What treatments are licensed and prescribed by General Practitioners (GPs) for the management of melasma in the United Kingdom (UK)?

Licensed Treatments for Melasma Management in the UK

In the UK, there are currently no specifically licensed treatments for melasma, but GPs can prescribe several topical agents that are commonly used for this condition based on clinical guidelines and evidence.

First-Line Treatment Options for GPs

Topical Agents

• Hydroquinone (4%):

  • Most effective first-line treatment for melasma 1, 2
  • GPs can prescribe as a short-term treatment (typically 2-3 months)
  • Should not be used continuously beyond 6 months due to risk of ochronosis (blue-black discoloration) 1
  • Common side effects include irritation and contact dermatitis

• Azelaic Acid (15-20%):

  • Alternative to hydroquinone with fewer side effects 1
  • Can be prescribed by GPs for longer-term use
  • Good option for patients who cannot tolerate hydroquinone

• Topical Retinoids:

  • Tretinoin can be prescribed by GPs
  • Often used in combination with hydroquinone for enhanced efficacy
  • May cause skin irritation, especially in sensitive skin types

Second-Line Treatment Options

Combination Therapies

• Triple Combination Cream:
  • Contains 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide
  • Most effective topical treatment with 77-94% of patients achieving clear or almost clear skin 1
  • GPs can prescribe, but typically reserved for resistant cases

Other Topical Agents GPs Can Prescribe

• Kojic acid - Less irritating alternative to hydroquinone 1, 3
• Vitamin C preparations - Antioxidant properties that reduce oxidative stress 1
• Niacinamide - Anti-inflammatory properties helpful for melasma 1, 4

When to Refer to Dermatology

GPs should refer patients to dermatology specialists when:

1. No improvement after 8-12 weeks of appropriate topical therapy 1
2. Severe or recalcitrant melasma
3. Significant adverse effects from first-line treatments
4. Consideration of advanced treatments is needed

Advanced Treatments (Specialist Only)

• Chemical Peels:

  • Glycolic acid or salicylic acid peels
  • Typically 3-4 sessions spaced one month apart 1, 5
  • Not typically initiated by GPs

• Oral Tranexamic Acid:

  • Promising treatment for moderate to severe cases (250mg twice daily)
  • Requires specialist monitoring due to thromboembolic risk 1, 2
  • Not typically initiated by GPs

Critical Adjunctive Measures

• Sun Protection:
  • Mandatory broad-spectrum SPF 70+ sunscreen 1
  • Inadequate sun protection is the most common reason for treatment failure
  • GPs should emphasize this as essential to any treatment plan

Treatment Monitoring

• Evaluation every 4-6 weeks using standardized photography 1
• Assessment using Melasma Area and Severity Index (MASI) score
• Adjust treatment if no improvement after 8-12 weeks

Common Pitfalls to Avoid

1. Failing to address hormonal factors: Oral contraceptives or hormone replacement therapy may exacerbate melasma 1

2. Discontinuing treatment too early: Melasma requires long-term management and maintenance therapy

3. Aggressive treatments: High-concentration peels or laser treatments can worsen hyperpigmentation, especially in darker skin types 1

4. Prolonged hydroquinone use: Using hydroquinone continuously beyond 6 months increases risk of ochronosis 1

5. Inadequate sun protection: This is the most common reason for treatment failure and recurrence 1