Two of the most vexing skin conditions that we manage as dermatologists are melasma and vitiligo. In one condition, too much pigmentation is present because of genetic, hormonal and environmental factors. In the other, there is a lack of melanin in the skin, presumably on an autoimmune basis. Seemal Desai, M.D., board-certified dermatologist, clinical assistant professor in the department of dermatology at University of Texas, Southwestern Medical Center in Dallas, and medical director of Innovative Dermatology, discusses treatment options for these two conditions with Dermatology Times editorial advisor, Norman Levine, M.D.
Dr. Norman Levine: I would like to talk about two specific problems with regard to dyspigmentation. The first one I would like to start with is melasma. What are our current treatment options and how well do they work?
Dr. Desai: I will preface my overview of melasma by saying that the majority of patients who I see for melasma end up on multiple combination therapies; I rarely have a melasma patient on monotherapy. I think that’s one of the things that becomes challenging for most dermatologists; they are not really used to doing combination therapies for melasma.
First-line treatments are topical, especially topical lightening agents and the prototypical one is hydroquinone. Not to be missed is the incorporation and use of topical retinoids, specifically tretinoin, adapalene, and tazarotene, along with low-potency and high-potency topical steroids.
In some circumstances, I have also used high potency topical steroids for very short duration on the face, without consequence; for example, class 1 topical steroids. The main issue here is that you have to discuss the risks and benefits with the patient, as well as administer the medication in a short pulse duration fashion. Again, this is not for every patient, but it can be useful in patients who do have an inflammatory component, mixed pathology, and/or you want some additional epidermal thinning to then help with cell turnover.