Melasma often is recalcitrant to treatment, making it difficult for patients and physicians; therefore, it is best to approach the treatment of melasma with realistic expectations for improvement. An individualized treatment plan is recommended for each patient, as a single method may not work for every patient. Because of the predilection for melasma to affect darker skin phototypes, physicians should avoid aggressive treatments that may lead to further hyperpigmentation, hypopigmentation, scarring, or keloid formation. Treatment options range from topical bleaching and medicinal agents to surgical techniques such as chemical peels as well as lasers and light sources. We describe a stepwise approach to treatment and long-term maintenance therapy options that account for the recalcitrant nature of the disease. Patient education about the importance of photoprotection and strong adherence to a sun protection regimen are central to treatment. If more aggressive techniques are warranted, such as chemical peels or laser modalities, they should only be performed by physicians with extensive experience in treating darker skin phototypes.
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