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Managing melasma is both an art and a science, according to Chee Leok Goh, M.D. at the 73rd annual American Academy of Dermatology meeting, because it requires finesse both clinically and in counseling patients. Learn more
Chee Leok Goh, M.D.Managing melasma is both an art and a science, according to Chee Leok Goh, M.D. at the 73rd annual American Academy of Dermatology meeting, because it requires finesse both clinically and in counseling patients. For starters, he says, "Melasma is diagnosed clinically. There is no laboratory test to confirm the diagnosis." Dr. Goh is a senior consultant dermatologist at the National Skin Center, Singapore, and clinical professor of dermatology at the National University of Singapore.
Perhaps more importantly, "There is no cure for melasma. Usually, it does not respond consistently to any light or laser treatment and may develop postinflammatory hyperpigmentation (PIH) following light or laser treatment. It is best treated with topical creams as a first-line treatment."
Because melasma affects women's cosmetic appearance, says Dr. Goh, it can have severe impact on women's quality of life. Due to melasma's often recalcitrant nature, "The dermatologist cannot just try the various treatment modalities and expect the patient to be satisfied. The dermatologist must assess how the disease is affecting the patient, and counsel the patient on ways to improve the melasma and prevent its recurrence. Hence it is an art to help patients accept and manage the disease." Above all, he says, melasma management requires sun avoidance and use of sunscreens for prevention.
Tranexamic acid (TA) is a synthetic analog of the amino acid lysine that competitively inhibits the transformation of plasminogen to plasmin, a molecule that degrades fibrin. As such, he says, it has long been used as an anti-fibrinolytic agent for patients with menorrhagia and in open-heart surgery. Its use in melasma was reported in 1979 when it was noticed that patients treated with TA for chronic urticaria noticed improvement of their melasma.1
More recently, investigators reported that oral TA controls melasma by preventing plasminogen from binding to keratinocytes, which reduces melanocyte tyrosinase activity.2 This leads to reduction in prostaglandins and arachidonic acid, which are inflammatory mediators involved in melanogenesis.
A standardized regimen for melasma includes 250 mg TA BID (taken orally) for 3 to 6 months in patients who have failed topical therapy, says Dr. Goh. In a study that used this regimen for 6 months, the proportions of patients who achieved reductions of more than 90%, 60% to 90%, and less than 30%, were 10.5%, 18.8% and 51.6%, respectively.3 Based on this study and others, says Dr. Goh, the treatment is contraindicated in elderly patients and those with allergies, ischemic heart disease or thrombotic disorders. Side effects are rare, he adds, although gastrointestinal upset can occur in a small proportion of patients.
A 25-patient retrospective study conducted in Singapore examined a regimen including 250 mg BID for an average of 3.7 months, combined with combination creams, lasers and/or intense pulsed light (IPL). After 3 months' treatment, mean melasma area and severity index (MASI) scores fell from 8.8 to 2.7.4 Investigators observed no side effects. However, after treatment concluded, 72% of patients relapsed.
TA treatment for melasma is used "off-label," says Dr. Goh. Ultimately, he added, duration of TA therapy matters more than dose. "We do not know the long-term side effects of the drug." Therefore, he says, most dermatologists hesitate to prescribe TA beyond 6 months.
"Longer than that, we don't know the implications. We know that 250 mg twice daily is adequate for most patients. Most patients will see substantial improvements after about 3 months' treatment, and most will see relapse about 2 to 3 months after stopping TA."
Traditional treatments with pigment lasers including the 532 nm, the 1064 nm Q-switched Nd:YAG and other Q-switched (QS) lasers have been disappointing in melasma, says Dr. Goh. Problems include lack of efficacy and PIH.
However, he notes that a handful of studies suggest that low fluence, large spot-size regimens using multiple 1,064 nm QS Nd:YAG treatment sessions are effective for melasma in Asian patients. Typical settings for these treatments include fluences of 1.5 J/cm2 (8 mm spot size) or 2.5 J/cm2 (6 mm spot size), says Dr. Goh. In a retrospective study involving 25 Korean women, 44% experienced marked clinical improvement; 7 of these (28%) had near-total clinical improvement; 5 improved moderately, and 2 had minimal to no improvement.5
"Laser toning is safe only if used conservatively; e.g., less than 1 treatment every fortnight," says Dr. Goh, adding that clinicians must stop treatment at the first sign of side effects. Most patients will improve, he says, but some will develop side effects including guttate hypopigmentation and rebound hyperpigmentation. Relapse will occur once treatment stops.
"Hence, laser toning is never used as first-line treatment. It is used only after other treatments have failed, and the patient is desperate to get better. However, the dermatologist must be conservative in dosing and frequency of treatment. Patients should be counseled on the pros and cons of the treatment outcome, including the complications, and then make an informed consent if they want to proceed."
Disclosures: Dr. Goh has received a travel grant and honoraria from Galderma Singapore. He has also received honoraria from Syneron Candela, and is a member of the company's Asian medical advisory board.
1. Sadako N. Treatment of melasma with tranexamic acid. The Clin Rep. 1979;13:3129-31. (Japanese).
2. Tse TW, Hui E. Tranexamic acid: an important adjuvant in the treatment of melasma. J Cosmet Dermatol. 2013;12(1):57-66.
3. Na JI, Choi SY, Yang SH, Choi HR, Kang HY, Park KC. Effect of tranexamic acid on melasma: a clinical trial with histological evaluation. J Eur Acad Dermatol Venereol. 2013;27(8):1035-9.
4. Tan A, Sen P, Chua SH, Goh BK. Oral tranexamic acid lightens refractory melasma. PSC Dermatology Bulletin. 2013;24(1):36-40.
5. Cho SB, Kim JS, Kim MJ. Melasma treatment in Korean women using a 1064-nm Q-switched Nd:YAG laser with low pulse energy. Clin Exp Dermatol. 2009;34(8):e847-50.