Pearls for the common, but vexatious, dermatologic condition of melasma.
Dermatologists walk a tough line in their daily practice lives. We must identify each patient’s true problem, which often (as we know) is not the problem stated on their intake sheet. We then need to examine the site, arrive at a diagnosis, formulate a treatment plan, and predict on how long it will take to respond to therapy: in other words, educate the patient. An incredibly important part of this education is setting reasonable expectations.
This article represents the accumulated wisdom of more than 50 years of dermatologic practice regarding a common, but vexatious, dermatologic problem—melasma.
Diagnosis
It would seem that the diagnosis and treatment of melasma would be straightforward. But not so fast. Sure, it is present on the face for everyone to see. And, of course, virtually every patient with melasma you see in your office has already consulted with, or closely read, Dr. Google, Dr. WebMD, or even Dr. RealSelf. They have already seen 6 other good dermatologists who have given them at least 8 different regimens, all of which, according to the desperate patient, have failed miserably. They are here to see you, however, because they have heard that you are “the absolute best”, and they want to be cured of this affliction—now.
A knotty and commonly encountered scenario and problem, indeed. Many patients with melasma are angry and psychologically exhausted by their disease, both from psychosocial impacts and multiple doctor visits. Even though insurance companies consider melasma a cosmetic nuisance, we all know it can carry just as much psychological burden as vitiligo. It is always there, looking at them in the mirror, in every selfie taken, at every event, all the time.
Patients consider medicines and therapies that initially worked, but then stopped doing so, as failures. Your initial patient history should always go into great detail regarding all treatments they have tried before (including those that were self-initiated), what worked, for how long, and what did not. Here are 4 pearls for diagnosing melasma:
• The most important thing when encountering a patient with melasma is to take the time to listen to the patient tell their tale of woe, anger, exasperation, and anxiety. This may be the first time the patient has had someone listen to their entire saga, and it can be very cathartic for them and extremely important in building the trust needed for a good therapeutic result.
• Touch the patient. The more involved and tactile you are in your examination, the more value the patient will perceive in it. Make sure to use loupes and good lighting, and absolutely use both hands to gently move the head back and forth during the examination. Take a look at the arms and hands (almost always overlooked and sometimes involved, especially in men).
• Use a Wood’s lamp and view all sites under that light. Many debate the utility of a Wood’s lamp during this examination, but we have found over the years that finding pigment that stands out under the light correlates with greater treatment success. You can explain to the patient that their pigment is relatively superficial, and thus more likely to respond to therapy. It also makes the patient feel that you are going the extra mile, doing everything you can to diagnose and make their condition better.
• Take photographs. Patients never, (and in our experience) ever, accurately remember what they looked like before treatment, and before and after images are invaluable.
Article continues on page 2
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Patients need to understand that melasma is almost always associated with female hormone exposure, whether from hormonal therapy or as a consequence of pregnancy. On the other hand, many cases dermatologists see are idiopathic in nature, and thus we usually tell patients (with a very nice professional smile) that we term this type as “due to aliens.” We just do not have good reasons for it occurring in some people and not others, and we make sure that patients understand that it is easier to try to make their pigmentation better than to tell them why they have it.
Probably the most important thing for patients is the need for them to wrap their minds around the fact that they are what we term “melasmoholics”, and that they will always be in recovery from it. Patients also need to clearly understand that improvement, not perfection, is the goal.
Once melasma is diagnosed, look the patient in the eye and let them know you can definitely improve their skin’s appearance and make the condition much better, but that it will take effort and time. Patients need to hear this. A positive perception is so important, and the only way patients will know this is if you tell them. You need to manage their expectations by giving them a period in which this improvement might be expected to happen. Be specific in your recommendations, so that there are as few unanswered questions left as possible.
Treatment Considerations
Higher SPF sunscreens are valuable, and daily application with reapplication are the norm. This is where we tell them that the higher the SPF, the better it is for them, and do not forget UV-A protection. Do not miss the opportunity to let patients know how to properly apply it, and not only to the face. Good sun hygiene should include a broad-brimmed opaque hat, UPF-rated clothing, and sunglasses. We urge all patients to use Heliocare, an over-the-counter oral sun-protectant containing a fern extract called Polypodium leucotomos. Although there are no published studies regarding Heliocare usage in melasma, we believe it works via its suppressing effect on dimerization of DNA, as well as down-regulating melanin production secondary to sun exposure.
