Table 8.
Level and quality of evidence for melasma therapies
| Therapy | Level of evidence | Quality of evidence | References |
|---|---|---|---|
| Topical | |||
| 2% HQ | II–ii | C | [83] |
| 4% HQ | I | B | [27, 43, 78, 85] |
| 0.1% tretinoin (RA) | I | B | [20, 100] |
| 0.05% RA | I | C | [92] |
| 0.05% Isotretinoin | II–ii | C | [92, 101] |
| 4% N-acetyl-4-S-Cysteaminylphenol | III | C | [101, 102] |
| 5% HQ + 0.1–0.4% RA + 7% LA/10% AC | III | C | [102, 103] |
| 3% HQ + 0.1% RA | III | C | [102, 103] |
| 2% HQ + 0.05% RA + 0.01% fluocinolone acetonide | I | A | [38, 39, 41, 74, 85, 103, 104] |
| 2% HQ + 0.05% RA + 0.01% dexamethasone (modified KF) | III | C | [55, 86] |
| 2% HQ + 0.05% RA + 0.01% dexamethasone (modified KF + 30–40% GA peel) | III | B | [55, 86] |
| 5% HQ + 0.1% RA, and 1% hydrocortisone | III | C | [32, 33] |
| 4% HQ + 5% GA | II–ii | B | [104, 105] |
| 4% KA + 5% GA | II–ii | B | [98, 99] |
| 2% KA + 2% HQ + 10% GA | II–iii | C | [83, 84] |
| 2% HQ + 10% GA | II–iii | C | [83, 84] |
| 4% HQ + 10% GA | I | B | [105, 106] |
| 20% Azelaic acid | I | B | [42, 43] |
| 20% Azelaic acid + 0.05% RA | III | C | [106, 107] |
| Vitamin C iontophoresis | II–i | C | [107, 108] |
| Adapalene | II–ii | B | [99, 100] |
| Chemical peels | |||
| 10–50% GA | II–ii/III | C | [53, 59] |
| 10% + 2% HQ + 20–70% GA | II–ii | C | [56, 58] |
| 20–30% GA + 4% HQ | II–i | B | [108, 109] |
| 70% GA | II–i | B | [109, 110] |
| Jessner’s solution | II–i | C | [109, 110] |
| 20–30% Salicylic acid | III | C | [54, 55] |
| 1–5% RA | III | C | [108, 111] |
| 50% GA + 10% KA | III | C | [109, 112] |
| Laser therapy (+ chemical peels + topical therapies) | |||
| Q-switched ruby | IV | C | [110, 113] |
| Pulsed CO2 + Q-switched alexandrite | IV | C | [67, 68] |
| Q-switched alexandrite laser | IV | C | [69, 70] |
| Q-switched alexandrite laser + 15–25% TCA peel + Jessner’s solution | III | C | [111, 114] |
| Erbium: YAG | III | D | [112, 115] |
| Dermabrasion | II–iii | E | [76, 113] |
In accordance with the US preventive services task force levels of evidence for grading clinical trials. Reproduced with permission from [48]
A: There is good evidence to support the use of the procedure, B: There is fair evidence to support the use of the procedure, C: There is poor evidence to support the use of the procedure, D: There is fair evidence to support the rejection of the use of the procedure, E: There is good evidence to support the rejection of the use of the procedure
AC ascorbic acid, GA glycolic acid, HQ hydroquinone, KA kojic acid, KF kligman’s formula, LA lactic acid, RA retinoic acid, TCA trichloroacetic acid