What Kind Of Melasma Cream Should I Use?

Topical treatment of melasma is often its first line treatment. Unfortunately for those who are attempting to treat this skin ailment on their own, there are so many over-the-counter melasma cream options that it can be nearly impossible to find one that works.

Let’s make that process a little simpler and review the different types of melasma creams and topical agents available for those ready to rid themselves of those pesky dark patches of skin.

Hydroquinone

The first topical medication often available in cream form that is worth exploring is hydroquinone. Study after study has conclusively shown that this medication is demonstrably effective in the treatment of melasma; it is among the melasma creams that work (Monteiro).

There are some marginal concerns related to the potential side effects of hydroquinone cream for melasma, such as:

• Mild inflammation
• Redness
• Dryness

However, hydroquinone is a potent tool with which to fight against melasma, and it can be used safely, especially under the supervision of a skin care professional who can guide you through your fight against melasma. They will be able to provide you with a melasma cream prescription that will get to work on clearing up your hyperpigmentation quickly. Your dermatologist will know when it is appropriate to modulate the strength of the cream as needed.

Azelaic Acid

Another potent tool to lighten your complexion and deal with persistent melasma is azelaic acid. Although essentially every melasma medication available, cream or otherwise, has not been studied as scrupulously as hydroquinone, there is good clinical evidence to support the efficacy of newer medications like azelaic acid (Sarkar).

Azelaic acid is a naturally occurring compound produced from yeast. It has been available in the US since its approval by the FDA in 2015. Azelaic acid works by affecting melanin synthesis (Abdel). It has the added benefit of working as an antimicrobial agent and therefore has multiple uses that extend beyond treating hyperpigmentation.

Several studies of azelaic acid have corroborated its status as a known skin-lightening agent (Sarma et al). In fact, studies have shown efficacy similar to that of the well-established hydroquinone.

Because azelaic acid cream for melasma will thin your skin, its use is associated with higher sensitivity to UV radiation, so liberal broad-spectrum sunscreen use is recommended. Other side effects might include a slight stinging sensation or dryness, both of which indicate that your medication is working.

Triple Cream

By now, anyone who has melasma is likely acutely aware of how difficult it is to treat this condition. Unfortunately, despite several medications exhibiting evidence of efficacy, no single medication or treatment has ever risen as the definitive answer to melasma (Sarma et al.).

As a result, the approach to melasma will often involve combination therapy, and topical treatment will often consist of the use of multiple melasma-fighting agents at once.

This so-called triple cream for melasma, similar to the ones here at Kirsch Dermatology, will blend several of the most effective creams, especially ones that have been shown to work well in conjunction with each other.

One of these combinations is hydroquinone with fluocinolone acetonide and tretinoin. This particular combination of medication has been shown to work well, even better than the “gold standard” melasma treatment hydroquinone when used as monotherapy (Chan). The idea in using all three in conjunction is simple: the tretinoin works to promote cell turnover of the outer layer of skin to allow the bleaching agent, hydroquinone, to penetrate more deeply into the skin. And because some amount of inflammation is endemic to hydroquinone’s mechanism of action, a corticosteroid like fluocinolone acetonide is used to mitigate some of that inflammation.

Note that some of these adjunct medications work best synergistically with other medications. For example, monotherapy in the form of tretinoin cream for melasma is not optimal (Sarma et al.).

Silymarin

Beyond the aforementioned chemicals, there are still other topical agents that are sold as skin lighteners and depigmentation agents. Some of these are plant extracts like silymarin, more commonly known as milk thistle.

While not as effective when used as monotherapy, silymarin cream for melasma can work as ancillary medication to more standard treatment. Many of these natural extracts are powerful antioxidants which can treat melasma as well as some of the side effects associated with bleaching products like hydroquinone (Karimi). Silymarin is not known to be toxic to humans, but like all medications, it does carry some risk for an allergic reaction.

Pycnogenol

Similarly to silymarin, pycnogenol cream for melasma is an antioxidant that can decrease inflammation and prevent cell damage. In the one study done to determine its effect on melasma, patients did exhibit less hyperpigmentation than their control group (Muhammad). More research will need to be carried out before pycnogenol can be corroborated as an effective melasma treatment.

