Stubborn melasma. What can I do? (Photo)

Thank you for your question, Melasma needs a combination approach to get the best improvement and will need a series of treatments. In our practice, we combine Clear + Brilliant, peels, microneedling/PRP, Aerolase, and sometimes Erbium (Cool Laser) to get the best results. See an expert for a formal evaluation. Best, Dr. Emer

Thank you for your question.  I would suggest doing a fractional treatment for melasma.  Apply hydroquinone morning and evening two weeks prior to your treatment.  The fractional treatment would help to suppress the discoloration and improve texture of your skin along with shrinking your pores.  

Thank you for your question.  Skin discoloration is a very prevalent problem in women over the age of twenty.  It is also increasingly common in men with increased sun exposure.  
Risk factors include thyroid disease, sun exposure, hormones, pregnancy, family history, PIH, and birth control. Melarase AM and Melarase PM have been extremely effective in reducing pigmentation associated with skin discoloration and hyperstimulation of melanocytes. 
In my practice, patients with hyperpigmentation benefit from twice daily application of the creams. Melarase AM in the morning, followed by Melarase PM in the evening. Melarase AM contains four active sunblocks, so sunscreen is not needed unless your sun exposure is very high or you had a recent procedure/laser. SPF of 30. Melarase PM contains active skin lighteners to even out skin pigmentation. If you are concerned about the development of pigmentation, contact our office to discuss details and to obtain a regimen for Melarase. 
Recommendations:  5-step Daily Brightening Kit has everything you need to improve dark spots, skin discoloration, melasma, and hyperpigmentation caused by sun exposure, hormones, scarring, and the environment. It’s a powerful daily brightening kit that can help bring out your skin’s natural, healthy glow. Ideal for use on the face, neck, and hands. 
Includes: Melaclenz, Melapads, Melarase AM, Melarase PM, Elevase, and Spectrase
Best, 
Dr. Karamanoukian
Los Angeles

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!

STUBHi there, Melasma is chronic and frustrating. I have it also. You must wear sunblock every day, and you must reapply every hour you are outside and every two hours you are inside. It should be reapplied. I would recommend VI peels every four weeks and Skin Medica's Lytera 2.0 twice daily. I recommend Skin Medica's Total Defense and Repair, which protects against UVA/UVB rays and visible light, and repairs Infrared damage. Above all, before correcting your pigmentary disorder, diligence and consistency with protection from the sun is paramount - and will be very challenging, albeit possible - when living in such a sunny climate.Good luck,

Melasma needs long term commitment with skin care and avoidance of skin factors such as sun exposure (Spectrase Sun Block) which has wide UV spectrum and SPF 30+ protection. 
Daily good habits with topicals may well help you chieve your goals with a good skin system like the Brightening Kit from KareSkin (see link). You may want to start with Melarase and Pigmentation Correction Complex. Scler-X from another vendor is for PIH relief (see link). 
Melarase AM is non hydroquinone based. 
Clear + Brilliant laser can be added once you start your pretreatment with topicals. 
Best
H Karamanoukian MD FACS

i think you are still able to do a Picosure laser with a lens of 10. hard to be sure without seeing you in real life. however the Picosure laser fires 1,000 times faster than any other laser which means there is much less inflammation. In fact, there is NO DOWNTIME. You need to plan 3 treatments, each done one month apart.good luckdavid berman md

Probably a good starting point is to see a dermatologist. It s not just the products that will improve your melasma but a combination of things. Using low dose laser is NOT a problem if the power is kept to a minimum as I see ethnic patients on a daily basis with melasma. Melasma can not be completely cured, however effective treatment are possible. This is because your skin is extremely sensitive to UV and even the smallest amount can stimulate your pigment cells to produce colour. The mainstay of treatment is strict UV protection- hats, sunglasses and SPF every 4 hours.

I prefer to use a combination of creams and laser for melasma. Hydroquinone can be used (5-8%), along with vitamin A creams. I usually start my patients on laser (low dose Q switch or Picosure) a few weeks after they commence on creams. Another laser I use is the Clear and Brilliant in the Permea setting combined with creams.

In some cases I combine glycolic AHA peels, and in other cases low concentration TCA peels. 
All the best, Dr Davin Lim. Laser, surgical and aesthetic dermatologist. Brisbane, Australia 

If this is truly melasma, then there are only two treatments I have found effective. One is the Obagi Nu-Derm System. The other is an IPL that is very restricted in its light output, such as the Ellipse machine. Both work well in ethnic skin.