Consider combinations for melasma treatment success

San Francisco - While melasma remains a disease without a cure, today's therapies are becoming increasingly refined by the ability to properly diagnose and match the most successful treatments to each patient's skin and melasma types.

Defined as an acquired hypermelanosis of the face, neck and forearms, melasma affects five to six million women annually in the United States, alone and occurs during as many as 50 percent of pregnancies, primarily affecting women of Asian, Indian, Latin and African descent. Dr. Baugh reported on the topic at the 64th Annual Meeting of the American Academy of Dermatology here. While melasma is considered a cosmetic concern by most patients and a difficult treatment problem by most dermatologists, Dr. Baugh points out that in some Asian cultures it is considered "bad luck," which adds an additional psychosocial burden for some sufferers.

"You can't just give a patient some topical bleaching cream and expect them to be cured," says Dr. Baugh, who is an assistant clinical professor at the University of California Irvine School of Medicine. "Today we have diagnostic tools such as high definition digital photography used in conjunction with a Wood's lamp to establish baseline features of melasma, and track treatment progress. We can also use other instruments, such as colorimetry and reflectance spectrophotometers, to establish objective pre- and post-treatment characteristics of melasma," he says. The melasma area severity index (MASI) score, he adds, may also be used to track a patient's progress.

Once the patient's baseline features are established, the patient is instructed to minimize the effect of exacerbating factors such as sun exposure, heat exposure and use of exogenous hormones, Dr. Baugh tells Dermatology Times.

"This approach will help the patient to achieve better results and prevent recurrence," he says. In conjunction with this, a customized therapeutic regimen is established for each patient. "This typically involves application of a topical 'bleaching' cream once to twice daily. More advanced regimens may be introduced utilizing 'brightening' cleansers and specific antioxidant creams along with the standard bleaching creams. The addition of some antioxidants such as green tea polyphenols will not only complement the use of most bleaching creams by innately working against pigmentation, but also ameliorate many of the standard bleaching creams' side effects, such as dryness or irritation," he adds.

Topical antioxidant creams that are often used contain a single agent or a combination of vitamin C, green tea and vitamin E. In addition to topical medications, some forms of oral antioxidants such as grape seed extract, beta carotenes and polypodium leucotomos show potential benefit in the fight against melasma.

Therapeutic combinations

Hydroquinone-based products remain the gold standard of topical medications used to treat melasma. Tri-Luma (Galderma), which contains 4 percent hydroquinone, tretinoin cream 0.05 percent, and fluocinolone acetonide 0.01 percent is one of the most effective combination products available by prescription, Dr. Baugh points out.

"Many combination products have been developed, which in addition to hydroquinone contain sunscreen, such as Claripel (Stiefel), Glyquin XM (Valeant), Lustra AF (Medicis) and Solaquin Forte (Stiefel)," Dr. Baugh says. "Other medications may contain hydroquinone plus retinol, such as Alustra (Medicis) and Epiquin Micro (SkinMedica). Still others combine hydroquinone plus glycolic acid, such as Glyquin, Glyquin XM, Lustra and Lustra AF," he adds.