Treatment of Melasma: systematic review

Introduction: Melasma is an acquired hypermelanosis of sun-exposed areas. The pathophysiology of melasma is uncertain. The most important factor in the development of melasma is exposure to sunlight, but it has also seems to be related to hormonal and vascular factors, genetic predisposition, and proteins related to tyrosinase. Due to its refractory and recurrent nature, the treatment of melasma is often diffi cult. The goals of treatment often include prevention or reduction of the affected area with the fewest possible adverse effects. The principles of therapy include protection against UV radiation, the inhibition of activity of the melanocytes and melanin synthesis. Objective: To perform a systematic review to identify the most effective and safe treatment, including topical treatments, oral treatments and surgical procedures for the melasma. Method: The study was conducted in the period from February 5th to March 15th 2009, using three databases: MEDLINE (1966-2009), Cochrane Library and LILACS. After establishing criteria for the selection of studies,the best controlled and comparative studies were described individually. Results: 703 articles in MEDLINE, 89 in LILACS and 100 in Cochrane Library have been detected, and from 143 articles 10 were descriptive studies (6,99%), 30 were reviews (20,97%), and 103 were randomized controlled trials (72,03%). Descriptive studies and reviews were analyzed together. Forty two articles with the best design were chosen for individual description. Twelve of 42 included controlled studies (28,57%) and 30/42 were comparative (71,43%), like split face 18 from 42 (42,86%) or parallel groups, 24 from 42 (57,14%), and 34 from 42 randomized (80,95%). Eight (19,05%) studies had the ideal design, i.e., blind placebo-controlled. Limitations: Heterogeneity of the studies, few with good methodological quality. Conclusions: The use of broad-spectrum sunscreen is important, as is topical hydroquinone, the most common treatment for melasma. Other skin-lightening agents include retinoic acid, azelaic acid, kojic acid and others. Combination therapies increase efficacy as compared with monotherapy. Chemical and physical peels, laser treatments, and intense pulsed light therapy are additional modalities that have been used to treat melasma.

Keywords: MELASMA, HYPERPIGMENTATION, CHLOASMA, TREATMENT