The most common melasma therapies include 2% hydroquinone (HQ) creams like the over-the-counter products Esoterica and Porcelana and prescription-strength 4% creams like Obagi Clear, Tri-Luma, NeoCutis Blanche, and 4% hydroquinone. Certain sunscreens also contain 4% hydroquinone, such as Glytone Clarifying Skin Bleaching Sunvanish SPF 23 and Obagi's Sunfader sunscreen. Products with HQ concentrations above 2% sometimes require a prescription or are dispensed through physician's practices. Clinical studies show that creams containing 2% HQ can be effective in lightening the skin and are less irritating than higher concentrations of HQ for melasma. These creams are usually applied to the brown patches twice a day. Sunscreen should be applied over the hydroquinone cream every morning. There are treatments for all types of melasma, but the epidermal type responds better to treatment than the others because the pigment is closer to the skin surface.
Melasma may clear spontaneously without treatment. Other times, it may clear with sunscreen usage and sun avoidance. For some people, the discoloration with melasma may disappear following pregnancy or if birth control pills and hormone therapy are discontinued.
In order to treat melasma, combination or specially formulated creams with hydroquinone, a phenolic hypopigmenting agent, azelaic acid, and retinoic acid (tretinoin), nonphenolic bleaching agents, and/or kojic acid may be prescribed. For severe cases of melasma, creams with a higher concentration of HQ or combining HQ with other ingredients such as tretinoin, corticosteroids, or glycolic acid may be effective in lightening the skin.
- Azelaic acid 15%-20% (Azelex, Finacea)
- Retinoic acid 0.025%-0.1% (tretinoin)
- Tazarotene 0.5%-0.1% (Tazorac cream or gel)
- Adapalene 0.1%-0.3% (Differin gel)
- Kojic acid
- Lactic acid lotions 12% (Lac-Hydrin or Am-Lactin)
- Glycolic acid 10%-20% creams (Citrix cream, NeoStrata)
- Glycolic acid peels 10%-70%
- Other proprietary ingredients and mixtures of ingredients as in Elure, Lumixyl, and SkinMedica's Lytera products
Possible side effects of melasma treatments include temporary skin irritation. People who use HQ treatment in very high concentrations for prolonged periods (usually several months to years) are at risk of developing a side effect called exogenous ochronosis. In this condition, the skin actually darkens while the bleaching agent is used. Hydroquinone-induced ochronosis is a permanent skin discoloration that is thought to result from use of hydroquinone concentrations above 4%. Although ochronosis is fairly uncommon in the U.S., it is more common in areas like Africa where hydroquinone concentrations upward of 10%-20% may be used to treat skin discoloration like melasma. Regardless of the potential side effects, HQ remains the most widely used and successful fading cream for treating melasma worldwide. HQ should be discontinued at the first signs of ochronosis.