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Melasma (1 of 8)

Melasma (1 of 8)

(1 of 8)

1 Patient presents w/ symmetric hyperpigmented macules, which can be confl uent or punctate suggestive of melasma

2 DIAGNOSIS No ALTERNATIVE Does clinical presentation DIAGNOSIS confirm melasma?

Yes

A Non-pharmacological therapy • Patient education • Camoufl age make-up • Sunscreen B Pharmacological therapy Monotherapy • or •

TREATMENT Responding to No treatment? See next page

Yes

Continue treatment © MIMSas required

Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.

B94 © MIMS 2019 • • • • • Solar & ultraviolet exposure is the most important factor in its development inits isthe important factor most exposure &ultraviolet Solar &common their inwomen years during before Rare reproductive More common inwomen than in men commonlyMost aff &IV III Fitzpatrickects skinphototypes - (chloasma) &w/the ofcontraceptive use commonly Occurs most w/ pills - ofthe &arms , neck areas the sun-exposed in lightoccurring macules todark brown irregular by skindisorder characterized Acquired hyperpigmentary

© &certain orthyroid cosmetics dysfunction, ovarian mild genetic factors, implicated , intheOther etiopathogenesis factors are photosensitizing MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B A B A Patient unresponsive to initial therapy toinitial Patient unresponsive Chemical peels Chemical • • • Triple  Combination erapy therapy Pharmacological • • • • • therapy Non-pharmacological • or • •  Combination Dual erapy therapy Pharmacological • • • therapy Non-pharmacological Topical steroid Tretinoin plus Hydroquinone plus therapy Sunscreen Camouflage make-up Patient education acid Azelaic Tretinoin Hydroquinone plus Sunscreen Camouflage make-up Patient education Melasma (2of8) 1 Responding to Responding treatment? MELASMA B95 No Yes Continue treatment Continue treatment as required as © MIMS 2019

MELASMA MELASMA • • • Laser erapy • • (IPL) Light Intense Pulsed • Dermabrasion/Microdermabrasion • Cryosurgery Physical erapies • Camouflage make-up • Sunscreens • • Patient Education • • Exam Physical onclinical characteristics based is Diagnosis • Classifi cation • Wood’s Exam Lamp • • • • • Combination of QS + fractional CO +fractional Combination ofQS resistant toother treatment second-line therapies as incases Used fractional lasers, (QS) Eg Q-switched poorly responds w/coften lesions pigmented than toIPL deeper better respond Epidermal types adjuvant treatment as therapy totopical used May be melasma fordermal used May be are tofreezing susceptible anoptionbecause May be coverageHeavy whileblending w/unaff oflesions skincolor mayected help thatUse UVA of sunscreens block light are highly recommended &UVB ordiscontinuation pregnancy oforalcontraceptive after resolved pills Oftentimes Avoid sunlight exposure - pattern onclinical classifi may be Based to: ed Patient macularhyperpigmentation w/well-demarcated presents tantobrown - w/enhancement Light brown, ofpigmentation under Wood’s light - Epidermal orboth the , excessive localize tothe tovisually , Used ofpigmentation the involved °ree area Grades - &chin malarregion, left forehead, right malarregion, involved: which relies on4areas Index(MASI), usingthe &Severity Area Melasma measured may be Severity Pigment may have also abluishappearance are the over lesions ramus Mandibular ofthe mandible - &nose oncheeks appears Malar - Indeterminate &dermis foundinepidermis Melanin deposition - enhancement only Dark brown, areas insome isseen - Mixed - orbluish-gray, Ashen noenhancement ofpigmentation under Wood’s light - Dermal Epidermal pigment ismore amenable totreatment than pigment dermal - - - -

