To assess interventions used in the management of all types of
melasma: epidermal, dermal, and mixed.
SEARCH STRATEGY: In May 2010 we searched the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, and LILACS. Reference lists of articles and ongoing trials registries were also searched.
SELECTION CRITERIA: Study selection, assessment of methodological quality, data extraction, and analysis was carried out by two authors independently.
MAIN RESULTS: We included 20 studies with a total of 2125 participants covering 23 different treatments. Statistical pooling of the data was not possible due to the heterogeneity of treatments. Each study involved a different set of interventions. They can be grouped into those including a
bleaching agent such as
hydroquinone, triple-combination creams (
hydroquinone,
tretinoin, and
fluocinolone acetonide), and combination
therapies (
hydroquinone cream and
glycolic acid peels), as well as less conventional
therapies including rucinol,
vitamin C iontophoresis, and skin-lightening complexes like Thiospot and Gigawhite.Triple-combination cream was significantly more effective at lightening
melasma than
hydroquinone alone (RR 1.58, 95% CI 1.26 to 1.97) or when compared to the dual combinations of
tretinoin and
hydroquinone (RR 2.75, 95% CI 1.59 to 4.74),
tretinoin and
fluocinolone acetonide (RR 14.00, 95% CI 4.43 to 44.25), or
hydroquinone and
fluocinolone acetonide (RR 10.50, 95% CI 3.85 to 28.60).
Azelaic acid (20%) was significantly more effective than 2%
hydroquinone (RR 1.25, 95% CI 1.06 to 1.48) at lightening
melasma but not when compared to 4%
hydroquinone (RR 1.11, 95% CI 0.94 to 1.32).In two studies where
tretinoin was compared to placebo, participants rated their
melasma as significantly improved in one (RR 13, 95% CI 1.88 to 89.74) but not the other. In both studies by other objective measures
tretinoin treatment significantly reduced the severity of
melasma.Thiospot was more effective than placebo (SMD -2.61, 95% CI -3.76 to -1.47).The adverse events most commonly reported were mild and transient such as skin irritation,
itching, burning, and stinging.
AUTHORS' CONCLUSIONS: The quality of studies evaluating
melasma treatments was generally poor and available treatments inadequate. High-quality randomised controlled trials on well-defined participants with long-term outcomes to determine the duration of response are needed.