Severe melasma that doesn’t respond to treatment, and is life altering!

Hi Dr. Irwin. I'm 50 years old and Chinese ethnicity. I'm struggling with melasma. Also I have the Hashimotos and sjogren antibodies, however, the Dr said my thyroid is fine and no sjogren disease. I used triluma and was please with the results. I switched to finacea foam (15% azelaic acid) & tretinoin to maintain results. It's been 8 days since I started azelaic acid and notice my melasma slowly darkening. What should I do now? Due to my antibodies, I was told that lasers and peels should be avoided. Am I at a lost cause and nothing can help me? Will melasma start to fade once I reach menopause? I avoid sun like the plague, apply sunscreen every 2 hrs and 3-4 hours if I'm indoors in the office (I sit away from windows and only turn on a small light). I wear hats and sunglasses when outdoors. I'm doing everything possible. This is discouraging and I feel like I'm being punished.

My heart goes out to you on this. Especially your last sentence. Many people with this problem struggle with how persistent it is, how difficult it is to make improvements and feel discouraged. I just want you to know that you are not alone and there is a whole community of people who are reading this and sending you some empathy. I personally have melasma too from my pregnancies (ok… 22 years ago now) and mine is not visible any more.

Please take hope because there are many things we can do now and it WILL improve if you do them. Be patient it’s slow, but eventually you’ll have great control, even if there is no true “cure”  –  YET!  🙂

Usually, Hashimotos, Sjogrens and other autoimmune diseases are not a cause of melasma. Some autoimmune diseases cause increased sensitivity to UV light, but generally that is a minor effect. Same for the medications often used to treat these diseases.

The basics for melasma – always, always, always!!

The two enemies of melasma are hormones and natural light.

  • A large brimmed hat every time outside.
  • A high zinc (15-20%) sunscreen every morning and 20 minutes before going outside.
  • A second high zinc sunscreen that you can layer over the first one every morning and when going outside. (See the Colorscience powder brush option).
  • Keep female hormones stable and lower estrogen is better. Work with your gynecologist and tell her/him you have melasma.
  • During pregnancies, try to be outside early in the am or in the evening… not midday.
  • Use a lightening cream daily on the whole face. If you are using a hydroquinone based system, try to use only 4 months of the year. The rest of the year use a plant based lightening cream like Lytera. You can use the plant based creams twice a day.
  • Light peels done by an experienced aesthetician with strict light/sun avoidance, are fine for melasma, even with most autoimmune diseases.

Resources for very severe, stubborn melasma:

  • Look for an academic dermatology department at a large university near you for more specialized help. For example, Dr. Pearl Grimes and associated dermatologists at UCLA are internationally known. The Mayo Clinic and the Cleveland Clinic also have derm departments.
  • Consider a thorough evaluation by an endocrinologist because there are other conditions associated with glands that can cause pigment and make melasma worse.
  • Consider a thorough evaluation by a gynecologist to rule out hormone issues that might be making the melasma worse.
  • Certain medications can make melasma/pigment worse. You can look this up on the web usually.

Newer options to discuss with your doctor:

  • If there is a visible network of small blood vessels in the area of melasma, treating these with a pulsed dye laser may be helpful.
  • Topical Tranexamic acid. The oral version has serious potential side effects.
  • Polypodium leucotomas, oral and usually dosed at 240mg three times a day for 12 weeks.
  • Oral glutathione. Warning: DO NOT USE INTRAVENOUS (IV) GLUTATHIONE. Several deaths have been associated with IV.

Hope this helps, Dr. I


Dr. Brandith Irwin, MD

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Hi, I’m Dr. Irwin. I believe that consumers deserve a medically trained and unbiased skin care advocate.

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