Melasma and vitiligo are acquired disorders of pigmentation that, despite recent advances, present a therapeutic challenge. This is partly due to their complex pathogenesis. This article includes an evidencebased review of recent advances in the management of these diseases and highlights promising novel and experimental approaches.
Several factors are implicated in the pathogenesis of melasma, including genetic predisposition, UV radiation, thyroid disease, pregnancy, oral contraceptives, and drugs. The current approach to management incorporates a prevention strategy that includes sun avoidance, a broad spectrum sunscreen, discontinuation of oral contraceptives, avoidance of contact allergens and sensitizers, and minimization of heat and friction in the skin. An intrauterine levonorgestrel-releasing device may be safer than oral contraceptives when melasma is concerned.
Topical medications are first-line treatment for melasma. A triple combo cream containing 0.05% tretinoin, 4.0%, hydroquinone (HQ), and 0.01% fluocinolone acetonide is specifically used for moderate-tosevere melasma together with sun protection measures. This triple cream can be safely used for up to 24 weeks with minimal risk of skin atrophy after 6 months of use. Additionally, a plethora of adjunctive topical agents has emerged to assist in the treatment of melasma, including mequinol, azelaic acid, arbutin, Kojic acid, ascorbic acid, rucinol, resveratrol, N-acetyl glucosamine, niacinamide, dioic acid, 4- n-butylresorcinol, oligopeptides, and botanicals such as sylimarin, orchid extracts, and licorice extract. Combining HQ with any of the above products can be more effective than HQ alone. Nonetheless, the efficacy of most of these agents remains to be demonstrated in randomized controlled studies despite promising in vitro and animal data. Some of these compounds are contact sensitizers and/or have other adverse effects.