Hydroquinone (HQ) is the most popular fading agent used in dermatology because it works for the majority of people most of the time. We have, on the other hand, never found the commercially available 4% formulations much help as a single agent. In our opinion, Kligman’s Formula (developed and studied by I. Willis and A. M. Kligman) is the best topical therapy available for melasma, lentigines, and other pigmented disorders. It consists of 5% HQ, 0.1% tretinoin, and 0.1% dexamethasone in hydrophilic ointment. We explain to patients that the tretinoin thins the “dead outer layer of skin” (the stratum corneum) to allow the HQ to penetrate more deeply and evenly. The hydrocortisone helps stabilize or soothe the presumably irritated melanocytes (by modifying their metabolic activity), as well as “putting a blanket on the fire of the irritation” brought by the tretinoin. We will go as high as HQ 10% in a compounded formula, and have not encountered any irritation, worsening, or increased hyperpigmentation. There are other agents in use, of course, but none comes close to the effectiveness of HQ, in our opinion.
Chemical peels, especially those using trichloroacetic acid (TCA), can be used as an effective adjunctive therapy. The patient will gauge the level of improvement from the topical therapy at the monthly visit, and if it seems to be lagging, we will recommend a series of TCA peels. We use 20% TCA and make it “short and light.” Always remember that your patient has an active melanocyte system that is responsive to many stimuli, and that heavy or aggressive peels will almost always lead to more pigmentation, instead of reducing it. You can gradually increase the percentage of TCA to 35%, but remember to always keep it light. The “melanocyte unit sensitivity” is the prime reason that lasers are rarely successful when it comes to treating melasma.
Keep reminding patients that the sovereign remedy for melasma consists of applying a fading agent and scrupulous sun hygiene. They must be aware that melasma can return at any time, with even a single unguarded sunlight exposure. They need to understand that they will have to work at this and maintain protection for as long as they want to stay clear.
Melasma can be a tremendously frustrating disease for both the patient and dermatologist. However, good results can be achieved if you remember to do the following: listen, touch, look, prescribe, and set reasonable expectations for yourself and the patient. If both take the time to do it correctly, everyone will be pleased with the results.
Dr Resnik is a voluntary clinical professor of dermatology and cutaneous surgery at the University of Miami School of Medicine in Miami, FL, and is in private practice in Aventura, FL.
Dr Rudolph is a clinical professor of dermatology at the University of Pennsylvania in Philadelphia, PA.
Dr Resnik is a voluntary clinical professor of dermatology and cutaneous surgery at the University of Miami School of Medicine in Miami, FL, and is in private practice in Miami, FL.
Disclosure: The authors report no relevant financial relationships.
Pearls for the common, but vexatious, dermatologic condition of melasma.
Dermatologists walk a tough line in their daily practice lives. We must identify each patient’s true problem, which often (as we know) is not the problem stated on their intake sheet. We then need to examine the site, arrive at a diagnosis, formulate a treatment plan, and predict on how long it will take to respond to therapy: in other words, educate the patient. An incredibly important part of this education is setting reasonable expectations.
This article represents the accumulated wisdom of more than 50 years of dermatologic practice regarding a common, but vexatious, dermatologic problem—melasma.
Diagnosis
It would seem that the diagnosis and treatment of melasma would be straightforward. But not so fast. Sure, it is present on the face for everyone to see. And, of course, virtually every patient with melasma you see in your office has already consulted with, or closely read, Dr. Google, Dr. WebMD, or even Dr. RealSelf. They have already seen 6 other good dermatologists who have given them at least 8 different regimens, all of which, according to the desperate patient, have failed miserably. They are here to see you, however, because they have heard that you are “the absolute best”, and they want to be cured of this affliction—now.
A knotty and commonly encountered scenario and problem, indeed. Many patients with melasma are angry and psychologically exhausted by their disease, both from psychosocial impacts and multiple doctor visits. Even though insurance companies consider melasma a cosmetic nuisance, we all know it can carry just as much psychological burden as vitiligo. It is always there, looking at them in the mirror, in every selfie taken, at every event, all the time.
