Table 1.

Review of treatments for melasma and post-inflammatory hyperpigmentation.

Treatment	Mechanism of action	Disadvantages	Strength of Recommendation Taxonomy (SORT)
Photoprotection	- Reduces UV and visible light exposure, which is known to induce inflammatory responses stimulating and exacerbating pre-existing hyperpigmentation	- Needs to be reapplied regularly - Is not an active treatment for depigmentation	B
Topical/systemic
Hydroquinone and combinations	- Inhibit tyrosinase activity - Promote melanocyte destruction - Promote degradation of melanosomes	- Erythema, burning, pruritis, desquamation - Hydroquinone halo - Ochronosis	A
Retinoid	- Vitamin A derivative - Increase epidermal cell turnover - Express anti-inflammatory properties	- Burning, dryness - Retinoid dermatitis - Risk of post-inflammatory hyperpigmentation	B
Azelaic acid	- Inhibit tyrosinase activity - Selective antiproliferative and cytotoxic effects on melanocytes	- Transient erythema, irritation, pruritis, dryness, burning	B
Kojic acid	- Inhibit catecholase activity of tyrosinase	- Transient erythema - Risk of contact dermatitis	B
Tranexamic acid	- Inhibits UV-induced plasmin activity and impairs melanogenesis	- Erythema, scaling, dryness - Oral side effects include abdominal discomfort, bloating, headache, hypomenorrhea - Risk of thrombotic events in specific populations	B
Cysteamine	- Inhibit tyrosinase and peroxidase - Chelate metal ions required for melanin synthesis - Scavenging dopaquinone	- Transient dryness, burning - Malodorous	B
Chemical peels: glycolic acid, salicylic acid, Jessner solution, trichloroacetic acid	- Controlled destruction of skin layers depending on peel depth - Increase keratinocyte turnover	- Post-inflammatory pigmentary changes - Burns, erythema, irritation, desquamation - Scarring	B
Laser
Ablative laser	- Causes controlled damage to and removes layers of skin	- High risk of post-inflammatory pigmentary changes - Burns, erythema, pain - Scarring	Not recommended
Non-ablative fractioning laser	- Produce coagulative damage within the dermis below the wounding threshold causing melanin extrusion	- Risk of post-inflammatory pigmentary changes in darker skin tones - Burns, erythema, pain - Requires optimization based on patient’s skin type	B
Low-fluence Q- switched laser	- Selectively destroys melanin pigments	- Risk of post-inflammatory pigmentary changes in darker skin tones - Burns, erythema, pain - Requires optimization based on patient’s skin type	B
Picosecond laser	- Produce short pulse durations with higher pulse energies leading to lower thermal effect and greater fragmentation of melanin	- Erythema, pain, blister formation - Still has risk of post-inflammatory pigmentary changes - Limited studies in skin of colour	B