How to cure melasma, according to a dermatologist

Photo-Illustration: by The Cut; Photo: Getty Images

This column was first published in Valerie Monroe’s newsletter, How not to fuck your facethat you can subscribe to in Substack.

Next, a frustrated reader, asking about a condition she mistakenly refers to as her “miasma mustache.” it’s actually a melasmas mustache, but it can feel just as unpleasant as an unwanted intrusion.

Q: My miasma mustache. Why God why?! What should I do?

TO: I feel your pain. As for the whys and reasons for her problem, I turned, as usual, to HNTFUYF DermDiva Heidi Waldorf.

First, the less good news. “Melasma is much more difficult to improve than standard photodamage hyperpigmentation,” Waldorf said. “It’s triggered by a combination of UV exposure, estrogen, and inflammation in someone who is genetically predisposed.” Unfortunately, we don’t know what makes someone predisposed. Continuing the unfortunate vein, there’s no easy fix with over-the-counter devices or topicals, which have limited effect on melasma and are best used as adjuncts in addition to prescription treatment, Waldorf said.

What is the prescription? “The classic treatment for melasma is a prescription topical cream made up of retinoic acid, hydroquinone, and a corticosteroid,” Waldorf said. He can get the cream as a pre-made brand-name prescription or as a custom blend made by a compounding pharmacy as ordered by his dermatologist (which is usually much less expensive than the brand-name version).

How does the cream work? Retinoic acid, the active retinoid in tretinoin, aids in cell renewal and acts directly on pigmentation, Waldorf said. The hydroquinone “turns off” the enzyme that produces the pigment. And corticosteroids reduce the inflammation caused by retinoic acid and hydroquinone, thus limiting the inflammatory aspect of melasma.

While over-the-counter hydroquinone is available at up to 2 percent, prescriptions typically use concentrations of 4 to 10 percent. (Waldorf generally uses 6 percent.) Retinoic acid is usually prescribed at 0.025 percent, 0.05 percent, or 0.1 percent. The corticosteroid is used in mild to medium potency, Waldorf said.

Although vitamin C, polyphenols, cysteamine, and tranexamic acid are some of the ingredients that commonly help reduce pigmentation, their effects on melasma are less studied. For the most resistant and extensive cases, Waldorf said off-label prescription oral tranexamic acid is effective. But because its main use is to promote clotting to treat uterine bleeding, a thorough review of your medical history is essential before prescribing it.

Although treatment of photodamage pigmentation is straightforward with lasers and other energy-based devices, there is a significant risk of triggering increase pigmentation when using any heat-based device with melasma, Waldorf said. The MOST important strategy to prevent melasma is ultraviolet protection, in other words, sun protection. She recommends a high-strength physical sunscreen, a wide-brimmed hat (I love these and bought one in Tokyo) and/or face shield, and limited outdoor exposure during peak sun hours.

By chance, I recently received some emails about hyperpigmentation, also known as photodamage spots on the face. As Waldorf points out, photodamage is different from melasma and somewhat easier to treat. I wrote about hyperpigmentation and how to diminish it here. Bottom line: You don’t have to live with hyperpigmentation or melasma, no matter how patchy your past.

Valerie Monroe was a beauty director at Ooprah magazine where he wrote the monthly “Ask Val” column for nearly 16 years. Now she writes the weekly newsletter. How not to fuck your face. Her goal continues to be to shift our thinking in the field of beauty from self-criticism to self-pity and learn to be loving witnesses to ourselves and others as we age.

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