Stubborn melasma. What can I do? (Photo)

PIcoway laser and Kojic acid help a lot. SUNSCREEN IS A MUST!!! You can buy a cheap soap over seas Koji san and get some Kojic acid creams from dermatologist and this helps a lot as well as the Picoway laser and religious use of sunscreen!!! Sunscreen daily is a must.  Wear a moisturizer or powder or both with sunscreen all the time.  I recommend zinc or titanium dioxide.  A daily one I use is ELTA MD but any daily sunscreen and sun avoidance

Thank you for your question and for sharing your
photographs mauilex. I understand your concern. Melasma is a not uncommon condition characterized by the appearance of dark patches on the skin.It is difficult to make an assessment without a
formal exam in the office where I can view the skin in multiple angles using special lighting.Melasma can be stubborn and difficult to treat. It is caused by an internal imbalance of hormones that makes the skin very sensitive to the sun and leads to the formation of dark patches, or tanned areas, with very little sun exposure. Areas most commonly affected by melasma include the cheeks, forehead, and upper lip. Melasma is more common in women and often times occurs when hormone levels change such as during or after pregnancy, when taking birth control pills, and during menopause. The biggest challenge with melasma is that since the cause is internal, no matter what we do on the skin it usually comes back. Therefore melasma is a condition that we control, not cure; and after initial treatment maintenance treatments are required every three to six months. Melasma is more common in people of darker skin tones and in these people the sunlight causes the skin to make more pigment, which can be deposited in different layers of the skin. There are three types of melasma depending on exactly where the pigment is. In superficial melasma the pigment is close to the surface and often appears darker. In deep melasma, as it's name suggests, the pigment is deeper in the skin and often appears lighter or more faint. The third type, combination melasma, is perhaps the most common and is when there is pigment in both parts of the skin, deep and surface. The depth of the pigment can be determined by viewing the skin with an ultraviolet light called a Wood's lamp. Superficial melasma is easier to treat because the products and treatment used can reach the pigment easier. With deep melasma, the products and treatments have to penetrate deeper, making treatment more challenging. When the deep pigment is treated it is often exfoliated to the surface making it appear darker, or worse. Many people get frustrated when they see this because they think that their efforts and investments have made the problem worse. However, it is important to understand that the pigment is coming closer to the surface and a deep treatment will likely lead to improvement.I find that a combination approach works best for treatment of melasma. First sunscreen use is critical. I recommend a sunscreen with SPF 30 or more with UVA and UVB protection. This should be applied daily, rain or shine, throughout the year. Second a good skin care regimen is important to decrease the pigment production in the skin. Common ingredients include hydroquinone, kojic acid, alpha arbutin, retinoic acid, vitamin C, vitamin E, salicylic acid, glycolic acid, and hyaluronic acid. Treatments for superficial melasma include IPL photofacial treatments, laser peels, and chemical peels. Superficial melasma is easier to treat because the pigment is closer to the surface of the skin. This means that topical products to not have to penetrate too deep to reach their target. This is also true with treatments with lasers and chemical peels.Deep melasma is more challenging because the pigment is deeper in the skin, making it more difficult to reach with topical products and treatments. I have found that the use of fractional lasers helps to target the pigment. Fractional laser resurfacing works by creating thousands of microscopic holes in the skin. This allows for channels through which the pigment can be extruded from the skin. At the same time it allows for channels for delivery of drugs such as hydroquinone. When hydroquinone is applied topically immediately after a fractional laser treatment, the deep pigment can be targeted and outstanding results can be achieved.The most important things to remember about melasma are that strict sun avoidance and daily sunscreen use are mandatory and continuous maintenance therapy will be required.Please consult with a doctor for specific
recommendations. Good luck!