Melasma management in primary care

BackgroundMelasma, a condition characterised by hyperpigmented patches on the face, is one of the common skin conditions in women seeking treatment from primary care practitioners (PCPs).Several treatment modalities are available for PCPs as well as dermatologists.Each treatment option has its pros and cons, including accessibility and cost. ObjectiveThis article aims to explore and address the treatment options that PCPs can offer for melasma. DiscussionThis article outlines how to offer treatment from the PCP's perspective conveniently and cost-effectively.Combined topical treatment seems to be the first-line form that PCPs can offer and manage in the general practice setting.Of the various treatments available, the triple combination of topical hydroquinone with retinoid and corticosteroid is widely described in the literature.MELASMA, also known historically as chloasma or the mask of pregnancy, is an acquired skin hyperpigmentary disorder and is common among adult women.Melasma is characterised by brown or dark-brown pigmentation symmetrically involving the face: cheeks, forehead, nose, upper lip, chin and jawline.Figure 1 shows melasma in a woman and in a man.Melasma may start with macules that later become large patches with ill-defined borders and no pruritus.Based on the depth of pigment infiltration as determined using a Wood lamp, dermatoscope or histology, melasma is divided into epidermal, dermal and mixed (combined epidermal and dermal) types.1,2 Although the prevalence of melasma globally has been reported to be 1% based on data from Western countries, its prevalence is actually much higher, especially in women with skin of colour, namely those with Fitzpatrick phototypes III-V (ie those of Asian, Middle Eastern, Mediterranean African and Hispanic/Latin American descent), commonly affecting those aged 30-50 years.[3][4][5] In this population of women, the actual prevalence of melasma has been reported to range from 9% to 40%, with higher rates among South Asian and Southeast Asian women.[3][4][5][6] Aboriginal and Torres Strait Islander and Polynesian women are also affected, although no exact data have been established for these groups.Men can also be affected by melasma, but this is rare, with a male to female ratio of 1:9. 4 In women, melasma can cause psychological morbidity, with aesthetic concerns and low self-esteem affecting quality of life.Thus, it is important to know how to manage melasma at the primary care practice (PCP) level when it is encountered.Common differential diagnoses for melasma are listed in Table 1.5,6 Melasma can readily be diagnosed clinically based on the distribution and characteristics of pigmentation, as well as skin type or ethnicity, and a biopsy is rarely required.The cause of melasma is complex and multifactorial, and the precise aetiopathogenesis remains largely unknown.However, the risk factors listed in Box 1 are related to the development of melasma, 1,5,7,8 and are important to identify and address.