There’s strong evidence supporting the use of hydroquinone as a first-line treatment for melasma.
The science suggests tranexamic acid is a very promising melasma treatment.
The low-fluence Q-switched laser remains one of the best laser and light options for treating melasma, especially in darker types.
And overall studies suggest that chemical peels do not have better melasma treatment outcomes than topical therapy.
That’s according to a literature review on clinical trial evidence for melasma treatments, published October 11, 2019, in the Journal of Cosmetic Dermatology.
Author Natalia M. K. Spierings, B.Sc., M.B.B.S., M.R.C.P.(UK), M.R.C.P (Derm), M.B.A., M.Sc., a consultant dermatologist at Queen Mary University of London, UK, conducted a literature search in July 2019, looking for English-language studies published on melasma treatments in the last decade. She found four clinical trials focused on topical hydroquinone as a first-line option; 12 papers on tranexamic acid use; 19 looking at various novel melasma therapies; 42 investigating laser and light treatments; and 11 analyzing outcomes of peels for melasma.
Based on her findings, Dr. Spierings suggests a melasma treatment ladder starting with topical hydroquinone and retinoid-based products as first line for the first three months, at least. If there are no contraindications she recommends also adding oral tranexamic acid 250 mg daily to the first-line treatment. Her second-line melasma treatment recommendation is to use lasers, including low-fluence Q-switched Nd:YAG, picosecond laser and pulsed dye lasers for lighter skin types. Dermatologists and other providers might consider peels as a third-line therapy, with glycolic acid or trichloroacetic acid (TCA) peels showing the greatest efficacy in outcomes for melasma, according to the paper.
A Closer Look
Topical treatments rank high among commonly used melasma therapies. These include photoprotection, since UV light and visible light can worsen pigmentation in all skin types. Dr. Spierings notes that physical, not chemical sunscreens, are recommended for melasma since titanium dioxide and zinc oxide protect against not only UV light but also visible light damage.
Hydroquinone works by inhibiting the tyrosinase enzyme in melanin’s production. Researchers have also found triple combination creams effectively treat melasma. The most recent such FDA-approved cream being Tri-Luma (Galderma), which is hydroquinone 4%, tretinoin 0.05% and 0.1% fluocinolone acetonide.
The author adds the FDA approved nonablative fractional 1550/1540 nm laser for melasma treatment in 2005, and in 2012 approved Lutronic’s Spectra laser, a Q-switched laser for melasma.
Spierings, NMK. Melasma: A critical analysis of clinical trials investigating treatment modalities published in the past 10 years. J Cosmet Dermatol. 2019;00:1– 6.