title: Evidence-based treatment for melasma: expert opinion and a review.
abstract: BACKGROUND
  Melasma is one of the most common pigmentary disorders seen by dermatologists and often occurs among women with darker complexion (Fitzpatrick skin type IV-VI). Even though melasma is a widely recognized cause of significant cosmetic disfigurement worldwide and in India, there is a lack of systematic and clinically usable treatment algorithms and guidelines for melasma management. The present article outlines the epidemiology of melasma, reviews the various treatment options along with their mode of action, underscores the diagnostic dilemmas and quantification of illness, and weighs the evidence of currently available therapies.
  
  
  METHODS
  A panel of eminent dermatologists was created and their expert opinion was sought to address lacunae in information to arrive at a working algorithm for optimizing outcome in Indian patients. A thorough literature search from recognized medical databases preceded the panel discussions. The discussions and consensus from the panel discussions were drafted and refined as evidence-based treatment for melasma. The deployment of this algorithm is expected to act as a basis for guiding and refining therapy in the future.
  
  
  RESULTS
  It is recommended that photoprotection and modified Kligman's formula can be used as a first-line therapy for up to 12 weeks. In most patients, maintenance therapy will be necessary with non-hydroquinone (HQ) products or fixed triple combination intermittently, twice a week or less often. Concomitant camouflage should be offered to the patient at any stage during therapy. Monthly follow-ups are recommended to assess the compliance, tolerance, and efficacy of therapy.
  
  
  CONCLUSIONS
  The key therapy recommended is fluorinated steroid containing 2-4% HQ-based triple combination for first line, with additional selective peels if required in second line. Lasers are a last resort.
authors.affiliation: Department of Dermatology, Skin Diagnosis Centre, Mahabodhi Mallige Hospital, Manipal Hospital, 98, HAL Airport Road, Bangalore, 560017, Karnataka, India, dermakrupa@yahoo.com.
authors.forename: Krupa
authors.initials: K
authors.lastname: Shankar
authors.forename: Kiran
authors.initials: K
authors.lastname: Godse
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Aurangabadkar
authors.forename: Koushik
authors.initials: K
authors.lastname: Lahiri
authors.forename: Venkat
authors.initials: V
authors.lastname: Mysore
authors.forename: Anil
authors.initials: A
authors.lastname: Ganjoo
authors.forename: Maya
authors.initials: M
authors.lastname: Vedamurty
authors.forename: Malavika
authors.initials: M
authors.lastname: Kohli
authors.forename: Jaishree
authors.initials: J
authors.lastname: Sharad
authors.forename: Ganesh
authors.initials: G
authors.lastname: Kadhe
authors.forename: Pashmina
authors.initials: P
authors.lastname: Ahirrao
authors.forename: Varsha
authors.initials: V
authors.lastname: Narayanan
authors.forename: Salman Abdulrehman
authors.initials: SA
authors.lastname: Motlekar