Treatment for melasma always begins conservatively. The three most widely used conservative treatments are sun protection, reducing exposure to female hormones, and depigmenting agents.

Patients undergoing treatment for melasma must protect their skin from exposure to the sun. Regardless of how melasma is treated, the treatment will fail unless sun exposure is properly managed. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen. The sunscreen must protect against both UV-A and UV-B ultraviolet light and should have an SPF of 30 or higher. We especially like sunscreens that contain zinc oxide and titanium dioxide. These are physical sunscreens that work by preventing the sunlight from reaching the skin. They are inert compounds that have unparalleled safety, have a negligible rate of allergic reactions, and provide both UV-A and UV-B protection.

If at all possible, it is preferable for women undergoing melasma treatment to discontinue their use of birth control pills and other sources of female hormones. Although melasma can be treated while continuing the use of birth control pills, it is not optimal. If melasma develops after starting birth control pills, it may improve after discontinuing their use. However, melasma resulting from the use of birth control pills usually persists even after the pills are stopped. Thus, melasma resulting from birth control pills usually requires medical treatment.

The melasma resulting from pregnancy usually, but not always, disappears spontaneously over a period of several months after giving birth.

Depigmenting agents work by reducing the amount of melanin pigment in the skin. Patients with melasma should apply their depigmenting cream to the areas of darkening only. In some patients we combine the use of the depigmenting agent with a mild chemical peel in order to further improve the treatment results.

Hydroquinone is the most commonly used depigmenting agent; it works by decreasing the production of melanin pigment. In addition, hydroquinone can be used in combination with tretinoin (retinoic acid) and a steroid. The tretinoin acts by increasing cellular turnover, resulting in a quicker response to therapy, and the steroid acts to reduce inflammation in the skin. Tri-Luma cream conveniently combines hydroquinone, tretinoin, and a steroid in one medication, and is available by prescription.

Other depigmenting medications for treating melasma include ascorbic acid (vitamin C), azelaic acid, kojic acid, and alpha arbutin. These medications also work by reducing pigment formation.

Treatment of melasma with sun avoidance, hormonal control, and depigmenting agents takes several months. Patients should expect gradual lightening of the melasma pigment during this period.

When the response to these three conservative measures is not adequate, consideration is given to treating the melasma with lasers. Lasers provide a fourth method for treating melasma.

Patients who have not responded well to conservative treatment can consider laser treatment. The FDA has approved the use of the Fraxel laser for the treatment of melasma. At the Santa Monica Laser and Skincare Center, we have had good success in treating melasma by combining Fraxel laser treatment with hydroquinone, sun avoidance, and sunscreen.

Generally, an optimal result can be obtained after three laser treatments given at four to six week intervals.

In addition to the Fraxel laser, the Q-switched Nd-YAG laser is also a safe and effective treatment for melasma. Two to four treatments are generally required at four to six week intervals. These treatments are quick, nearly pain free, and have no down time.