Tretinoin

Tretinoin is used in the treatment of melasma; however, it is typically used as an adjunct melasma treatment and is not recommended as monotherapy (Sarma et al.). Tretinoin does not directly bleach skin in the same way that a hydroquinone based topical treatment would. It helps to promote cell turnover and is therefore effective in combination with bleaching agents to allow medications to penetrate more deeply into the skin.

Like almost any medication, there are some side-effects associated with tretinoin:

• Increase skin sensitivity
• Mild irritation
• Skin dryness
• Increases your sensitivity to UV rays

Therefore, liberal sunscreen use is recommended alongside application of tretinoin.

Kojic Acid

Kojic acid is a byproduct of fungi with a variety of medicinal and commercial applications. It is a known depigmentation agent (Desai). It works through its ability to regulate tyrosinase and therefore melanin production.

The primary side effect of kojic acid is that it can contribute to dermatitis in some patients (Nakagawa). It is also associated with heightened skin sensitivity that is characteristic of most topical treatments which bleach the skin in some form.

Which Type Of Melasma Cream Should I Use?

Ultimately, melasma treatment is difficult because of the complicated nature of its underlying causes, and choosing a melasma cream that works for you isn’t a straightforward process. Consult with a board certified dermatologist to get additional support.

References

• Abdel Naser Zaid* and Rowa’ Al Ramahi, “Depigmentation and Anti-aging Treatment by Natural Molecules”, Current Pharmaceutical Design (2019) 25: 2292. https://doi.org/10.2174/1381612825666190703153730
• Chan, R., Park, K., Lee, M., Lee, E.‐S., Chang, S., Leow, Y., Tay, Y.‐K., Legarda‐Montinola, F., Tsai, R.‐Y., Tsai, T.‐H., Shek, S., Kerrouche, N., Thomas, G. and Verallo‐Rowell, V. (2008), A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0·01%, hydroquinone 4%, tretinoin 0·05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma. British Journal of Dermatology, 159: 697-703. doi:10.1111/j.1365-2133.2008.08717.x https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2133.2008.08717.x
• Desai, S., Ayres, E., Bak, H., Manco, M., Lynch, S., Raab, S., . . . Zheng, Q. (2019, May 1). Effect of a Tranexamic Acid, Kojic Acid, and Niacinamide Containing Serum on Facial Dyschromia: A Clinical Evaluation. Retrieved April 19, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/31141852
• Karimi G, Vahabzadeh M, Lari P, Rashedinia M, Moshiri M. “Silymarin”, a promising pharmacological agent for treatment of diseases. Iran J Basic Med Sci. 2011;14(4):308–317. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586829/
• Monteiro RC, Kishore BN, Bhat RM, Sukumar D, Martis J, Ganesh HK. A Comparative Study of the Efficacy of 4% Hydroquinone vs 0.75% Kojic Acid Cream in the Treatment of Facial Melasma. Indian J Dermatol. 2013;58(2):157. doi:10.4103/0019-5154.108070 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657227/
• Muhammad Kamran Khan, Larysa Paniwnyk and Sadia Hassan, Polyphenols as Natural Antioxidants: Sources, Extraction and Applications in Food, Cosmetics and Drugs, Plant Based “Green Chemistry 2.0”, 10.1007/978-981-13-3810-6_8, (197-235), (2019). https://onlinelibrary.wiley.com/doi/abs/10.1002/ptr.1085
• Nakagawa, M., Kawai, K. and Kawai, K. (1995), Contact allergy to kojic acid in skin care products. Contact Dermatitis, 32: 9-13. doi:10.1111/j.1600-0536.1995.tb00832.x https://www.ncbi.nlm.nih.gov/pubmed/7720390
• Sarkar R, Gokhale N, Godse K, et al. Medical Management of Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group. Indian J Dermatol. 2017;62(6):558–577. doi:10.4103/ijd.IJD_489_17 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724303/
• Sarma N, Chakraborty S, Poojary SA, et al. Evidence-based Review, Grade of Recommendation, and Suggested Treatment Recommendations for Melasma. Indian Dermatol Online J. 2017;8(6):406–442. doi:10.4103/idoj.IDOJ_187_17 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5707834/

Share this Article

Brandon Kirsch, MD

Brandon Kirsch, MD, FAAD, is a board-certified dermatologist specializing in clinical drug development and medical innovation. He is the founder of Kirsch Dermatology in Naples, Florida and is also the Chief of Dermatology at the Naples Community Hospital.