Dr Shefali Trasi-Nerurkar, MD Skin, Consultant Dermatologist, Dr Trasi’s Clinic and La Piel, elaborates on the use of laser treatments and chemical peels to treat melasma.

M elasma is a common hyperpigmentation disorder. It is an acquired condition that most commonly affects females with darker skin type. The exact cause of melasma is unknown; however, it is triggered by several factors such as sun exposure, genetic influences, certain drugs and female sex hormones.

The pathology is complex and extends beyond melanocytes – the pigment cells of the skin. This unknown pathogenesis makes melasma extremely difficult to target and likely to recur post treatment.

Cosmetically, it impacts the quality of life of affected individuals. As a result, there is a demand for newer and better therapeutic strategies for treatment of this condition.

A 45-year-old married female with Fitzpatrick skin type 5 came to our clinic with complaints of dark patches on cheeks, nose, upper lip, forehead for 20 years.

The lesions were asymptomatic, such that they were not itchy or painful. However, they exacerbated on sun exposure. The cosmetic appearance of the patches made the patient conscious of her appearance. The patient did not have a history of atopy or other skin diseases.

Upon enquiry, the patient said she has a history of brown patches after her first pregnancy, and did not take any treatment for it. Gradually, the patches became darker and bigger.

She also had a history of regular use of hair dyes.

She approached several doctors who prescribed topical creams. However, the lesions subsided temporarily and then increased again after stopping the usage of the creams.

Upon examination, we observed bilateral, symmetrical and welldemarcated hyperpigmented macules coalescing to form patches with irregular shapes, smooth surface and variable pigment intensity on cheeks, nose, forehead and upper lips.

On woods lamp, no accentuation was seen suggestive of dermal location of pigment.

On dermoscopy, light to dark brown pseudo reticular network, multiple brown dots with granules and globules with sparing of perifollicular region was seen. Increased vascularity and telangictasia was also observed.

The treatment was challenging because of the chronic and persistent nature of the condition. The patient was consulted regarding the nature of condition, its causes and further line of management.

We asked her to completely stop using commercial hair dyes and to shift to pharmacologically tested hair dyes. We also explained the benefits of regular use of broad-spectrum sunscreens and its re-application every four hours on the exposed parts of the body, even while at home or on rainy days. She was also told to use physical barriers like scarves and broad-brimmed hats while going out in sunlight.

The patient was prescribed oral antioxidants and tranexmic acid tablets 250 mg twice a day.

Topically, she was given triple combination creams with hydroquinone, retinoid and mild steroid to apply at night on dark patches. In the mornings, she was asked to apply vitamin C serums and whitening creams containing tranexamic acid, arbutin and kojic acid.

Once the patient was satisfied with some improvement, she was advised to start Q-switched Nd-YAG laser treatment every three to four weeks, alternating with chemical peels.

Q-switched Nd-YAG was started from low dose of 500 J, which was increased in every sitting by 50 after examination. A total of six sittings were done every month.

The patient was also given a combination of peels starting with glycolic acid and kojic acid. Later, she was shifted to phenol peels and retinol peels.

She showed good response to the treatments, with gradual improvement in over six months. Even after the treatment was stopped, the patient was advised to continue using maintenance skin lightening creams and sunscreens.

Conclusion

The use of broad-spectrum (UVA + UVB) sunscreen is important, along with topical hydroquinone – the most common treatment for melasma. Other lightening agents include retinoic acid (tretinoin) and azelaic acid. Combination therapies such as hydroquinone, tretinoin and corticosteroids have been used to treat melasma, and are thought to increase the efficacy as opposed to monotherapy. Kojic acid, arbutin, tranexamic acid and SabiWhite are other compounds that have been researched for their ability to reduce hyperpigmentation. Chemical peels, laser treatments and intense pulsed light therapy are additional therapeutic modalities that have been used to treat melasma.