I really want to talk about melasma. When I came into medical dermatology, I was really unfamiliar with it. 10 years later, we know a little more about it as well as some treatment options. There was a patient we were treating at the first practice I worked at who had really bad melasma, and looking back, I can't believe what we were doing. I think a lot of people still don't know the best steps to take.

There's a genetic component that is causing people to be more susceptive to melasma, and it's been reported in 41-61% of patients in Brazil. Skin pigmentation really does follow an inheritance pattern. There's also an inflammation component that I don't think we were appreciating until recently.

We're now at the point where we can really look at melasma, accept that there's no cure, and determine the best treatment. First of all, sun protection is key, and it should be started early. You should use a physical sunscreen rather than a chemical one, as chemical sunscreens can actually flare parts of the melasma.

Hydroquinone is another topical treatment, and it interferes with the melasma genesis. It prohibits DNA/RNA synthesis that alters the formation of melasma. However, hydroquinone can cause some rebound pigmentation in the long-term. Azelaic is another good topical treatment, and it can be used during pregnancy whereas hydroquinone cannot.

There are also some oral treatments that need more research, but moving to in-office methods, chemical peels are fantastic. There are also people that will use IPL or BBL lasers, but I never would. It's not a solution, it's a bandaid. We certainly don't have all the answers for treating melasma right now, but some devices are really helping us find good solutions.

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