Preventing Melasma Recurrence (chloasma, pregnancy mask): any hope ? (For professionals)

Preventing melasma recurrence: prescribing a maintenance regimen with an effective triple combination cream based on long-standing clinical severity. Arellano I, Cestari T, Ocampo-Candiani J, Azulay-Abulafia L, Bezerra Trindade Neto P, Hexsel D, Machado-Pinto J, Muñoz H, Rivitti-Machado MC, Sittart JA, Trindade de Almeida AR, Rego V, Paliargues F, Marques-Hassun K. J Eur Acad Dermatol Venereol. 2012 May;26(5):611-8. doi: 10.1111/j.1468-3083.2011.04135.x. Epub 2011 May 31.

• Melasma (Chloasma) (Pregnancy Mask) is a skin problem which typically affects females of childbearing age. Although many etiological theories exist, the cause of this condition remains largely unknown.
• Melasma is classified in many ways but because of the varying efficacy of treatments, we prefer the classification according to the depth of the localization of pigment. Its depth can be epidermal, dermal or mixed (differentiation may be done by using Wood’s lamp or confocal microscopy). Epidermal melasma is the easiest to treat and responds to topical (local) treatments. Dermal melasma tends to respond partially to IPL (Intense-Pulsed light). Mixed Melasma is the most common type and its treatment yields mixed results. All types can be improved by using sunprotection (typically with a SPF of 30 or higher, prefer a sunblock to a chemical sunscreen).

• Multiple treatments are available ranging from creams (which are the mainstay of treatment) to laser treatment (more exactly IPL (flash lamp, intense pulsed light).

Goal: To evaluate the efficacy of a triple combination cream (fluocinolone acetonide, hydroquinone and tretinoin) after being used as a treatment for 8 weeks

Methodology:

• In this article 320 patients with mild to moderate melasma (Global Severity Score (GSS) of 2 or 3) were enrolled in Brazil (20) and Mexico (80).and were put into 2 groups with a different therapeutical regimen:

1. either the triple combination cream was applied twice a week
2. either the treatment was applied three times a week for a month, then twice a week the second month and the once a week thereafter.

• Evaluation of results was done according to the following methods:

1. Global Severity Score (GSS)
2. Melasma Area and Severity Index (MASI)
3. Subject’s Assessment
4. Quality of life questionnaire (MelasQol)
5. side effects.

Results

• After daily treatment for 8 weeks, of 242 patients remaining at the end of the study, 78.8% of them had no or little melasma left. After 6 months, 53% of patient remained relapse-free. No difference was observed between the 2 therapeutical regimen groups (after 190 days of treatment).

Comments

• According to our experience, all the treatment effects are difficult to maintain with time and this study is interesting as it tries to deal with this issue.
• The authors conclude that 78.8% of patients showed a clearance of melasma or a slight residual melasma. This result could be over evaluated; indeed 78 patients did not make it to the end of the study (of the 320 patients initially, 242 ended the study). One of the reasons is that in some patients, the lesions persisted or relapsed during the first 8 weeks of treatment (according to the GSS score)…one can comment here that there is no mention of the methodology and one can speculate that the authors never took into account of the depth of the pigmentation.
• Also, one can doubt the ability of a cream to penetrate into the dermis (The authors only mention”moderate to severe” melasma without mentioning the depth of pigmentation).

Study financed by Galderma® and one of the authors is an employee.