Topical Anti-Estrogen Therapy To Treat Melasma

DEAR EDITOR:

I read with interest the recent report by Snyder et al1 describing melasma associated with the application of a topical estrogen cream. The development of melasma is multifactorial and female sex hormones have been implicated in the pathogenesis of this condition.2 Estrogen receptor expression is increased in melasma lesions.3 Also, melanogenesis of cultured human melanocytes can be stimulated by estrogens and inhibited by estrogen antagonists.4

The induction of melasma with a topical estrogen raises the possibility that the treatment of this condition could be facilitated by the use of a topical anti-estrogen. I recently proposed a novel topical approach for the treatment of melasma that utilized an anti-estrogen, such as a selective estrogen receptor modulator (tamoxifen or raloxifene) or an aromatase inhibitor (anastrozole or tetrozole or exemestane).5 The topical agent would also include a vascular endothelial growth factor inhibitor (bevacizumab) that would be directed toward blocking the angiogenesis component of melasma pathogenesis.5 Investigation of this novel—topically administered—therapy for melasma is warranted.