Treatment of melasma involves the use of a range of topical depigmenting agents and physical therapies.
Varying degrees of success have been achieved with these therapies. The Pigmentary Disorders Academy
(PDA) undertook to evaluate the clinical efficacy of the different treatments of melasma in order to generate
a consensus statement on its management. Clinical papers published during the past 20 years were
identified through MEDLINE searches and methodology . The consensus of the group was that firstline
therapy for melasma should consist of effective topical therapies, mainly fixed triple combinations.
Where patients have either sensitivity to the ingredients or a triple combination therapy is unavailable,
other compounds with dual ingredients (hydroquinone plus glycolic acid) or single agents (4% hydroquinone,
0.1% retinoic acid, or 20% azelaic acid) may be considered as an alternative. In patients who failed
to respond to therapy, options for second-line therapy include peels either alone or in combination with
topical therapy. Some patients will require therapy to maintain remission status and a combination of
topical therapies should be considered. Lasers should rarely be used in the treatment of melasma and,
if applied, skin type should be taken into account. 


Melasma is a pigmentary disorder of the face involving the cheeks, forehead, andcommonly the upper lip. This condition is more common in women, accounting for 90% of all cases. It appears in all racial types, but occurs more frequently in those persons with Fitzpatrick skin types IV to VI who live in areas of high
ultraviolet radiation; sun exposure deepens these hyperpigmented areas. Treatment of melasma involves the
use of topical hypopigmenting agents, such as hydroquinone (HQ), tretinoin (RA), kojic acid, and
azelaic acid. Physical therapies, such as chemical peels (glycolic acid [GA], trichloroacetic acid [TCA]),
laser therapy and dermabrasion, similar to that used in other hyperpigmentary disorders, have also been
evaluated with varying degrees of success. One aim of the Pigmentary Disorders Academywas to estimate the clinical efficacy of the different treatments of melasma in order to generate a consensus statement on its management. A research was conducted on therapeutic options for
melasma. Clinical studies (excluding case studies) that have been published over the past 20 years were
reviewed and the data classified according to specific
criteria . Subsequent treatment recommendations were generated on the basis of this published clinical evidence and expert opinion.
TOPICAL THERAPIES
Hydroquinone-HQ inhibits the conversion of dopa to melanin by inhibiting the activity of tyrosinase. Other proposed mechanisms of action are inhibition of DNA and RNA synthesis, degradation of melanosomes, and
destruction of melanocytes.1 HQ can cause permanent depigmentation when used at high concentrations
for a long period of time. It is commonly used at concentrations ranging from 2% to 5%, the higher
concentrations trading off greater efficacy with Abbreviations used:
FA: fluocinolone acetonide
GA: glycolic acid
HQ: hydroquinone
KF: Kligman’s formula
MASI: Melasma Area and Severity Index
RA: tretinoin
TCA: trichloroacetic acid


From:
Dermatology and Aesthetic Center
Departments of Dermatology, Phototherapy, Lasermedicine
Universities of Italy and France
Departments of Dermatology 
Departments of Cutaneous Physiopathology of the San Gallicano Dermatological Institute
International Centres of Study