The patchy brown pigment of melasma is among the most prevalent, challenging, and emotionally charged conditions that dermatologists treat. “It’s unbelievably common—affecting easily a billion women worldwide—and [can be] incredibly upsetting,” notes Dr. Jeffrey Dover, a board-certified dermatologist in Chestnut Hill, Massachusetts. “I literally have women between the ages of 25 and 65 coming into the office, crying with this, on a daily basis.” The majority fall within skin types II through V on the Fitzpatrick Scale, he adds.
While melasma is fueled by UV light, just like sunspots, and influenced by hormones, as with acne and the marks it leaves behind, melasma is far harder to squelch. In fact, the devices commonly used to eviscerate the discoloration associated with those issues tend to make melasma worse by virtue of their heat, which can spark more pigment formation in the weeks following treatment. Fearing this rebound effect, dermatologists have come to lean on heat-free solutions, like gentle chemical peels and, more recently, energy-free microneedling treatments—typically, in conjunction with potent fade creams and strict sun avoidance.
While not everyone sees microneedling as a home run for melasma, emerging research supports its success in hundreds of cases, across skin tones—attributing its efficacy, in large part, to the channels it creates in the skin. These carefully oriented punctures serve as tiny portals, allowing select lightening agents to seep into the skin’s deeper layers, which are impossible to reach with ordinary creams. But the benefits of microneedling don’t end there.
Ahead, dermatologists reveal the exact characteristics that make melasma so tenacious and share the specific microneedling protocols they’ve devised to tame it.
Why is melasma so difficult to treat?
Melasma can stain the epidermis, or topmost layer of skin, as well as the deeper dermis—and oftentimes affects both. “The epidermal component usually clears with lightening creams, but the dermal component is really resistant to treatment,” Dr. Dover says.
Beyond the placement of pigment, what make melasma so difficult to tamp down are the omnipresent stimuli responsible for its creation. Since the condition is fueled primarily by female hormones and sunlight, “you have these two really strong forces trying hard to make melasma—and we can beat it back, but it’s sort of like the neverending army,” says board-certified Boston dermatologist Dr. Papri Sarkar. “We don’t have a great way to cut off the stimulus for melasma.” There are things docs can do to help curtail it, however.
Melasma is perpetuated by both endogenous estrogen—our own innate supply, which waxes during pregnancy and wanes with menopause—as well as exogenous sources, like birth control pills and hormone therapy. While derms don’t meddle with inherent hormones, “we do try to suggest that women [with melasma] stop the Pill, if they can, and use alternate forms of contraception,” says Dr. Dover—though he notes, “we never stop it if someone needs it for endometriosis or another medical problem.” Working with patients’ gynecologists, they may transition melasma sufferers to a low-dose pill, or if safe and appropriate, wean them off external hormones completely in order to reduce the instigative effect on pigment production.
Equally unrelenting is the sun—which is why most derms won’t even attempt to treat melasma with anything other than sunscreen and prescription creams during the UV-intense summer months. “That’s fighting an uphill battle,” says Dr. Dover. “Five minutes in the sun can actually reverse a month of treatment.” Whether inside, outside, or in the car, broad-spectrum sunscreen with a high SPF is mandatory—as are hats with circumferential brims wide enough to shield melasma hot spots, like the forehead, upper lip, cheeks, and nose.
How can microneedling help minimize melasma?
Unlike pigment-targeting lasers, tuned to seek and vaporize excess melanin, mechanical microneedling, through a series of clean, controlled punctures, “effaces a certain depth of skin, including the epidermis and superior dermis, where we see melasma,” Dr. Sarkar explains. “We’re essentially getting rid of that and forcing the surrounding skin [via its healing mechanisms] to make brand-new, fresh skin that hasn’t yet experienced the effects of hormones and sun.” (As a nice bonus, needling also ramps up collagen growth and gives a pretty glow.)
