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 and outcome assessed according to guidelines adapted from the US Preventive Services Task Force (USPSTF). The consensus of the group was that first-line 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.
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