Melasma in Latin America: options for therapy and treatment algorithm.
OBJECTIVE
To examine approaches to therapy for melasma in Latin Americans and to propose treatment algorithms for patients with mild, moderate and severe melasma.


BACKGROUND
Melasma is prevalent in up to 10% of the Latin American population. It is found in all racial groups and is more common in subjects with darker skin phototypes. A number of topical treatments and procedures have been used for melasma. Topical treatments containing hydroquinone are the most popular. Care must be taken when treating melasma to avoid inducing post-inflammatory hyperpigmentation and ochronosis. Determination of the severity of melasma (using the Melasma Area Severity Index and/or Physician's Global Assessment) and choice of the most effective and suitable treatment and/or procedure for individual patients is therefore essential. Sun protection is mandatory for all melasma patients.


METHODS
Thirty-one clinical studies of topical treatments, chemical peels and laser and other therapies used for treating melasma were assessed for the level and quality of clinical evidence, by the Latin American Pigmentary Disorders Academy. The results of this analysis were combined with differential diagnosis guidelines and methods for assessing treatment success to establish algorithms for treating mild and moderate-to-severe melasma.


RESULTS
The most appropriate first-line treatment for mild melasma is hydroquinone 4%, triple combination cream containing hydroquinone 4%, tretinoin 0.05% and fluocinolone acetate 0.01%, double combination (e.g. 4% hydroquinone and 0.1% tretinoin) or non-phenolic therapy where there is an allergy to compounds. In moderate-to-severe melasma, triple combination cream is the recommended first-line treatment. Second-line treatment is double combination or hydroquinone 4% where triple therapy is not available or if allergic to compounds. Sun avoidance measures and broad spectrum sunscreens with high SPF are fundamental for the successful management of the disease.
Cestari
T
T
University of Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Brazil. tcestari@terra.com.br
Arellano
I
I
Hexsel
D
D
Ortonne
J P
JP
D000465:Algorithms; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine; D005446:Fluocinolone Acetonide / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000627:therapeutic use; D006801:Humans; D006873:Hydroquinones / Q000008:administration & dosage / Q000627:therapeutic use; D007843:Latin America / Q000453:epidemiology; D008548:Melanosis / Q000188:drug therapy / Q000453:epidemiology*; D011788:Quality of Life; D014212:Tretinoin / Q000008:administration & dosage / Q000627:therapeutic use
D006873:Hydroquinones; D005446:Fluocinolone Acetonide; D014212:Tretinoin; C035394:fluocinolone; C031927:hydroquinone