and achieve optimal results.
Pharmaceutica North American provides prescription steroids and NSAIDs, high-quality bulk active pharmaceutical ingredients, and emollient delivery bases for compounded topical treatments. Contact us today to talk about how we can support your pharmaceutical needs.
- “Melasma,” July 2016, http://emedicine.medscape.com/article/1068640-overview ↩
- “Melasma Unmasked,” accessed August 2016, http://www.dermalinstitute.com/ca/library/118_article_Melasma_Unmasked.html ↩
- “Melasma Combination Therapy Digs Deep,” May 2014, http://dermatologytimes.modernmedicine.com/dermatology-times/content/tags/cosmetic-dermatology/melasma-combination-therapy-digs-deep ↩
- “Managing Melasma is an Art and a Science, October 2015, http://dermatologytimes.modernmedicine.com/dermatology-times/news/managing-melasma-art-and-science ↩
- “Expert Insights in Managing Melasma and Vitiligo,” March 2015, http://dermatologytimes.modernmedicine.com/dermatology-times/news/expert-insights-managing-melasma-and-vitiligo?page=0,0 ↩
- “Melasma May Require Aggressive Combination Therapy,” August 2014, http://dermatologytimes.modernmedicine.com/dermatology-times/news/melasma-may-require-aggressive-combination-therapy?page=0,0 ↩