Positive results were seen w/ the use of pulsed CO w/the ofpulsed werePositive use seen results Broad spectrum sunscreen w/SPF >30coverage sunscreen isrecommended Broad spectrum Wear clothing protective when going outdoors &chin ,nose forehead, upper &patches w/macules ontheCentrofacial cheek, isthe common most type Melanin increase in basal, suprabasal &stratum suprabasal layers corneum inbasal, melanocytes &pigmented Melanin w/highlydendritic increase layer melanophages onthePerivascular superfi inthe w/less epidermal dermis cial &deep - Melanin deposition found indermis Melanin deposition - Inapparent under Wood’s light - © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing A NON-PHARMACOLOGICAL THERAPY 2 & QS + IPL are forallskintypes recommended +IPL & QS 2 Melasma (3of8) DIAGNOSIS B96 2 laser w/ Q-switched alexandrite laser alexandrite w/Q-switched laser © MIMS 2019 • • • • • • Tretinoin Topical • • • Mequinol • • • Kojic Acid • • • • • Hydroquinone Topical Agent Depigmenting • • Topical Corticosteroids • • acid Salicylic • • • acid) Lactic , (Glycolic Acid • • • • Peels Chemical • • • • Acid Azelaic forms are generally than forms Cream irritating gels less &solution toirritation pigmentation secondary increase May also Typically improvement clinical 2months at takes least tosee Eff incombination when used w/other are seen monotherapy compounds results as but better ective synthesis dopachrome well conversion as as transcription thereby interrupting melanin Inhibits Actions: toreduce0.05-1% preparations pigmentation are known lentigines whenincombination given forsolar Usually w/Tretinoin used melanocytes whilesparing tyrosinase inhibits Competitively Action: alternativeA phenolic treatment depigmenting agent as forHydroquinone-intolerant used patients With potential highsensitizing TyrosinaseAction: inhibitorthat chelates copper at the ’s activesite analternative treatment depigmenting agent as A non-phenol forpatients used allergic toHydroquinone incombination used w/otherMay be agents at permanent highconcentrations cause when used Can oftime foralongperiod greater skinirritation at concentrations used Commonly 2-5%, higher from concentrations ranging greater effi provide but w/ cacy - tyrosinase AhydroxyphenolicActions: compound that the conversion inhibits ofDOPA tomelanin inhibitionof by forthe treatment used ofhyperpigmentation formany been decades Has combination oftriple combinations part therapy as were if previous Used ineffective acetateEg 0.01%Fluocinolone More eff incombination when treatments used w/topical ective activity tyrosinase Inhibits Actions: that melasma wellStudies epidermal lacticacidworks against showed are effAlso adjunctive agents as treatments totopical ective activity tyrosinase Inhibits Actions: of the skin chemical applying agents by Performed tothe skintoinduce exfoliation ofthe progressive superfi cial layers rate ofpatientsImproves the therapy response totopical alternative therapy as agentsRecommended iftopical combination &triple therapy are noteff ective acid,Trichloroacetic acid,Mandelic Glycolic acid,Phytic Salicylic Eg acid,Resorcinol, acid,Lactic acid incombination used w/otherMay be agents Studies that have shown effi- iscomparable acidformelasma ofAzelaic tothatcacy w/Hydroquinone Eff ects: - AnaturalActions: acidthat eff dicarboxylic antiproliferative has &cytotoxic onmelanocytes ects pigmentation tolessen 10, 15,20&35%preparations are used

melanocytes of destruction &promotes induces ofmelanosomes degradation synthesis, &RNA DNA inhibits Also specifireductase, synthesis dehydrogenases &DNA c mitochondrial thioredoxin enzyme cell membrane-associated including inhibitionoftyrosinase, mechanisms several by Acts © MIMS 1-2 mth intensity after in melasma seen Reduction may w/continuous be application forupto8 mth Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B PHARMACOLOGICAL THERAPY Melasma (4of8) B97 © MIMS 2019

