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    Persistent melasma best treated with patient compliance

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    Dr. Bucay
    San Antonio — Melasma can be both recurrent and persistent, so it is imperative that clinicians treat it sooner rather than later, according to a dermatologist specializing in treating the condition.

    "You can get melasma, have it clear up, and you get it again," says Vivian Bucay, M.D., dermatologist and clinical assistant professor, University of Texas, San Antonio. "Most of the time treatment is patient-driven. The patient says it is really bothersome, and it does have an impact on quality of life. If the patients have it, but are too shy to talk about it, I will mention it to them."

    Melasma appears as a result of a spike in progesterone levels, either presenting in pregnancy or in women who are taking birth-control pills.

    If the melasma tends to disappear after pregnancy, it will likely not be persistent, but if it does remain beyond giving birth, that is a sign that the condition is not transient and will be harder to treat, Dr. Bucay says.

    High risk

    Women with Fitzpatrick skin types III or IV are particularly at risk of developing melasma. Those who have family members who have had melasma also are at increased risk of developing the condition.

    Typically, women of Asian, Hispanic or African-American origin are at risk of developing melasma during pregnancy.

    Melasma can appear on the neck, forearms and chest, but it is usually presentation on the face that drives patients to seek treatment, according to Dr. Bucay.

    "I think the cornerstone of treatment is topical agents that are tyrosine inhibitors, like hydroquinone," Dr. Bucay says. Tyrosine is an enzyme required to make melanin. "Hydroquinone, as a prescription therapy, is regarded as the gold standard. Part of the treatment is also sunscreen. The sunscreen needs to work against UVA and UVB rays since UVA rays are important to stimulating pigment production."

    When patients use sunscreen, they need to ensure the sunscreen contains ingredients such as zinc oxide or titanium dioxide, Dr. Bucay says.

    Hydroquinone 'holidays'


    A patient is shown after using hydroquinone 4 percent twice daily for treatment of hyperpigmentation for several months (left) and about one month later, after adding lignin peroxidase cream (Elure, Syneron) twice daily. (Photos: Vivian Bucay, M.D.)
    Patients cannot apply hydroquinone indefinitely. Indeed, they will need hydroquinone "holidays." Patients can turn to numerous alternative therapies, one of which is a new cosmeceutical treatment called Elure (Syneron), a topical cosmetic containing an enzyme called Melanozyme that breaks down melanin in the epidermis, decreases skin discoloration and leads to a lighter and brighter skin complexion.

    The product, which has been on the market since the beginning of 2011 and has a rapid onset of action, is designed to mimic what happens when a fungal enzyme called lignin peroxidase takes the color out of tree bark.

    "You can see results (with Elure) in two weeks versus six to eight weeks with hydroquinone," Dr. Bucay says. "It's a morale booster for patients."

    Tretinoin is beneficial because it can inhibit pigment production, she says.

    "Patients can use tretinoin at night, hydroquinone twice daily, and a sunscreen," Dr. Bucay says. Patients may also apply makeup to cover up the uneven tone of their complexion, but they should not use makeup as a substitute for sunscreen.

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    Louise Gagnon
    Louise Gagnon is a medical writer and editor based in Oakville, Ontario, Canada.

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