Melasma spreading even with treatment. Desperate for help.

Question

My melasma started on both cheeks. It has spread to my forehead, nose, upper lip & recently below my lower lip. I have been using kojic acid and meladerm every night & have tried azelaic acid & hydroquinone. I was dignosed with low pregesterone, high testosterone & vitamin D deficiency but unsure if that is related. I am hoping a doctor can give me some advice as to why it continues to spread and remain unresponsive to treatment. I cannot find a derm in my area that specializes in melasma.

Nelson Lee Novick, MD · Answer

Unfortunately, melasma is a chronic condition, which means it is not curable in the traditional sense and that it is characterized by periods of ups and downs. Equally unfortunately, we do not yet completely understand the cause and we do not have a definitive cure for it. Hormonal issues, such as pregnancy and the use of the BCP have been linked to the appearance or worsening of the condition in some patients. It is not an infectious condition, so it really does not "spread" from one area to another, it simply shows up in certain characteristic regions, such as the forehead, cheeks and upper lips, as in your case. It may show up at one time or at different times for unclear reasons.The good news is that we have a number of different prescription medications and compounds for home use, as well as in-office treatments, that have been shown to be quite helpful for improving signficantly, and in some cases, even clearing, the condition. Sun protection and the assiduous use of sunscreens is an absolute essential ingredient in any treatment plan, since ultraviolet light most certainly can trigger the appearance of new patches and darken pre-existing ones.In my experience, the combined and prolonged use of high potency topical hydroquinone preparations, along with kojic acid, azelaic acid, arbutin and vitamin C canbe extremely help, especially if supplemented by periodic in-office treatments using high potency glycolic acid or Jessner's solution or low concentrations of TCA. The right regimen specifically for you is best determined by a board certified aesthetic physician with extensive experience and expertise in treating melasma.

Anil R. Shah, MD · Answer

Hello, please see below. Melasma is a condition which requires multiple steps and treatments to effectively improve the condition consistently over time.  In our office, here are steps which are effective:
-Pico lasers- The best type of laser for improving the condition.  Please not it takes multiple steps to improve melasma safely
-Nd:YAG Nano lasers with toning- Here a laser is used for deeply resistant melasma to break up particles without generating excessive heat
-Melanage peels- A variety of peels can work and melanage is one of the best for melasma
-Skin topicals- A variety of products including use of lighteners (we prefer natural lighteners such as arubtase found in our product Luminoso) as well as sunscreens can help improve the condition
-Lifestyle choices-Avoiding the sun, hormonal changes (we have a hormone expert in Dr. Chughtai in our office) can all impact melasma.
While melasma is common, patients must understand a multi pronged approach is often the best strategy and controlling this condition.
Best, 
Anil Shah MD

Raffy Karamanoukian, MD, FACS · Answer

Melasma and pigmentation can be controlled effectively. I would start with a combination of Clear and Brilliant lasers, Melapeels, and the Brightening Kit which contains Melarase creams and Melapads to lighten the skin. 
Best, 
Dr. Karamanoukian
Los Angeles

Harold J. Kaplan, MD · Answer

Generally speaking, Melasma is not well understood.  All evidence points to hormonal changes that trigger it, but the exact way in which it starts and spreads is unknown.  For this reason, no one can give you an answer as to why it's spreading.  As to how to mitigate the concern, the first piece of advice is diligent sun screen every day, at least 30 SPF and more likely 50 SPF with a chemical and physical sunblock.  Step 2 would be diligent sun avoidance.  Any sunlight (UV), winter, summer, vacation, even cloudy days can make Melasma worse so avoid the sun at all costs.  When you do need to be outside, use sunscreen diligently and wear a full coverage hat or visor.Finally, we use hydroquinone formulations between 6% - 8% to treat it.  We use greater than the standard 4% to treat it because many of our Melasma patients have failed 4%.  We also take patients off the product every three months because of the higher strength of the hydroquinone.  Finally, the formulation does not use a steroid or Retin A.  Below you can see before and after pictures of our Los Angeles and Orange County Melasma patients that have used our product.

Andrea Hui Austin, MD · Answer

Hello there,Melasma has many different causes, and must be approached this way. One common cause is hormonal imbalance or use of hormone medications such as oral contraceptives or supplements. Please be sure to check in with your internist to make sure everything is ok. If you are using any unnecessary supplements, stop those. Sun exposure is another important trigger of melasma. Be sure to wear a mineral sunblock every day, and re-apply throughout the day if possible. The ingredients you should look for include: zinc oxide, titanium dioxide, and ferrous oxide. Powder sunblocks are a great addition to your daily routine. You can even take supplements such as Heliocare, which provides internal sunblock, or niacinamide, which can decrease the uneven pigmentation and any inflammation. Wear a hat and/or use umbrellas when you walk outside.Next, at-home prescription and physician-dispensed treatments can help. Medications like Triluma contains a lightener (hydroquinone), retinoid (tretinoin) and anti-inflammatory (fluocinolone). Usually my patients use a medication like this for 4-6 months until they achieve their aesthetic goals, and then we transition to a tretinoin-only product. Procedures such as chemical peels can also help. Please caution use of lasers, as this can cause worsening of melasma if done incorrectly. Of course, good skincare is very important. Use gentle cleansers and moisturizers, and avoid using acids at home, which can irritate the skin. Good luck!

Melasma spreading even with treatment. Desperate for help.

Answers (5)

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