Melasma Management
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Direct answer
Sun protection with a broad-spectrum, re-applied sunscreen does more for melasma than any prescription cream, because visible light — not just ultraviolet — drives pigment in Indian skin. Next in the ladder is triple combination cream (hydroquinone 2–4% with tretinoin and a mild steroid, the Kligman regimen) used for a limited four-to-six-month course, with azelaic acid as the pregnancy-safe alternative and oral tranexamic acid as an adjunct in refractory cases. Wood's lamp typing into epidermal, dermal and mixed melasma sets expectations: epidermal responds, dermal barely does — the distinction NEET-PG Medicine examiners expect.
What you must remember
- Three clinical patterns: centrofacial (commonest), malar and mandibular — the last typically in older women.
- Wood's lamp: epidermal melasma shows accentuated brown contrast and responds best; dermal appears grey-blue without accentuation and resists treatment; mixed is intermediate.
- Triggers: ultraviolet and visible light, pregnancy (the "mask of pregnancy"), combined oral contraceptives, thyroid disease; a family history is common in Indian skin.
- Triple combination cream at night for up to four to six months only — prolonged hydroquinone risks exogenous ochronosis, particularly in darker phototypes.
- Azelaic acid 10–20% is effective and safe in pregnancy.
- Visible-light protection requires iron-oxide-containing tinted sunscreens; clear UV filters alone underperform in skin of colour.
- Oral tranexamic acid (commonly 325 mg twice daily) is an adjunct for refractory melasma, contraindicated with thromboembolic risk.
- Procedures — glycolic acid peels, microneedling — are adjuncts after photoprotection and topicals, not first moves.
- Recurrence with sun and hormone exposure is the rule; maintenance shifts to non-hydroquinone agents.
How to work through a typical case
A 34-year-old woman develops symmetric brown-grey patches over the cheeks, forehead and nose during her second pregnancy; they persist two years later while she takes combined oral contraceptives for contraception.
Step one: characterise — symmetric, photosensitive hypermelanosis over the centrofacial pattern in a woman of childbearing age is melasma clinically; exclude the mimics by history: no prior drug intake (minocycline, amiodarone), no adrenal features, and no ashen-grey gradual photoexposed change suggesting exogenous ochronosis. Step two: type it with Wood's lamp — accentuation marks the epidermal component (good prognosis), a grey-blue non-accentuated hue marks dermal pigment (guarded prognosis), and most Indian patients are mixed. Step three: remove drivers — discuss progestin-only or non-hormonal contraception and enforce sun discipline: broad-spectrum SPF 30+ sunscreen in generous quantity, reapplied at midday, preferably iron-oxide tinted to block visible light, plus hats and avoidance of peak hours. Step four: treat — since she is not pregnant, triple combination cream nightly for four months with monthly review, watching for irritation, rebound or early ochronotic darkening, then step down to azelaic acid or a non-hydroquinone maintenance regimen. Step five: if response plateaus after adequate photoprotection, add oral tranexamic acid after screening for thrombotic risk, and consider serial glycolic peels in combination, never as a substitute for sun avoidance. Throughout, the counselling that melasma improves with discipline rather than disappearing with one prescription is therapy in itself.
Where students slip
The predictable error is unlimited-duration hydroquinone: examiners specifically probe how long triple combination may be used and what prolonged use causes — exogenous ochronosis, a bluish-black discolouration that is largely irreversible and commoner in darker races. The second slip is forgetting pregnancy safety: azelaic acid is the answer for the pregnant patient, not hydroquinone or tretinoin combinations. Third, candidates prescribe "sunscreen SPF 50" and stop — without reapplication and visible-light coverage, Indian phototypes relapse within weeks. Fourth, dermal melasma treated aggressively with peels yields dyschromia and disappointment; the Wood's lamp typing must be cited before promising results.
Frequently asked questions
How is melasma classified using the Wood's lamp?
Epidermal melasma shows enhanced brown contrast and responds well; dermal melasma shows grey-blue colour without enhancement and responds poorly; mixed type shows partial enhancement.
What is triple combination cream and its usage limit?
Hydroquinone 2–4% with tretinoin and a mild topical steroid (the Kligman regimen), applied at night for a limited course, generally no more than four to six months to avoid exogenous ochronosis and steroid atrophy.
Which topical agent is preferred for melasma in pregnancy?
Azelaic acid 10–20%, which is effective and safe in pregnancy, unlike hydroquinone-based combinations.
Why do clear sunscreens fail in Indian melasma?
Ultraviolet filters alone do not block visible light, which independently stimulates melanogenesis in darker phototypes; iron-oxide-containing tinted formulations provide visible-light protection.
When is oral tranexamic acid used?
As an adjunct in refractory melasma at commonly 325 mg twice daily, after excluding thromboembolic contraindications, always layered over photoprotection.