MELASMA MELASMA • • Combination erapies • Others • • • Tranexamic Acid • • Vitamin (Nicotinamide, Niacinamide B3) • • Arbutin • • () Acid Ascorbic Adjunctive erapies • • • • Adapalene • - combination used widely therapy Most - therapeutic success than monotherapy combination triple Fixed dose therapy w/Hydroquinone, acid&corticosteroids greater Retinoic provides effi toincrease Employed &reduce sideeffcacy ects (Pycnogenol) Indomethacin, Vitamin Rucinol, Gigawhite, Pyocyanidin E, Coff Orchid, Soybean, AloePlant vera, (Licorice, seed, extracts Grape algae), marine tea, eeberry, Green the toprove Further effi studiesare needed ofTranexamiccacy acidformelasma orally, given May be formulation incombination topical often subcutaneously, w/other agents ortopically; - inhibitorthat UV-induced aplasmin prevents pigmentation as Acts Actions: PAR-2 Action: adjunctive therapy skinlightening as duetoits formelasma &brighteningUsed effects 5,6-hydroxyindole-2-carboxylic maturation acid,&melanosome tyrosinase, Inhibits Action: analternative treatment as ofHydroquinone toHydroquinoneA derivative used thereby melanin inmelanocytes reducing production tyrosinase, Directly inhibits Action: Alternative treatment toHydroquinone skinlightening that eff adverse w/less provides ects Studies that show Adapalene effi isequally comparedcacious toTretinoin follicular epithelial Modulates cellActions: differentiation binding to specifi by c nuclear acid receptor retinoic treatment melasma forlong-term 0.1% preparations are used Alternative treatment forTretinoin-intolerant patients - Hydroquinone, Glycolic acid&/orKojic acid - &Tretinoin Mequinol - acid Hydroquinone &Azelaic - Hydroquinone acid &Retinoic - Other combination therapies include: -

penetration, allowing pigment elimination & increasing keratinocyte proliferation pigment elimination keratinocyte allowing penetration, &increasing Addition ofTretinoin the oxidation 0.05-0.1%prevents improving epidermal well ofHydroquinone, as as formelanogenesis needed & arachidonic acidproduction prostaglandin reduces w/cinturn bindingtokeratinocytes plasminogen prevents melanogenesis: inhibits Also metabolism eff cellular decreasing inhibitingmelanin by well synthesis as as ofthe agents, hypopigmenting ects Addition ofcorticosteroids the toacombinedirritative therapy involving Hydroquinone decreases 0.1% Tretinoin in patients combination to triple acid are orsensitivity 20% Azelaic used who develop therapy combinationDual therapy w/Hydroquinone &Glycolic acidorsingleagent therapy w/4%Hydroquinone, © MIMS receptor the modulating protease-activated melanin by transfer synthesis melanosome after Inhibits Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not B Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) Melasma (5of8) B98 © MIMS 2019 1 Combination w/ other emollients are available. Please see latest MIMS forspecifiCombination latest w/other MIMS emollients see are available. Please c formulations. oi cdCemApply to Cream Kojic acid Apply to soap Cream, Apply to Glycolic acid Cream Arbutin Mandelic acid 40% soln Apply a few Apply afew 40%soln Mandelic acid (micronized) acid Azelaic Drug Drug Products listed above may not be mentioned in the management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Available 20% cream 15% gel & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly Strength All dosage recommendations are for non-pregnant & non- women, women, &non-breastfeeding non-pregnant for are recommendations dosage All Available Available © MIMS Strength EMOLLIENTS, CLEANSERS&SKINPROTECTIVES Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing TREATMENT PREPARATIONS afterwards cold Wash off w/ 10-20 min & leave for face cleansed on drops 6 mth 12 hrly x aff area ected Apply to 12-24 hrly aff area ected 12 hrly aff area ected 12 hrly aff area ected Dosage Dosage Dosage Guidelines Melasma (6of8) • • • Instructions Special • Reactions Adverse • • Instructions Special • • Reactions Adverse B99 • • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse • Instructions Special • • Reactions Adverse Apply sunscreen & avoid sun exposure during use Apply during &avoid sunscreen sunexposure Avoid contact w/eyes application Test to ofthe onasmallarea the prior skinbehind ear redness Irritation, Avoid contact w/eyes Avoid toexcessive radiation exposure sunlight orUV , photosensitivity burning ofapplication: pruritus, Skin irritation, frequency Usually w/continued resolve decreasing orby use Avoid contact w/eyes Use w/ caution inpatients <12 yr toapplication prior area andpatClean dry photosensitivity occasional , contactIrritant , Avoid &other contact mucous w/eyes membranes toapplication prior area andpatClean dry photosensitivity occasional erythema, contactIrritant dermatitis, Use w/caution inpatients <12 yr hyperpigmentation w/highconcParadoxical photosensitivity occasional erythema, contactIrritant dermatitis, Remarks Remarks 1 © MIMS 2019

