# Melasma (Chloasma) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: BAD Guidelines for Management of Hyperpigmentation 2021 · DailyMed Hydroquinone 4% Cream Package Insert, SetID 8f3bf0d0-40e1-4560-a2ea-9e7978cece4d · UK eMC Skinoren 20% Cream SmPC (Bayer plc), product id 1423 - Verified date: 2026-08 ## Verified against - DailyMed Hydroquinone 4% Cream Package Insert, SetID 8f3bf0d0-40e1-4560-a2ea-9e7978cece4d - UK eMC Skinoren 20% Cream SmPC (Bayer plc), product id 1423 - Melasma (Chloasma) - disease-level clinical article (melasma-full.txt) ## Treatment metadata - Hydroquinone — topical - Azelaic acid — topical ## Complete treatment card ```text MELASMA (CHLOASMA) Sources: BAD Guidelines for Management of Hyperpigmentation 2021 · DailyMed Hydroquinone 4% Cream Package Insert, SetID 8f3bf0d0-40e1-4560-a2ea-9e7978cece4d · UK eMC Skinoren 20% Cream SmPC (Bayer plc), product id 1423 Review status: REVIEWED against DailyMed Hydroquinone 4% Cream Package Insert, SetID 8f3bf0d0-40e1-4560-a2ea-9e7978cece4d, UK eMC Skinoren 20% Cream SmPC (Bayer plc), product id 1423, Melasma (Chloasma) - disease-level clinical article (melasma-full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (2) - Gradual onset with flare-ups during periods of more sun or visible-light exposure is typical - Melasma commonly starts or worsens during pregnancy or with oral contraceptives or hormone therapy SIGNS - what you find (3) - Symmetric, irregularly bordered, evenly colored brown patches appear on the face, most often in a centrofacial pattern [pigmentation change] - The patches are not scaly or raised and cause no symptoms, unlike inflammatory skin conditions that can look similar - Extrafacial melasma on the forearms or neck is more common after menopause TESTS (4) - Melasma is a clinical diagnosis, and routine lab testing is not needed in typical cases - Wood lamp findings are unreliable, especially in darker skin, and should not guide treatment decisions - Dermoscopy can show a brown network pigment pattern, sparing around hair follicles, and visible small vessels - Hormone-related blood tests are not routinely needed unless the presentation is atypical IF NOT THIS - what else fits (4) - Exogenous ochronosis causes paradoxical blue-black pigmentation after long-term hydroquinone use and resists treatment - Post-inflammatory hyperpigmentation typically follows a prior inflammatory skin condition, unlike melasma - Lichen planus pigmentosus, including facial forms, can mimic melasma's facial pigmentation - Drug-induced hyperpigmentation and pigmented contact dermatitis are also on the differential Source StatPearls "Melasma" - disease-level clinical article Status traced to the source above 1. HYDROQUINONE [1st line] Adult Apply Hydroquinone 4% Cream to affected areas twice daily, in the morning and before bedtime Peds Safety and efficacy in pediatric patients have not been established Source DailyMed Hydroquinone 4% Cream Package Insert, SetID 8f3bf0d0-40e1-4560-a2ea-9e7978cece4d Why Inhibits tyrosinase, the rate-limiting enzyme in melanin synthesis, lightening the hyperpigmented patches of melasma; first-line topical agent. Caution There is a risk of post-inflammatory hyperpigmentation or exogenous ochronosis with prolonged use. Strict daily broad-spectrum photoprotection (SPF 15 or greater) is mandatory. Discontinue if no improvement is seen after 2 months of treatment. Egypt CLEARALIQUE FORTE 4% CREAM 30 GM DELTA PHARMA 8.00 EGP MELOQUIN 4% CREAM 20 GM BIOPHARM EGYP... 60.00 EGP CLEARALIQUE 2% CREAM 30 GM DELTA PHARMA 6.00 EGP 2. AZELAIC ACID [2nd line] Adult Apply 15% gel or 20% cream twice daily (morning and evening) to affected areas after washing x up to 6 months Peds Safety and efficacy in children under 12 years have not been established for melasma/hyperpigmentation Source UK eMC Skinoren 20% Cream SmPC (Bayer plc), product id 1423 Why Also inhibits tyrosinase to reduce melanin production, used as the alternative to hydroquinone in patients who cannot tolerate it, including during pregnancy and lactation. Caution Inhibits tyrosinase; safe alternative in hydroquinone-intolerant patients. Transient local burning or stinging is common during the initial weeks. Not an unqualified safe-in-pregnancy drug. The Skinoren 20% Cream SmPC says at 4.6, verbatim: "Caution should be exercised when prescribing azelaic acid to pregnant women." For lactation: "Infants must not come into contact with treated skin/breast." It remains the usual choice for melasma arising in pregnancy, where the alternatives are worse, but the label does not call it safe. Egypt AZECLEAR 20% CREAM 30 GM BIOPHARM EGYP... 21.60 EGP EZALIC 20% CREAM 30 GM MULTI-APEX 26.40 EGP SKINOREN 20% CREAM 30 GM INTENDIS MANU... 35.50 EGP AZADERM 20% CREAM 30 GM MUP 87.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)