How deep providers go generally depends on a few factors—the location of the pigment (again, epidermal versus dermal); the patient’s propensity to create more melanin as a result of inflammation (aka postinflammatory hyperpigmentation, or PIH, a common risk with darker skin); the overall sensitivity of the skin (someone prone to rosacea or hives, for instance, may require a milder, shallower treatment); and the amount of downtime a patient will tolerate. That said, derms are working within a range of 0.5–2.5 millimeters when microneedling. “But I almost never use the same setting on the whole face,” Dr. Sarkar adds. She’ll vary her depth across the face, based on the density of the pigment she’s aiming to eliminate (needling more aggressively on more melasma-rich zones) and the thickness of the skin (the cheeks can accommodate a greater depth than, say, the under-eyes or nose).
The tunnels made during microneedling allow doctors to funnel medications directly into areas of concern—and many derms believe this to be the true magic of microneedling for melasma. “I love microneedling as a means of assisted drug delivery,” says Dr. DiAnne S. Davis, a board-certified dermatologist in Dallas. “By creating tiny injury zones or columns, I am able to then apply active ingredients that can further help to treat pigment in my melasma patients”—a practice she finds to be generally safe and effective even for her patients of color, who are prone to PIH.
In a new study published in the Journal of the American Academy of Dermatology—a review of 459 melasma patients, from seven different countries—researchers found that “topical therapy with microneedling improved melasma severity with a large effect … beyond eight weeks [and] best results seen at 12 weeks.” According to Dr. Dover, a co-author on the paper, the fine print attached to this procedure should read: “Microneedling does help melasma when used with topical therapy—but on its own, it’s not effective.”
Related: The 11 Best Skin-Care Products for Hyperpigmentation and Melasma, According to Derms
Ingredients that boost the effects of microneedling for melasma
Lighteners come into play, at various stages of the process, when microneedling to improve melasma. First, derms will typically have patients “pretreat” their skin, for two weeks prior to needling, with a bleaching cream—either prescription-strength hydroquinone (HQ) or a compounded formula, like Kligman’s, containing HQ plus a retinoid and low-dose corticosteroid—or alternatively, a non-HQ brightener with kojic acid, vitamin C, niacinamide, a retinoid, or some mix thereof. This pretreatment, Dr. Sarkar says, serves to “weaken the enemy before the attack,” subduing pigment cells so they’re less aroused before, during, and after microneedling.
On appointment day, doctors introduce active ingredients by “using them as a glide so that they go into the skin as we’re needling or slathering them on right after,” Dr. Sarkar says. For this purpose, she orders specially formulated, high-concentration prescription agents—including tranexamic acid (TXA), glutathione, vitamin C, niacinamide—that are intended to be used in the skin or in the blood. “A lot of them are meant for intravenous use,” she notes, the thinking being: “If they’re sterile enough to go into your bloodstream, they’re sterile enough to go into your skin.”
Brightening potions made for topical use—those that have not been specifically tested in conjunction with microneedling or fractional lasers and shown to be safe under the skin—should never be applied to freshly perforated skin, Dr. Sarkar warns, since preservatives, silicones, and other additives commonly used in skin care can cause allergic reactions and granulomas (inflamed bumps) if delivered below the skin.
Dr. Davis counts tranexamic acid and PRP, or platelet-rich plasma, among her favorite add-ons for microneedling. Dr. Sarkar also has patients who prefer PRP, appreciating the fact that it’s derived from their own blood—nothing in any way foreign—and that it helps speed healing.
In the few days after each round of microneedling—derms usually suggest several sessions, spaced four to six weeks apart—you’ll use only gentle cleansers, healing ointments, and mineral sunscreens before resuming your normal regimen, including whatever lightening/brightening products you were on pre-procedure. (Doctors don’t recommend using any HQ-containing cream for more than two months at a time, however.)
