how not to f*ck up your face

How to Get Rid of Melasma, According to a Dermatologist

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

This column first ran in Valerie Monroe’s newsletter, How Not to F*ck Up Your Face, which you can subscribe to on Substack.

Ahead, a frustrated reader, who asks about a condition she mistakenly refers to as her “miasma mustache.” It’s actually a melasma mustache, but it can feel as unpleasant as an unwanted intrusion.

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

A: I feel your pain. As for the whys and wherefores of your problem, I turned, as usual, to HNTFUYF DermDiva Heidi Waldorf.

First, the less-good news. “Melasma is much harder to improve than standard hyperpigmentation from photodamage,” said Waldorf. “It’s triggered by a combination of ultraviolet exposure, estrogen, and inflammation in someone who happens to be genetically predisposed.” Unfortunately, we don’t know what makes someone predisposed. Continuing in the unfortunate vein, there isn’t an easy fix with over-the-counter topicals or devices, which have limited effect on melasma and are best used as adjuncts, in addition to prescription treatment, said Waldorf.

What’s the prescriptive? “The classic treatment for melasma is a prescription topical cream composed of retinoic acid, hydroquinone, and a corticosteroid,” said Waldorf. You can get the cream as a preprepared branded prescription or as a customized mix made by a compounding pharmacy as ordered by your dermatologist (which is usually much less expensive than the branded version).

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

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

Though vitamin C, polyphenols, cysteamine, and tranexamic acid are some of the ingredients commonly shown to help reduce pigmentation, they’re less well studied for their effects on melasma. For the most resistant and extensive cases, Waldorf said that oral tranexamic acid prescribed off-label is effective. But because its primary use is to promote clotting to treat uterine bleeding, a thorough review of your medical history is critical before it’s prescribed.

Although treating pigmentation from photodamage is straightforward with lasers and other energy-based devices, there’s a significant risk of triggering increased pigmentation when using any heat-based device with melasma, Waldorf warned. The MOST important strategy to prevent melasma is ultraviolet protection—in other words, sunscreen. She recommends a high concentration physical sunblock, a brimmed hat (I love these and bought one in Tokyo) and/or face shield, and limited outdoor exposure during peak sun time.

Serendipitously, I recently received a few emails about hyperpigmentation—a.k.a. the spots on your face from photodamage. As Waldorf notes, above, 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 spotty your past.

Valerie Monroe was beauty director at O, The Oprah Magazine, where she wrote the monthly “Ask Val” column for nearly 16 years. Now she writes the weekly newsletter How Not to F*ck Up Your Face. Her goal continues to be to shift our thinking in the beauty arena from self-criticism to self-compassion and to learn how to be loving witnesses to ourselves and one another as we age.

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