Melasma treatment

The results of a TCA-SAS peel also depend on the quality and consistent use of cosmeceuticals after the peel. It is clear that a melasma treatment will produce better results if the TCA-SAS peel is followed by the application of a retinol-anti-tyrosinase-anti-oxidant cream or a hydro-quinone-based preparation. For acne or aging or sagging skin, the same comments apply as for AHAs above. These creams can be applied as soon as flaking is finished, usually on the 7th day. 

Any melasma treatment (apart from phenol) must be accompanied by long-term care with antioxidants, tyrosinase inhibitors and effective sun protection for a minimum of 6 months (although 1 year would be more effective). 

This is a permanent polyaUcylimide filler in the form of a removable endoprothesis. Fat transfer is used more often, as there is no risk of rejection and the implant is autologous. See the details of melasma treatment in Chapter 15. 

PIH, whether caused by trauma (e.g. a mosquito bite, scratch or wound), by laser or intense pulsed light (IPL) treatment, or by another peel, usually responds to four sessions of ETCA following the same guidelines as for melasma treatment. 

Lactic acid is an alpha-hydroxy acid not previously utilized in chemical peeling for melasma In a small group of 24 patients, lactic acid was found to be an efficacious and safe peeling agent for melasma treatment and was as effective as Jessner s solution [323]. In a group of seven Indian patients (Fitzpatrick skin types IV-V) treated with lactic acid peeling for superficial acne scarring, improvement was noted [324]. 

Ghersetich I, Troiana M, Brazzini B, Arunachalam M, Lotti T. Melasma treatment with 10 % tretinoic treatment mask J Cosmet Dermatol. 2010 9 117-21. 

Fig. 3.4. a Patient with melasma, b Patient after treatment with Jessner s peeling... 

Fig. 5.4a. Patient with melasma before treatment Fig. 5.4b. Patient with melasma after treatment...

The combination of salicylic acid and TCA 15% is also an effective treatment for mild to moderate photodamage, acne and melasma in types 1-111. Moderate to excellent improvement has been observed (Figs. 10.3a, b, 10.4a, b and 10.5a, b). Hence, the combination salicylic acid/TCA peeling protocol can be used in all skin types. 

Grimes PE (2005) The use of a combination salicylic acid/ trichloroacetic acid 10% chemical peel for treatment of melasma in darker racial ethnic groups. Dermatol Surg (in press)... 

Tretinoin 1% has also been used as a chemical peeling agent [22,23]. The efficacy of tretinoin peels was compared with glycolic acid peels in the treatment of melasma in dark skinned patients [23]. In a split face study of ten Indian women, 1% tretinoin was applied to one half of the face, while 70% glycolic acid was applied to the opposite side. Peels were performed weekly. Significant improvement occurred on both sides as assessed by photographs and a Modi-... 

Lim JT, Tham SN (1997) Glycolic acid peels in the treatment of melasma in Asian women. Dermatol Surg 20 27-34... 

Wang CM, Huang CL, Hu CT, Chan HL (1997) The effects of glycolic acid on the treatment of melasma among Asian skin. Dermatol Surg 23 23-29... 

Sarkar R, Kaur C, Bhalla M, et al (2002) The combination of glycolic acid peels with a topical regimen in the treatment of melasma in dark-skinned patients a comparative study. Dermatol Surg 28 828-832... 

Lawrence NL, Cox SE, Brady HJ (1977) Treatment of melasma with Jessner s solution versus glycolic acid a comparison of clinical efficacy and evaluation of the predictive ability of Wood s light examination. J Am Acad Dermatol 36 589-593... 

Khunger N, Sarkar R, Jain RK (2004) Tretinoin peels versus glycolic acid peels in the treatment of melasma in dark-skinned patients. Dermatol Surg 25 270-273... 

Azelaic acid is a non-phenolic derivative (1,7-hep tanedicarboxylic acid) used at concentration of 10-20% twice a day to treat melasma with minimal side effects (allergic reactions). It acts to disturb the tyrosinase synthesis and can be used as a bleaching agent in patients sensitive to hydroquinone. Better results are obtained if a glycolic acid cream is applied sequentially to azelaic acid treatment. 

It is very difficult to treat melasma. Better results are obtained if between chemical peeling treatments, patients apply topical depigment-ing agents. The synergic action of the two treatments bleaches the skin and reduces melanin formation. 

Fig. i4.8a-d. Melasma of the face before and after combined peeling with 25% salicylic acid and 10% TCA gel. Note in c skin xerosis 2 days after the first treatment... 

Haddad AL, Matos LF, Brunstein F, et al (2003) A clinical, prospective, randomized, double-blind trial comparing skin whitening complex with hydroqui-none vs. placebo in the treatment of melasma. Int J Dermatol 42 153-156... 

Balina LM, Graupe K (1991) The treatment of melasma 20% azelaic acid versus 4% hydroquinone cream. Int J Dermatol 30 893-895... 

Garcia A, Fulton JE Jr (1996) The combination of glycolic acid and hydroquinone or kojic acid for the treatment of melasma and related conditions. Dermatol Surg 22 443-447... 

A new combination formulation containing hydroquinone 4%, tretinoin. 05% and fluocino-lone. 01% was approved in the United States for treatment of melasma. This combination has been approved for use in South America, Singapore, Korea, and Mexico. The formulation was based on the KligmanAVillis formula [44]. In addition, other new hydroquinone formulations contain 4% hydroquinone plus retinol in concentrations of 0.15 or 0.3%. These formulations also improve the dyschromia of photoaging. 

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