Patients consider medicines and therapies that initially worked, but then stopped doing so, as failures. Your initial patient history should always go into great detail regarding all treatments they have tried before (including those that were self-initiated), what worked, for how long, and what did not. Here are 4 pearls for diagnosing melasma:
• The most important thing when encountering a patient with melasma is to take the time to listen to the patient tell their tale of woe, anger, exasperation, and anxiety. This may be the first time the patient has had someone listen to their entire saga, and it can be very cathartic for them and extremely important in building the trust needed for a good therapeutic result.
• Touch the patient. The more involved and tactile you are in your examination, the more value the patient will perceive in it. Make sure to use loupes and good lighting, and absolutely use both hands to gently move the head back and forth during the examination. Take a look at the arms and hands (almost always overlooked and sometimes involved, especially in men).
• Use a Wood’s lamp and view all sites under that light. Many debate the utility of a Wood’s lamp during this examination, but we have found over the years that finding pigment that stands out under the light correlates with greater treatment success. You can explain to the patient that their pigment is relatively superficial, and thus more likely to respond to therapy. It also makes the patient feel that you are going the extra mile, doing everything you can to diagnose and make their condition better.
• Take photographs. Patients never, (and in our experience) ever, accurately remember what they looked like before treatment, and before and after images are invaluable.
Article continues on page 2
{{pagebreak}}
Patients need to understand that melasma is almost always associated with female hormone exposure, whether from hormonal therapy or as a consequence of pregnancy. On the other hand, many cases dermatologists see are idiopathic in nature, and thus we usually tell patients (with a very nice professional smile) that we term this type as “due to aliens.” We just do not have good reasons for it occurring in some people and not others, and we make sure that patients understand that it is easier to try to make their pigmentation better than to tell them why they have it.
Probably the most important thing for patients is the need for them to wrap their minds around the fact that they are what we term “melasmoholics”, and that they will always be in recovery from it. Patients also need to clearly understand that improvement, not perfection, is the goal.
Once melasma is diagnosed, look the patient in the eye and let them know you can definitely improve their skin’s appearance and make the condition much better, but that it will take effort and time. Patients need to hear this. A positive perception is so important, and the only way patients will know this is if you tell them. You need to manage their expectations by giving them a period in which this improvement might be expected to happen. Be specific in your recommendations, so that there are as few unanswered questions left as possible.
Treatment Considerations
Higher SPF sunscreens are valuable, and daily application with reapplication are the norm. This is where we tell them that the higher the SPF, the better it is for them, and do not forget UV-A protection. Do not miss the opportunity to let patients know how to properly apply it, and not only to the face. Good sun hygiene should include a broad-brimmed opaque hat, UPF-rated clothing, and sunglasses. We urge all patients to use Heliocare, an over-the-counter oral sun-protectant containing a fern extract called Polypodium leucotomos. Although there are no published studies regarding Heliocare usage in melasma, we believe it works via its suppressing effect on dimerization of DNA, as well as down-regulating melanin production secondary to sun exposure.
Hydroquinone (HQ) is the most popular fading agent used in dermatology because it works for the majority of people most of the time. We have, on the other hand, never found the commercially available 4% formulations much help as a single agent. In our opinion, Kligman’s Formula (developed and studied by I. Willis and A. M. Kligman) is the best topical therapy available for melasma, lentigines, and other pigmented disorders. It consists of 5% HQ, 0.1% tretinoin, and 0.1% dexamethasone in hydrophilic ointment. We explain to patients that the tretinoin thins the “dead outer layer of skin” (the stratum corneum) to allow the HQ to penetrate more deeply and evenly. The hydrocortisone helps stabilize or soothe the presumably irritated melanocytes (by modifying their metabolic activity), as well as “putting a blanket on the fire of the irritation” brought by the tretinoin. We will go as high as HQ 10% in a compounded formula, and have not encountered any irritation, worsening, or increased hyperpigmentation. There are other agents in use, of course, but none comes close to the effectiveness of HQ, in our opinion.
