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. 2017 Mar 21;3(1):11–20. doi: 10.1016/j.ijwd.2017.01.004

Table 1.

Proposed therapeutic ladder for melasma

First-line Therapy Control of risk factors (sun protection, discontinue hormone treatments or photosensitizing medications)
  • -

    Topical anti-Tyrosinase therapy

  • -

    Other inhibitors of the melanin synthetic pathway

    (e.g., protease-activated receptor-2 inhibitor)

  • -

    Topical exfoliant

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    Triple combination topical cream, if tolerated
Second-line Therapy Combination of first-line treatments + series chemical peels
Third-line Therapy Combination of first-line treatments with:
  • -

    NAFL (1927 nm)

  • -

    NAFL (1550 nm, 1540 nm, or 1440 nm)

  • -

    Fractional radiofrequency devices
Fourth-line Therapy Combination of first line treatments with:
  • -

    Intense pulsed light (test spots)

  • -

    Q-switch laser

NAFL, nonablative fractional laser.