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Chloasma Treatment

In every case it is essential to evaluate if any of the known factors are responsible for chloasma and remove the effect of the same, as far as possible. Thus, patients having contraceptive pills should be advised to use alternative methods of contraception, while female patients who are pregnant or receiving honnonal therapy for the gynaecological disorder should be-instructed to wait and complete the pregnancy or the treatment of their disease. Patients with a history of hepatic damage should be evaluated and treated, wherever possible. Investigations may also be undertaken to see if there is any other factor responsible for chloasma. Removing the cause should help in checking the progression of the disease, while the already present pigmentation can be made to disappear by topical or systemic treatment.

Hydroquinone is one of the most frequently used remedies for reducing the dark colour of the skin. It reduces the rate of formation of the pigment, but in a solution or cream form, it is very unstable; it turns brown within a few days and becomes ineffective. It is therefore, necessary to use properly stabilised formulations only. The therapeutic concentration varies from 2 to 5 per cent, the latter concentration being obviously more effective. One or two applications a day are usually sufficient, though the number of applications per day can be increased if required. It is however, very important to massage the solution/ointment into the skin so that the drug reaches the place where the disease is. The action of hydro quinone is slow; it generally takes one to two months for the pigmentation to start fading. The treatment should be continued till the pigmentation has faded completely. Hydroquinone is a fairly safe drug, but some patients develop redness, itching and papulo-vesicular lesions in the areas where the drug is applied. Allergy to the drug can be confirmed by a patch test with hydro quinone. Patients allergic to hydro quinone have to be treated with alternative drugs.

Monobenzyl ether of hydroquinone is a compound similar to hydro quinone; it is used in the manufacture of rubber and has been found to produce de- pigmentation on the skin because it destroys the melanocytes. This chemical was used in the past for the treatment of hyperpigmentary disorders including chloasma, but was found to produce patchy areas of completely de-pigmented skin. The end result therefore, was much worse than the original disease. This drug therefore has been banned from use for this purpose, but inadvertent use by unscrupulous practitioners or patients under some camouflaged names may lead to a serious result.

Retinoic acid in the form of 0.025 to 0.05 per cent ointment is another drug which can be used for reducing the colour of the skin. This agent acts by producing increased exfoliation of the skin which leads to a decrease in pigmentation. If however, applied in an excessive quantity, retinoic acid can produce severe inflammation in the skin leading to redness, exfoliation and burning sensation. This reaction is directly proportional to the amount of the ointment applied and is more severe and more frequent over the delicate areas ofthe skin. Thus, the patient should be strictly instructed to regulate the quantity of the ointment used, avoid application of the ointment in the areas adjoining the eyes, the nose and the mouth and ensure that the ointment does not get into the nose, mouth and the eyes. It is also necessary to ensure that the patient’ does not use so less a quantity of the ointment that it does not produce the desired clinical effect. The patient should be instructed to use the quantity of the ointment which produces a mild degree of scaling and a
slight pinkish erythema, but reduce the quantity of the ointment used if the patient feels discomfort in the skin or develops intense redness. Moreover, retinoic acid canbe applied only at night; it should be washed off during the day, because it often produces photosensitivity if used during daytime.

The other group of drugs which can be used for chloasma are topical corticosteroids, because potent topical corticosteroids are known to lead to a decrease in the colour of the skin on topical applications. The most potent topical corticosteroid- cIobetasolpropionate (0.05 per cent) has the strongest action in reducing the skin colour. One or two applications a day are usually sufficient in chloasma. It is however, necessary to be careful because opical corticosteroids can also lead to atrophy of the epidermis along with telangiectasia and hirsutism, if used for a prolonged period. It would be safe to check the patient at monthly intervals and in case there is evidence of atrophy or telangiectasia, further applications of the corticosteroid should be stopped till the skin has reverted back to its original normal state.

In the most resistant cases all the three drugs-hydroquinone, retinoic acid and topical corticosteroids–can be combined. Each of these agents can be massaged into the skin one after the other, and the sequence of application can be any. Some people mix all the three medicines in equal proportions before applying to the skin, not realising that by mixing equal quantities of three different medicines the concentration of each of the active ingredients is being reduced to one-third of the original concentration. This makes all the three drugs far less effective than ifeach drug is used independently, one after the other. Combining the use of topical corticosteroids with retinoic acid ointinent further helps to reduce the side effects of retinoic acid.

Ahigh proportion of the patients having chloasma also have some general nutritional deficiencies such as anaemia and/ or gastro-intestinal infestations. It therefore, helps to investigate these patients and supplement the treatment described above with iron and vitamin B-complex, and treatment for gastro-intestinal infestations, if any.

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