SAN FRANCISCO – Get the word out to your skin of color patients that effective treatments for melasma are available, Dr. Valerie D. Callender advised.
Dermatologists can do a great service by increasing awareness about therapeutic options for melasma, she said. Although melasma is “a pretty common condition” – affecting an estimated 5 million American women – only 2%-6% seek treatment from a physician (Arch. Dermatol. 1995;131:1453-7).
Melasma, also known as “dyschromia,” was second only to acne on a list of the most common diagnoses list in a study of 1,412 patients at a hospital-based dermatology practice (Cutis 2007: 80:387-94).
“Not only do they have melasma, they may not know there is treatment available,” Dr. Callender said at the seminar, sponsored by Skin Disease Education Foundation (SDEF).
Melasma, an acquired hypermelanosis, often affects sun-exposed areas of the face, neck, and forearms, making it difficult for patients to cloak their condition. A centrofacial presentation is featured in more than half of patients.
Another reason to increase treatment awareness is that melasma has a significant psychosocial impact, Dr. Callender said. “We know from quality of life studies that these women are really suffering,” she commented. Reductions in emotional well-being, social interaction, and recreation and leisure activities are reported (Br. J. Dermatol. 2003;149:572-7).
“Melasma can be emotionally and psychologically devastating,” Dr. Callender said. A study of 300 people with melasma in Brazil found 65% of patients were bothered all or most of the time, 55% were frustrated, and 43% felt unattractive because of their condition (Br. J. Dermatol. 2006;156:13-20).
Melasma can be generalized or localized, and disproportionately affects women. Hormonal changes from oral contraceptives, hormone therapy, and pregnancy are among the etiologies. Genetics, ultraviolet and visible light exposure, and thyroid dysfunction are other known causes. Only about 10% of patients are men,” said Dr. Callender, a dermatologist in private practice in Washington, D.C.
Effective medications for melasma include hydroquinone, tretinoin, and azelaic acid, often prescribed in combination. “We recommend a 3%-4% prescription [of hydroquinone],” Dr. Callender said. Higher-strength formulations are available from compounding pharmacies, but carry a great risk of adverse events. For example, concentrations as high as 8%-10% used in Africa are associated with exogenous ochronosis (where the affected skin gets darker instead or lighter). “Know the safety behind whichever hydroquinone form you choose, and monitor patients closely,” she said.
Chemical peels are sometimes recommended for melasma in combination with hydroquinone, Dr. Callender said.
Regarding safe and effective laser treatment for melasma, “we’re not there yet,” she said. One recent, small study indicates that fractional photothermolysis could hold some promise (Dermatol. Surg. 2010;36:1273-80). After two to seven treatments, five of the eight female patients in the study had a 50% clinical improvement or greater. Of note, there was no reported postinflammatory hyperpigmentation, which has been a limitation of laser therapy for this condition, Dr. Callender said.
Patient education about chronicity is another important goal of counseling. “Melasma is chronic and can come back,” Dr. Callender said. “It is most important to talk to your patients about maintenance therapy.”
Researchers are still searching for the optimal strategy to prevent melasma recurrence. For example, relapses were common in a study that assessed maintenance therapy with a triple-drug combination treatment of hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% (J. Am. Acad. Dermatol. 2010:62:962-7). In this open-label study, 70 patients applied this combination product daily for 6 weeks and then switched to twice-weekly application. A total of 21 patients relapsed and had to return to the daily treatment. “Maybe two times a week is not enough. Maybe three times a week would be better,” Dr. Callender said.
Emphasize the ongoing importance of sun avoidance. “They can finish treatment, go out in the sun for 1 hour, and it comes back,” she said. Advise patients to use sun protection with SPF-30 and “make sure the product you recommend is opaque and does not give a grayish tint to skin of color.” Also, Dr. Callender said she routinely tests for vitamin D levels and recommends patients take supplements as indicated.
She is a consultant and researcher for Allergan Inc., Galderma, Intendis, Medicis Pharmaceutical Corp., and Procter & Gamble.
SDEF and this news organization are owned by Elsevier.