NEW ORLEANS - Treatment for melasma can be effective, although the search continues for the ideal clinical strategy that yields optimal outcomes with minimal adverse effects, according to Dr. Amit G. Pandya.
The first challenge is to get patients into treatment. "There is a huge number of people out there with melasma who we are not seeing. A lot are being treated with over-the-counter products or are not being treated [at all]," he said at the annual meeting of the American Academy of Dermatology.
Melasma is a common condition. For example, Dr. Pandya and his colleagues found in a telephone survey that 8.8% of Latino women in the Dallas and Fort Worth, Texas, areas reported melasma (Arch. Dermatol. 2007;143:424-5).
"If I had a buck for each case of melasma, I could retire already," said session moderator Dr. Harvey Lui, professor and chair of dermatology and skin science at the University of British Columbia, Vancouver. "I just don’t know what to do with these patients."
Much of the treatment and management of melasma rely on physicians' clinical expertise. "The evidence we have out there is not huge," Dr. Pandya said. He is professor of dermatology at the University of Texas Southwestern Medical Center at Dallas.
The differential diagnosis includes ruling out postinflammatory hyperpigmentation and drug-induced photosensitivity. Also, "with the growing obesity epidemic, we also see more acanthosis nigricans on the face," Dr. Pandya said.
Treatment of melasma is important – whether it be with a hydroquinone preparation, a chemical peel, or microdermabrasion – because it improves quality of life for patients living with melasma, Dr. Pandya said. Multiple studies have demonstrated that melasma can have a significant negative effect on a person's social life, recreation and leisure activities, and emotional well-being (Brit. J. Dermatol. 2003;149:572-7; J. Am. Acad. Dermatol. 2006;55:59-66).
Dioic acid is a new treatment showing promise in the treatment of melasma, Dr. Pandya said. He cited results of a study of 96 Mexican females treated with 1% dioic acid cream twice daily vs. 2% hydroquinone cream twice daily (Int. J. Dermatol. 2009:48:893-5). After 12 weeks, both treatments were associated with significant decreases in Melasma Area Severity Index (MASI) scores. There were no significant differences in efficacy. and adverse events were similar, except for more pruritus associated with hydroquinone treatment. "This may be an agent we can use in the future," Dr. Pandya said.
Oral antioxidants for melasma also showed promise in a randomized, double-blind, placebo-controlled trial (Int. J. Dermatol. 2009;48:896-901). Researchers assessed a combination of oral procyanidin (a component of pine bark) plus vitamins A, C, and E in 60 women with bilateral epidermal melasma. Study participants took either the oral treatment or a placebo twice daily with meals for 8 weeks. Clinicians observed significant reductions, compared with baseline in pigmentation and significant improvements in MASI scores in the malar regions of faces treated with the antioxidants vs. placebo. The investigators said the combination was well tolerated with minimal side effects.
"This may be something else we can use in the future," Dr. Pandya said.
The tyrosine inhibitor hydroquinone remains a mainstay of melasma treatment, Dr. Pandya said. "Hydroquinone remains the most effective depigmentation agent." There are nine marketed products that contain hydroquinone 4%. Although higher concentrations might be more effective, skin irritation and tolerance become an important consideration.
Monitor patients for development of exogenous ochronosis, a rare but important adverse effect, Dr. Pandya advised. Also, some patients can develop telangiectasias after prolonged use.
Hydroquinone 4% is often found in combination products designed to balance efficacy and tolerability. For example, Tri-Luma Cream (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%, Galderma) is a triple combination product that was "shown to be better than any two components in the largest study done so far in melasma," Dr. Pandya said (Cutis 2003;72:67-72). Researchers in this study found a 75% reduction in melasma at 8 weeks in more than 70% of patients, compared with 30% of participants treated with a dual-ingredient product.
A majority "seem to do well, but the problem is irritation, especially in skin of color," Dr. Pandya said. "I usually start patients on this product every other day and then try to increase it, but in some cases, I cannot because of irritation." He emphasized the importance of monitoring patients closely to ensure they do not develop erythema or postinflammatory hypopigmentation.
Evidence on the efficacy of chemical peels in treating melasma is mixed, Dr. Pandya said. In one study of 40 women in India, glycolic acid and a modified Kligman's formula peel showed "some improvement, but it took six glycolic acid peels," Dr. Pandya said (Derm. Surg. 2002;28:828-32).