The risks associated with microneedling for melasma
“Because energy-free microneedling does not incorporate heat into the treatment, it is less apt to trigger postinflammatory hyperpigmentation [PIH] and/or rebound pigment compared to certain types of lasers,” says Dr. Davis. With microneedling though, “what can potentially cause PIH in melasma patients is the amount of pressure that the operator uses on the device.”
Indeed, microneedling outcomes—including the chance of complications—are supremely provider-dependent, our doctors say. As with the majority of medical procedures, “there are many ways for this to go wrong,” adds Dr. Sarkar. Two of the most obvious come down to sterility—if the skin isn’t cleaned properly prior to treatment or if the device itself isn’t sterile, there’s the likelihood of infection or even transmission of blood-borne viruses. And then there are the nuances of technique—“how deep you’re actually going and if you’re making the holes in the correct orientation” to promote optimal healing, explains Dr. Sarkar. To encourage tissue regeneration and minimize unnecessary trauma and potential PIH, she adds, the needles must be sufficiently sharp and enter the skin at a particular angle. Overtreating the face—needling for an hour or more—can also cause irritation-related complications, like scarring and PIH.
Last but certainly not least, there is a risk of spreading oral herpes if your provider doesn’t routinely administer antivirals, like Valtrex, before microneedling. Says Dr. Sarkar, “If they’re microneedling over something that looks like a pimple but is really a cold sore, they’ll microneedle that [virus] all over your face.”
Alternative and supplemental treatments for melasma
Let’s start with oral tranexamic acid, which our experts like as a supplement to both prescription creams and microneedling treatments. Dr. Dover points to a 2017 retrospective analysis of 561 patients, 89.7% of whom saw their melasma improve within two months of taking a daily dose of oral TXA. (The drug is known to cause blood clots in those who are prone, so doctors take a careful personal and family history before prescribing it.) Dr. Dover recently began treating appropriate patients with oral TXA and says this group represents “the best results [he’s] seen in the past decade.” Dr. Sarkar is also a fan, saying the drug “works like gangbusters”—but that she hasn’t prescribed it throughout the pandemic, since COVID-19 is known to cause clotting issues of its own. “On autopsy, when they look at patients who’ve had severe COVID-19, they find clots in almost every organ system, so I’ve been a little nervous to put patients on oral TXA during COVID-19.” Talk to your doctor about this and other risk factors.
Chemical peels are a popular fix for melasma because “they’re safe and effective for all skin types, depending on the chemical peel that is chosen, and are a great way to ‘peel’ off pigment that melasma patients will collect over the summer months or when they’re exposed to hot temperatures,” says Dr. Davis. (Heat—both ambient and exercise-induced—can cause melasma to flare in certain folks.) Dr. Davis finds bi- or tri-annual chemical peels can beautifully bolster her melasma patients’ topical regimens.
Dr. Sarkar finds peels particularly useful for those with melasma who are simultaneously battling active acne, especially since they don’t qualify for microneedling (it can cause inflammation and, potentially, acne scarring). She’ll often customize the acid solution, to clear both acne and the discoloration associated with melasma and inflammatory pimples.
The picosecond laser is another go-to for melasma, since it emits little to no heat. “The energy is delivered so quickly, literally in trillionths of a second, that there’s no time for it to convert from mechanical energy to thermal energy,” Dr. Dover says. A series of monthly treatments (performed in the off-season) is standard, and he notes, “I almost never do the laser alone,” believing HQ creams and sunscreen to be vital to its long-term success. He also urges melasma patients to see only experienced providers for this (or any) laser procedure, explaining that if a novice uses “settings for ordinary pigment, they can worsen melasma.”
Whether your version of melasma therapy includes microneedling or another type of treatment, bear in mind that there is no forever cure. “Because it is just a very stubborn condition,” says Dr. Davis, “it’s not a matter of if [your] melasma will rebound but when it will rebound.” For the best fighting chance, enlist the help of a dermatologist and be vigilant about sun protection.
