INTRODUCTION
Melasma is a term derived from the Greek word “ melasâ€
meaning black. Melasma is an acquired light or dark brown hyperpigmentation that commonly occurs on the sun exposed areas, most often on the face and arms.1,2 It is more common in females as compared to males. Males constitute only 10% of the melasma patients.3 The condition is most commonly seen in persons with Fitzpatrick skin types IV – VI,4 especially among those living in areas of intense ultraviolet radiation i.e. Asia, Middle East and South America.5
Various factors which are proposed in pathogenesis of melasma are genetic factors, UV light exposure, hormonal changes like pregnancy, lactation, ingestion of contraceptive hormones such as estrogen and progesterone, diethylstibesterol, medications
such as phototoxic and anti seizure drugs, cosmetics and thyroid dysfunction.6-10 However, it may be idiopathic also.5
Clinical examination of the melasma under Wood’s light (wavelength 365nm) helps to determine the location of melanin in the skin as the epidermal form of melasma is enhanced under Wood’s light whereas dermal form shows no enhancement.11 The term mixed and indeterminate are used to denote those forms of melasma that have equivocal enhancement under Wood’s light.12
Though there is a wide variety of therapeutic options available for this condition, management still remains a challenge. Besides the broad spectrum sunscreens, various topical therapies which are used for the treatment of melasma are hydroquinone in concentration
of 2%-5%;13 topical retinoids in the form of 0.1% tretinoin,14 0.05% isotretinoin15, adapalene 0.1%16 and topical corticosteroids17 which are used alone or in combination. In addition, azelaic acid,18 kojic acid,19 alpha hydroxy acids like glycolic acid,20 vitamin C,21 arbutin22 and licorice extract23 are also used. Combination of various topical agents have also been used by many workers for better results which include combination of retinoic acid plus hydroquinone,24 glycolic acid plus hydroquinone25 and glycolic acid plus kojic acid.19 The triple combination of hydroquinone, retinoic acid and topical steroid in various concentrations like hydroquinone 5% plus tretinoin 0.1% plus dexamethasone 0.1% known as Kligman’s formula26 or hydroquinone 2% plus tretinoin 0.05 % plus betamethasone valerate 0.1 %27 or hydroquinone 4% plus tretinoin 0.05 % plus flucinolone acetonide 0.01%28 have been shown to enhance the efficacy of treatment in melasma. Oral therapies like oral pycnogenol, grape seed extracts etc. have also been tried in melasma with moderate results.29,30
Chemical peeling has now become an established technique for the treatment of melasma. Depending upon the depth of peeling, the chemical peeling agents are classified into very superficial,superficial, medium and deep peels.31 In dark skinned individuals, deep chemical peels should not be used as it may result in post inflammatory hyperpigmentation.31 In Indian pa-