Chemical peels, especially those using trichloroacetic acid (TCA), can be used as an effective adjunctive therapy. The patient will gauge the level of improvement from the topical therapy at the monthly visit, and if it seems to be lagging, we will recommend a series of TCA peels. We use 20% TCA and make it “short and light.” Always remember that your patient has an active melanocyte system that is responsive to many stimuli, and that heavy or aggressive peels will almost always lead to more pigmentation, instead of reducing it. You can gradually increase the percentage of TCA to 35%, but remember to always keep it light. The “melanocyte unit sensitivity” is the prime reason that lasers are rarely successful when it comes to treating melasma.
Keep reminding patients that the sovereign remedy for melasma consists of applying a fading agent and scrupulous sun hygiene. They must be aware that melasma can return at any time, with even a single unguarded sunlight exposure. They need to understand that they will have to work at this and maintain protection for as long as they want to stay clear.
Melasma can be a tremendously frustrating disease for both the patient and dermatologist. However, good results can be achieved if you remember to do the following: listen, touch, look, prescribe, and set reasonable expectations for yourself and the patient. If both take the time to do it correctly, everyone will be pleased with the results.
Dr Resnik is a voluntary clinical professor of dermatology and cutaneous surgery at the University of Miami School of Medicine in Miami, FL, and is in private practice in Aventura, FL.
Dr Rudolph is a clinical professor of dermatology at the University of Pennsylvania in Philadelphia, PA.
Dr Resnik is a voluntary clinical professor of dermatology and cutaneous surgery at the University of Miami School of Medicine in Miami, FL, and is in private practice in Miami, FL.
Disclosure: The authors report no relevant financial relationships.
Pearls for the common, but vexatious, dermatologic condition of melasma.
Dermatologists walk a tough line in their daily practice lives. We must identify each patient’s true problem, which often (as we know) is not the problem stated on their intake sheet. We then need to examine the site, arrive at a diagnosis, formulate a treatment plan, and predict on how long it will take to respond to therapy: in other words, educate the patient. An incredibly important part of this education is setting reasonable expectations.
This article represents the accumulated wisdom of more than 50 years of dermatologic practice regarding a common, but vexatious, dermatologic problem—melasma.
Diagnosis
It would seem that the diagnosis and treatment of melasma would be straightforward. But not so fast. Sure, it is present on the face for everyone to see. And, of course, virtually every patient with melasma you see in your office has already consulted with, or closely read, Dr. Google, Dr. WebMD, or even Dr. RealSelf. They have already seen 6 other good dermatologists who have given them at least 8 different regimens, all of which, according to the desperate patient, have failed miserably. They are here to see you, however, because they have heard that you are “the absolute best”, and they want to be cured of this affliction—now.
A knotty and commonly encountered scenario and problem, indeed. Many patients with melasma are angry and psychologically exhausted by their disease, both from psychosocial impacts and multiple doctor visits. Even though insurance companies consider melasma a cosmetic nuisance, we all know it can carry just as much psychological burden as vitiligo. It is always there, looking at them in the mirror, in every selfie taken, at every event, all the time.
Patients consider medicines and therapies that initially worked, but then stopped doing so, as failures. Your initial patient history should always go into great detail regarding all treatments they have tried before (including those that were self-initiated), what worked, for how long, and what did not. Here are 4 pearls for diagnosing melasma:
• The most important thing when encountering a patient with melasma is to take the time to listen to the patient tell their tale of woe, anger, exasperation, and anxiety. This may be the first time the patient has had someone listen to their entire saga, and it can be very cathartic for them and extremely important in building the trust needed for a good therapeutic result.
• Touch the patient. The more involved and tactile you are in your examination, the more value the patient will perceive in it. Make sure to use loupes and good lighting, and absolutely use both hands to gently move the head back and forth during the examination. Take a look at the arms and hands (almost always overlooked and sometimes involved, especially in men).
• Use a Wood’s lamp and view all sites under that light. Many debate the utility of a Wood’s lamp during this examination, but we have found over the years that finding pigment that stands out under the light correlates with greater treatment success. You can explain to the patient that their pigment is relatively superficial, and thus more likely to respond to therapy. It also makes the patient feel that you are going the extra mile, doing everything you can to diagnose and make their condition better.
• Take photographs. Patients never, (and in our experience) ever, accurately remember what they looked like before treatment, and before and after images are invaluable.
