Treatment is open to NP/PA providers only

• Melasma is considered an acquired hyperpigmentation condition and typically presents on sun-exposed areas of the face as symmetrically distributed pigmented macules and patches in females over 25 (1). It most commonly affects the forehead, cheeks, upper lip, and chin.
  • Many factors play a role in the pathogenesis of melasma, such as:
    • people with naturally darker skin (Fitz Type III or higher), excessive UV radiation, hormones, genetics, and antiepileptic medications (2).
    • Exposure to UV radiation is the main factor in pathogenesis as UV radiation increases alpha-melanocyte-stimulating hormone and adrenocorticotropic hormone levels, which increases the proliferation of melanocytes. (3)
• Treatment is limited to melasma patients only
  • Ex: If condition does not meet criteria for melasma, or you are uncertain, discuss with your Clinical Director. Many mimickers exist — watch for meds onboard that can cause hyperpigmentation.
• All prescriptions for Portrait patients are to be sent in through Treat
• Notify/confer with your Clinical Director if
  • Patient is not responding as expected to therapy
  • Any questions about clinical candidacy

Before treatment is initiated

• mMASI score ideally should be documented
  • You can find a calculator here
• Familiarize yourself with the pitfall of melasma treatment, namely:
  • Exogenous Ochronosis

The following options are available/on formulary

Topical Options * Refer to contraindications page *

• Portrait’s compounded “tri-luma” Rx
  • 8%hydroquinone/0.025%tretinoin/0.1%triamcinolone compounded in versabase or similar, applied QHS
    • Rx is pre-populated in Treat, with added reminder: cycle 1 month on, 1 mo off
    • Note that patients should not use tretinoin in the areas where they are applying “tri-luma” to avoid tretinoin overuse / irritation.
• Topical tranexamic acid, up to 3% for QAM use
• Azelaic acid gel or foam, up to 15% for use 1-2x daily, recommended as OTC or Rx
• Portrait also offers:
  • ZO Skin Health - HQ Pigment Program
  • Pigment Control Cream 4% HQ
  • Pigment Control Blending Cream 4% HQ
• Superficial / medium depth peels
  • As per Portrait protocols
• Microneedling
  • As per Portrait protocols

Systemic Options Refer to contraindications page

• Tranexamic acid is not to be used while pregnant
• Hydroquinone is not to be used while pregnant or breastfeeding
• Research shows that “sun exposure” is a contraindication for hydroquinone use — essentially every patient we treat. [Pubmed]