Like eczema, psoriasis or diabetes, pigmentary skin conditions are chronic conditions that can be controlled, but not cured. In this article, Dr. Seemal R. Desai discusses new treatment strategies for melasma and hyperpigmentation.
Seemal R. Desai, M.D.,FAAD
Like eczema, psoriasis or diabetes, pigmentary skin conditions are chronic conditions that can be controlled, but not cured, said Seemal R. Desai, M.D., FAAD, during a talk at the Skin of Color Seminar Series held last month in New York City.
Dr. Desai, a dermatologist with Innovative Dermatology in Plano, Texas, who has a clinical interest in pigmentation, summarized the latest and most innovative treatments for melasma and hyperpigmentation. Dermatology Times spoke with Dr. Desai about new treatment strategies and how they can best be used.
Q: What is the gold standard treatment for melasma and hyperpigmentation?
A: Triple combination topical therapy is still first line where you have hydroquinone as a first-line agent. I would stress it’s best to use that in a triple combo form either with a topical steroid or a retinoid on board. That’s the main thing. It’s still the gold standard, but there are other things we can do. Most of what we do in pigmentation is off label, but then, most of what we do in dermatology is off label.
Q: Are there new treatments for melasma and hyperpigmentation?
A: One of the newer things is the use of second-line topical lightening agents like azelaic acid. I like using 15-20% azelaic acid during the off-hydroquinone period. I really like to do a rotational treatment. You have the patient start off with a topical hydroquinone based lightening regimen for about 8-10 weeks, and, then, you move on to second-line topical agents like azelaic acid or kojic acid, in addition to chemical peel treatments.
That leads me to the newest kid on the block - tranexamic acid. The exciting thing about this is that it’s the new, hot thing in melasma and in hyperpigmentation. It can be given orally, and it can be given between 250 mg to 500 mg twice a day. In the United States, there’s only one dose available, and it’s a 650 mg tablet, so I have patients split it in half and take one in the morning and one at night. That is off-label and not Food and Drug Administration-approved, so that’s important to let people know. Usually, with that, I do at least 8-12 weeks of treatment in order to see a result. It can’t be given to people who have a history of deep vein thrombosis, blood clots, people who are pregnant or nursing, or anyone who’s on birth control. But, otherwise, it’s a great additional option. I’m not advocating for that being first-line. I’m advocating for that being one later down the road.
The other exciting is tranexamic acid is also coming in a topical form. You should be able to get some cosmeceutical products with topical tranexamic acid, which is really exciting. That’s something that’s going to be very helpful in treating hyperpigmentation and melasma.
It’s also important to mention that we’re now seeing glutathione as the big thing. We want to educate our patients that glutathione for skin lightening or brightening has no scientific data. People are getting IV infusions of glutathione, and I would caution people from using it.
We’re also seeing lots of patient come in now who are on anti-hypertensive medicines or other drugs that are getting pigmentation issues. So, taking a B12 medication is very important, as well.
Q: Are there certain patients for whom these therapies work best?
A: I think with melasma, tranexamic acid is something you can use in any melasma patient as long as they don’t have any of those contraindications mentioned earlier. Just remember, these things aren’t something you use first line. I still like to use the hydroquinone-based lightening products initially - the triple combination to get things calmed down first. Once that has either succeeded or, if failed, you have other tricks up your sleeve.
Q: What experience have you had in your practice that demonstrates treatment difficulties?
A: I see a lot of skin of color patients, and I think the important thing to remember is that the longer a patient has hyperpigmentation or melasma, it matters. The person who’s had it for 10 years is more likely to have a treatment success than one who’s had it for 20 years.
I’ve also seen the impact of culture. Remember that in some cultures, an emphasis on lighter skin means more beautiful, more social stature, more possibility of getting married, getting better jobs, being treated better within their community.
Q: Are there limitations to treatment strategies?
A: First and foremost, access and cost are always an issue with any medication or dermatologic procedure. The other thing is compliance. The challenge is convincing people that this is not a one-time thing, and it’s not going to go away overnight. Convincing patients that they need to follow a strict regimen can be difficult. They may need hydroquinone over a long period of time or they may need to use cosmeceuticals with vitamin C or other antioxidants. And, of course, they will need UV protection.
Q: Are there stumbling blocks providers should recognize?
A: The main one is making a diagnosis correctly. I think people who aren’t familiar with hyperpigmentation may automatically look at every facial hypermelanosis condition as melasma. But, that’s actually not true. There are other common things that cause hyperpigmentation in the face, such as acanthosis nigricans, lichen planus pigmentosus, and drug-induced hyperpigmention. And, I think, if you’re not familiar with the nuances of all of those, it’s very easy to fall into the trap of thinking, “Well, that’s just melasma.” But, it’s not just melasma. If you don’t have the right diagnosis, then the treatment isn’t going to work either.
Q: What do you tell patients about how long treatment will take to show an impact?
A: With melasma, it’s going to take at least 6-8 weeks to even start to notice any improvement if you’re using triple combination treatment. If you see improvement before that, you’re really lucky, and be happy. But, that takes a little bit of time. I think 6-8 weeks is a good marker to get some improvement. Usually, I tell people, if you’re about 25-30% better at week eight, you’re doing good. I equate it to acne. With acne we say you might see some improvement in one month, but it can take up to 12 weeks for those topicals to kick in. It’s the similar kind of treatment, so if I equate it to acne, people can understand it a little bit more because they’re used to treating their acne.
Q: What are your key takeaway messages?
A: Counsel your patients on the importance of the life-long management of pigmentary diseases. It’s not something that goes away overnight. It’s not something that’s curable. It’s important when you have this discussion to set the stage up front.
And, remember that hydroquinone is still our gold standard. You want to use that in a triple combination form for a certain period of time before switching to a different type of treatment, such as azelaic acid, as a second-line treatment. You don’t want to use the hydroquinone long-term. You want to be able to give the skin a bit of a break. You can also think about tranexamic acid and chemical peels and all that good stuff.
One thing people need to understand about hydroquinone - they may not know that there are lots of things that can be done once you take the patient off the hydroquinone, such as azelaic acid, kojic acid, or cosmeceuticals, the tranexamic, the chemical peels. I think that’s an important message, as well.
Lastly, it’s critical to educate patients that they need to seek care early. The longer these diseases are present on the skin, the longer they delay treatment, the harder they are to help lighten and brighten.