Dermal melasma

Dermal melasma treatment

• Up to 20% of melasma can be resistant to medical therapy
• Dermal or deep melasma is harder to shift compared to superficial melasma
• Medical management entails vascular modulators & prescription topicals.
• Treatment options include specific non-ablative lasers & off label pico lasers
• Treatments are aimed at rebuilding the deeper structure of skin
• It often takes 6 to 12 months or longer for improvements to be seen
• Not all cases respond to laser

Why is it harder to treat?

As pigmentation is deep, this form of melasma is-

1. Out of reach to superficial lasers & chemical peels such as Dermelan & Cosmelan. 
2. Deep pigment requires your immune system to carry away pigment, as compared to superficial pigmentation that can be exfoliated. 
3. Dermal melasma requires special lasers in particular wavelengths to target deep pigmentation. Not all lasers are capable of penetrating into the deeper layers of skin. 
4. Dermal melasma requires remodeling of the dermis. This often takes months to years to achieve.

How do I know if I have dermal melasma?

Diagnosis is tricky, so be guided by your dermatologist. Deep dermal melasma can be diagnosed via 3 ways-

Clinically: a keen eye can pick the difference between mixed & primarily dermal melasma. The latter is gray, the form is brown-gray, whilst primarily epidermal melasma is brown. 

Dermatoscopically: is the best way to diagnose dermal pigmentation. Gray dots & pigment dropout can be seen with a 10X polarizing microscope. 

Woods light examination: is an old fashioned method, blue light highlights superficial pigment, deeper pigment is not visible. 

Biopsy: is the last line, but is super useful to exclude exogenous pigment-ochronosis. 

Your clinician should not label you as dermal melasma unless the above criteria are met as superficial melasma can also be resistant to treatment. 

What is the difference between resistant melasma & dermal melasma?

It is complex, but- dermal melasma is usually resistant to treatment, whilst mixed melasma can also be resistant to treatment. Confused? Read more. 

Factors that may contribute to ‘resistance’ (as opposed to true dermal melasma) include- 

1. Failure to initiate medical therapy for melasma. Medical therapy is provided by a dermatologist. This includes prescription topicals & systemics as well as tailored peeling or laser programs. 
2. Sun protection. This is the cornerstone of melasma management. Correct sun protection, correct sunscreen, correct application amount & frequency is pivotal to managing melasma. This is the biggest factor overlooked by patients. 
3. Accidental sun exposure. The sensitivity of melasma is such that the smallest amount of light can flare up pigment. 10 minutes of unprotected exposure can reverse  vigilance for the whole month. 
4. Heat & other sources of IR or infrared radiation. Especially in cooks, both occupation & domestic. Other sources include saunas & hot yoga. 
5. Inability to initiate, comply or tolerate medical therapy. This entails correct topical use as well as other adjunctive therapy. One can only lead a horse to water. 

Dermal melasma is often resistant to treatment, however the clinician should NOT label it as ‘dermal’ unless the depth of pigmentation is known. 

What topicals can you add to treat dermal melasma?

HQ is the standard, however it has to be used under supervision or side effects are not uncommon. Your dermatologist will guide you. Other agents include- 

• Cyspera- Cysteamine
• Meladerm, Melacream
• Ascorbic acid 15%, vitamin E, ferulic acid, kojic acid 
• Azelaic acid
• Niacinamide
• Botanicals such as bearberry extract & licorice root

A sensible option is to add specific antioxidants to your current first line topical therapy. 

Can chemical peels such as Cosmelan treat dermal melasma?

Novel peels such as Cosmelan, Dermamelan or the Vi Precision Peel can be effective in some cases of melasma, however they are dismally ineffective in dermal melasma. The depth of penetration is too shallow to target deep pigment. 

Deep peels such as phenol peels can be effective in some cases, however they have the risk of permanent hypopigmentation.

Tell me more about RF microneedling & dermal melasma

RF microneedling with devices such as the Potenza or Sylfirm X can be considered in dermal melasma. They work by-

1. Strengthening the basement membrane of skin to reduce the dropout of pigment into the dermal layers. 
2. Modulation of blood vessels 
3. Exfoliation of pigment & increased absorption of topicals (minimal effects).
4. Destruction of older cells (senescence) that play a role in cellular cross talk. 

RF microneedling is not our first line treatment of dermal melasma. In exceptional cases, it may be effective. 

• RF microneedling requires 8-10 sessions over 12 months
• Failure rate for dermal melasma is high, over 80%

Will supplements help with dermal melasma?

There are two sensible supplements that you can try, they can have marginal effects in some cases. Given the lack of side effects & low cost, we encourage patients to supplement their photoprotection with – 

1. Polypodium leucotomos extract (PLE). It can provide additional pigment clearances & is most useful as adjunctive therapy. The dose is 480 mg polypodium twice a day.
2. Oral glutathione at a dose of 250 to 500 mg daily. This acts as an antioxidant & skin

What is the difference between ochronosis & dermal melasma?

It can be tricky to tell the difference between the two, but here is a quick summary. 

Exogenous ochronosis is primarily due to over use of hydroquinone. It looks like dermal melasma but has several distinct differences, including-

• Clinically evident spots & dots that are raised (caviar spots) 
• Dermatoscopic signs of ‘worm bodies’ or squiggles
• Histological features of banana shaped bodies in the upper dermis

Your dermatologist can tell the difference upon close dermatoscopic examination. A biopsy is useful if in doubt.

What conditions can look like dermal melasma?

Many conditions can resemble dermal melasma, however a dermatologist can usually tell the difference. They include-

• Ochronosis due to overuse of HQ. 
• Hori naevi are more defined but can coexist with melasma
• Post inflammatory hyperpigmentation 
• Ashy dermatosis
• Pigmentation demarcation lines
• Ota naevi (bilateral)

Can dermal melasma be diagnosed virtually or via photos?

It is hit and miss. Photos can give some idea of the type of pigment & the depth, but a dermatoscopic examination in real time is best. The accuracy of photos are around 40-50%, whilst a 10x magnificent polarized light examination carries over 90% accuracy.

What is the cost for treating dermal melasma?

A lot. Unlike standard melasma, a dermatologist is involved. This adds to the cost of therapy. As a guide, lasers by a dermatologist range between $890 to $990 per session. Factor in 6 to 10 sessions & the cost adds up. In contrast, lasers by our physician & nurses are ¼ the costs of a dermatologist. 

*We aim to run a laser clinic in a public hospital in 2026/2027, this is under the umbrella of clinical research, limiting patient contact with a senior dermatologist. This may enable patients to undertake cost effective (free) treatments.