Article continues on page 2
{{pagebreak}}
Patients need to understand that melasma is almost always associated with female hormone exposure, whether from hormonal therapy or as a consequence of pregnancy. On the other hand, many cases dermatologists see are idiopathic in nature, and thus we usually tell patients (with a very nice professional smile) that we term this type as “due to aliens.” We just do not have good reasons for it occurring in some people and not others, and we make sure that patients understand that it is easier to try to make their pigmentation better than to tell them why they have it.
Probably the most important thing for patients is the need for them to wrap their minds around the fact that they are what we term “melasmoholics”, and that they will always be in recovery from it. Patients also need to clearly understand that improvement, not perfection, is the goal.
Once melasma is diagnosed, look the patient in the eye and let them know you can definitely improve their skin’s appearance and make the condition much better, but that it will take effort and time. Patients need to hear this. A positive perception is so important, and the only way patients will know this is if you tell them. You need to manage their expectations by giving them a period in which this improvement might be expected to happen. Be specific in your recommendations, so that there are as few unanswered questions left as possible.
Treatment Considerations
Higher SPF sunscreens are valuable, and daily application with reapplication are the norm. This is where we tell them that the higher the SPF, the better it is for them, and do not forget UV-A protection. Do not miss the opportunity to let patients know how to properly apply it, and not only to the face. Good sun hygiene should include a broad-brimmed opaque hat, UPF-rated clothing, and sunglasses. We urge all patients to use Heliocare, an over-the-counter oral sun-protectant containing a fern extract called Polypodium leucotomos. Although there are no published studies regarding Heliocare usage in melasma, we believe it works via its suppressing effect on dimerization of DNA, as well as down-regulating melanin production secondary to sun exposure.
Hydroquinone (HQ) is the most popular fading agent used in dermatology because it works for the majority of people most of the time. We have, on the other hand, never found the commercially available 4% formulations much help as a single agent. In our opinion, Kligman’s Formula (developed and studied by I. Willis and A. M. Kligman) is the best topical therapy available for melasma, lentigines, and other pigmented disorders. It consists of 5% HQ, 0.1% tretinoin, and 0.1% dexamethasone in hydrophilic ointment. We explain to patients that the tretinoin thins the “dead outer layer of skin” (the stratum corneum) to allow the HQ to penetrate more deeply and evenly. The hydrocortisone helps stabilize or soothe the presumably irritated melanocytes (by modifying their metabolic activity), as well as “putting a blanket on the fire of the irritation” brought by the tretinoin. We will go as high as HQ 10% in a compounded formula, and have not encountered any irritation, worsening, or increased hyperpigmentation. There are other agents in use, of course, but none comes close to the effectiveness of HQ, in our opinion.
Chemical peels, especially those using trichloroacetic acid (TCA), can be used as an effective adjunctive therapy. The patient will gauge the level of improvement from the topical therapy at the monthly visit, and if it seems to be lagging, we will recommend a series of TCA peels. We use 20% TCA and make it “short and light.” Always remember that your patient has an active melanocyte system that is responsive to many stimuli, and that heavy or aggressive peels will almost always lead to more pigmentation, instead of reducing it. You can gradually increase the percentage of TCA to 35%, but remember to always keep it light. The “melanocyte unit sensitivity” is the prime reason that lasers are rarely successful when it comes to treating melasma.
Keep reminding patients that the sovereign remedy for melasma consists of applying a fading agent and scrupulous sun hygiene. They must be aware that melasma can return at any time, with even a single unguarded sunlight exposure. They need to understand that they will have to work at this and maintain protection for as long as they want to stay clear.
Melasma can be a tremendously frustrating disease for both the patient and dermatologist. However, good results can be achieved if you remember to do the following: listen, touch, look, prescribe, and set reasonable expectations for yourself and the patient. If both take the time to do it correctly, everyone will be pleased with the results.
Dr Resnik is a voluntary clinical professor of dermatology and cutaneous surgery at the University of Miami School of Medicine in Miami, FL, and is in private practice in Aventura, FL.
Dr Rudolph is a clinical professor of dermatology at the University of Pennsylvania in Philadelphia, PA.
Dr Resnik is a voluntary clinical professor of dermatology and cutaneous surgery at the University of Miami School of Medicine in Miami, FL, and is in private practice in Miami, FL.
Disclosure: The authors report no relevant financial relationships.
