The first-line treatment for mild melasma is hydroquinone 4% cream. Two to four months and up to six months of treatment with hydroquinone might be followed by maintenance treatment for as long as necessary. Hydroquinone and ‘Maintenance therapy and prevention of recurrence’ are discussed in the following sections:
The Impact of usage of Hydroquinone in Melasma Treatment
Hydroquinone is prescribed in a wide range of concentrations and for a wide range of lengths of time by different doctors. In the authors’ opinion, hydroquinone can be safely and successfully utilized for longer than six months. The use of a combination of hydroquinone and non-hydroquinone skin-lightening treatments appears to be most effective in many circumstances. ‘Non-hydroquinone agents,’ farther down the page.
Skin lighteners that don’t include hydroquinone can be used as a first-line treatment for allergic or intolerant to hydroquinone. Azelaic acid, kojic acid, or niacinamide can be used alone or in combination. Azelaic acid is one of just a few medications that can be administered while pregnant, if necessary.
The fluocinolone, hydroquinone, and tretinoin triple combination cream (TCC) are preferred for moderate to severe melasma patients as the first therapy option (picture 1). For two to four months, the cream must be used to the face and neck at night. The TCC is the only FDA-approved treatment for melasma in the United States. For more information, see “Triple combination cream.”
To treat individuals who fail to react to topical therapy alone (algorithm 1), second-line therapies like chemical peels and oral tranexamic acid might be used as a last resort.
The results within this formula
Cosmetic chemical peels that are just applied to the skin’s surface: A variety of alpha-hydroxy acids, salicylic acid, the Jessner peel, and trichloroacetic acid are among the chemical peels routinely used to treat melanomas at the superficial level (table 1). In addition to frequent use of hydroquinone or non-hydroquinone lightening treatments, a few sessions (about five to six) provided at two- to four-week intervals can be helpful (Table 2). Because chemical peels only remove epidermal melanin without influencing melanogenesis or melanocytes, patients should be aware that any improvements are likely to be short-term. You may learn more about chemical peels by clicking on the links below.
To get the best results from chemical peels, you must first prepare your skin. Before the chemical peel, skin-lightening medications such as hydroquinone and Tretinoin are used to prime or prepare the skin to maximize the results of the peel and minimize the risk of post-inflammatory hyperpigmentation. Two to four weeks of priming is recommended. When it comes to whitening agents, you can keep using them up until the peeling occurs, but Tretinoin should be stopped at least seven to ten days beforehand. The peeling agent may penetrate deeper into the skin if Tretinoin is used. (For further information on skin preparation, see “Chemical peels: Procedures and Complications.”
As a hemostatic drug with antiplasmin activity, oral tranexamic acid is effective in treating melasma [24-26]. Relapses, on the other hand, are almost often the result of stopping the oral medication.
Medical professionals are concerned about tranexamic acid’s safety profile because of the drug’s propensity to cause thromboembolic events, despite clinical studies using lower dose levels for treating melanomas than for hemorrhagic diseases (3500 mg daily). Table 3 lists the many thrombotic risk factors that patients should be evaluated for before administering oral tranexamic acid. Thrombosis is a condition in which blood clots form in the veins.
In cases when topical treatments and chemical peels have failed to show adequate improvement in the skin, lasers and light therapies can be used as a third-line therapy for melasma. Because of the danger of post-inflammatory hyperpigmentation, lasers and light sources should be used with extreme caution in people with darker skin.