Managing Melasma in a 51-Year-Old Female Patient
By: Ashley Baldree
At Village Dermatology, serving patients across Katy and Houston, Texas, we frequently evaluate and manage pigmentation disorders, including melasma. This case highlights the journey of a 51-year-old female patient who presented for a follow-up evaluation of persistent melasma.
Patient History
The patient has been managing melasma affecting her left inferior lateral malar cheek and right inferior central malar cheek. Her initial treatment regimen included:
Gentle cleanser for daily skin care
Moisturizer with SPF 30+ applied every morning
Hydroquinone (applied to dark spots at night for two months)
Tretinoin (a pea-sized amount applied nightly to the entire face)
At follow-up, she reported ongoing use of hydroquinone and tretinoin but noted limited improvement. She also mentioned using niacinamide, which we recommended she reserve for morning application, separate from prescription medications.
Due to her hormone replacement therapy, she was not a candidate for tranexamic acid, a treatment sometimes used for resistant melasma. Instead, we advised continuing and optimizing her topical therapy, with careful cycling of hydroquinone use—three months on, followed by one month off—to minimize side effects.
Examination and Findings
Hyperpigmentation consistent with melasma was observed on both cheeks.
No evidence of secondary complications such as pseudoochronosis (a rare side effect of hydroquinone use).
The patient was otherwise in good health, alert, oriented, and not in acute distress.
Treatment Plan
Our treatment plan for this patient included:
Continuation of topical hydroquinone (compounded prescription strength).
Nightly tretinoin to improve skin cell turnover and enhance pigment fading.
Daily broad-spectrum sunscreen SPF 30+, reinforced as essential in preventing worsening hyperpigmentation.
Patient education regarding triggers of melasma, such as sun exposure, hormonal changes, and heat.
She will return for a follow-up evaluation in four months to assess progress.
Patient Counseling
We discussed the following with the patient:
Expectations: Melasma is a chronic skin condition that requires consistent management. While improvement is expected, recurrence is common, especially with sun exposure.
Side Effects: Hydroquinone may cause dryness, irritation, or rare paradoxical darkening of the skin. Retinoids can cause dryness and peeling, especially when first started.
Sun Protection: Daily sunscreen use, sun-protective clothing, and minimizing direct sun exposure are critical for long-term improvement.
Conclusion
Melasma can be frustrating, but with the right combination of topical treatments, sun protection, and patient education, many patients achieve meaningful improvement. At Village Dermatology in Katy and Houston, Texas, our team tailors treatment plans to each individual’s needs while providing guidance on safe and effective long-term skin care.
If you are struggling with melasma or other pigmentation concerns, schedule a consultation with us to explore your treatment options.