MELASMA 1 Combination w/ other emollients are available. Please see latest MIMS forspecifiCombination latest w/other MIMS emollients see are available. Please c formulations. acid Tranexamic (Nicotinamide) Niacinamide extract Licorice Hydroquinone Drug Drug EMOLLIENTS, CLEANSERS&SKINPROTECTIVES Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed oia e Apply to Topical gel cream Topical lotion, serum Cream, 4% cream, gel4% cream, gel2% cream, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All Available © MIMS Strength Available Strength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 12 hrly aff area ected 12 hrly aff area ected Apply to 12 hrly aff area ected Apply to OTHER DERMATOLOGICALS Dosage Dosage Guidelines 12 hrly Apply toaff areas ected Melasma (7of8) Dosage B100 • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse complications Use w/caution inpatients at forthrombotic risk burning pruritus, erythema, Skin irritation, Avoid use during sunexposure Wash face thoroughly toapplication prior sensation, irritation burning skin,erythema, Dry Avoid contact w/eyes toapplication prior area andpatClean dry photosensitivity occasional erythema, contactIrritant dermatitis, • • • • Instructions Special • Reactions Adverse darkening ofthe skinoccurs Discontinue blue-black ifagradual 2 mth after oftreatmentis noted Discontinue ifnolightening use eff ect inpatientsContraindicated <12 yr infl occurs) response ammatory formation, vesicle orexcessive itching, contraindication, butdiscontinue if isnota unbroken skin(minorredness of tosmallarea applying by product Test using before for skinsensitivity &nailbleaching postinfl pigmentation, ammatory transient erythema, mild burning, , dermatitis, Irritant Remarks 1 (CONT’D) Remarks © MIMS 2019

MELASMA MELASMA 1 Available in combination w/ vitamins. Please see latest MIMS forspecifi latest MIMS Available see Please incombination w/vitamins. c formulations. furoate mometasone tretinoin/ Hydroquinone/ acetonide fl uocinolone tretinoin/ Hydroquinone/ glycolic acid Hydroquinone/ acid) (Retinoic Tretinoin Topical Preparations Pyocyanidin Drug Drug 1 Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed gel 0.1% microsphere gel 0.04% microsphere 0.1% soln 0.1% cream lotion, soln gel,0.05 %cream, gel0.025% cream, gel0.01% cream, cap 24 mgsoft-gelatin furoate 1% furoate Mometasone Tretinoin 0.025%, Hydroquinone 2%, acetonide 0.01% Fluocinolone Tretinoin 0.05%, Hydroquinone 4%, Glycolic acid10%, Hydroquinone 2%, Glycolic acid4%, Hydroquinone 2%, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, are for & non-breastfeeding non-pregnant All recommendations dosage © MIMS Available Strength Available Strength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing OTHER DERMATOLOGICALS (CONT’D) Please see the end of this section for the reference list. reference the for section this of end the see Please COMBINATION THERAPIES Dosage Guidelines bedtime Apply 24 hrly at 24 mg PO 12-24hrly 24 mgPO aff area ected tothethe evening Apply once dailyin surrounding skin surrounding &0.5 cmof on lesions bedtime min before Apply once daily30 the aff area ected nightduring timeto Apply once daily Melasma (8of8) Dosage Dosage B101 • • Instructions Special • • Reactions Adverse • Instructions Special • Reactions Adverse • Instructions Special • Reactions Adverse • Instructions Special • Reactions Adverse • • • Instructions Special • Reactions Adverse or UV radiation or UV Avoid toexcessive exposure sunlight concentrationincrease tolerated as formulation w/weaker Start & hyperpigmentation, photosensitivity or hypo- temporary ofthe skin, crusting blistering, , peeling ofwarmth, erythema, feeling ofapplication: Stinging, frequency Usually w/decreasing resolve Take w/food GI eff (GIupset) ects See individual components individual See components individual See See individual components individual See components individual See Avoid treatment during sunexposure membranes angle, thin skin,ormucous Avoid mouth, nose contact w/eyes, inpatientsContraindicated <12yr erythema & eyes, nose skinaround the skin,cracked Dry Remarks Remarks © MIMS 2019

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