Q: My 34 years old aunt is having melasma for many years now. She has used many topical creams like tri-luma cream and sunblocks to get rid of it. Initially, she got an excellent response but later she had a relapse of melasma. Now her skin has become photosensitive, dry and red. Does she need to undergo any investigations?

A:While there is no cure for melasma, many treatments have been developed. Melasma may disappear after pregnancy; it may remain for many years, or a lifetime. Sunscreens are essential in the treatment of melasma. They should be broad spectrum, protecting against both UVA and UVB rays from the sun. A SPF 30 or higher should be selected. In addition, physical sunblock lotions and creams such as zinc oxide and titanium oxide may be used to block ultraviolet radiation and visible light. Sunscreens should be worn daily, whether or not it is sunny outside, or if you are outdoors or indoors. A significant amount of ultraviolet rays is received while walking down the street, driving in cars, and sitting next to windows. Any facial cleansers, creams, or make-up, which irritates the skin, should be stopped, as this may worsen the melasma. If melasma develops after starting birth control pills, it may improve after discontinuing them. Melasma can be treated with bleaching creams while continuing the birth control pills. A variety of bleaching creams are available for the treatment of melasma. These creams do not bleach the skin by destroying the melanocytes, but rather, decrease the activity of these pigment-producing cells. Over-the-counter creams contain low concentrations of hydroquinone, the most commonly used depigmenting agent. This is often effective for mild forms of melasma when used twice daily. A dermatologist may prescribe creams with higher concentrations of hydroquinone. Normally, it takes about three months to substantially improve melasma. Creams containing tretinoin, steroids, and glycolic acid are available in combination with hydroquinone to enhance the depigmenting effect. Other medications, which have been found to help melasma, are azelaic acid and kojic acid. It is important to follow the directions of your dermatologist carefully in order to get the maximum benefit from your treatment regimen and to avoid irritation and other side effects. Remember, a sunscreen should be applied daily in addition to the bleaching cream. Some bleaching creams are combined with a sunscreen. Chemical peels, microdermabrasion, and laser surgery may help melasma, but results have not been consistent. These procedures have the potential of causing irritation, which can sometimes worsen melasma. Generally, they should only be used by a dermatologist in conjunction with a proper regimen of bleaching creams and prescription creams tailored to your skin type. People should be cautioned against non-physicians claiming to treat melasma without supervision because complications can occur. Management of melasma requires a comprehensive and professional approach by your dermatologist. Avoidance of sun and irritants, use of sunscreens, application of depigmenting agents, and close supervision by your dermatologist can lead to a successful outcome.