What is your approach to treating patients with melasma that does not respond to hydroquinone-based topical therapies?

This is my Melasma algorithm:

1. Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen
2. Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare)
3. Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/azelaic in the morning
4. Cysteamine cream a few times weekly at bedtime
5. Add on microneedling to topicals before higher-risk things (peels, lasers)

Depends on the reason one is not responding. For example, one of our approaches for treating patients that are not responding to hydroquinone is a product called Cyspera. This cream helps to decrease melanin pigment within the skin without the use of HQ or Retinol. Easy to apply, leave on uncleaned skin for 15-20 min and wash off daily.

Another example is if the person has been using HQ too long and it has stopped working then we would recommend starting the non-HQ ZO Skin health protocol. Including Daily power def. Retinol skin brighter, exfoliation accelerator, wrinkle and texture repair, hydrating cream and, of course, SPF.

Micro-needling as well as chemical peels after the patient has been using products for 5 weeks to suppress melanin...