A 40-year-old woman presents with symmetrical, light-brown malar hyperpigmentation worse in summer and improved in winter. She is on oral contraceptive pills. Dermatoscopy shows a pigment network in the epidermis. Wood's lamp examination shows enhancement of the lesion. The most appropriate first-line topical treatment is:
- A Azelaic acid 20% cream
- B Topical retinol 0.025%
- C Hydroquinone 4% cream combined with sunscreen (modified Kligman's formula) ✓
- D Kojic acid 2% cream monotherapy
Explanation
Melasma management requires photoprotection (broad-spectrum SPF 50+ sunscreen) as the cornerstone, combined with tyrosinase inhibitors. Modified Kligman's formula (hydroquinone 2–4% + tretinoin 0.025–0.05% + mild corticosteroid) is the gold-standard topical depigmenting treatment. Hydroquinone inhibits tyrosinase, the rate-limiting enzyme in melanin synthesis. OCP discontinuation should be advised. Wood's lamp enhancement confirms epidermal melasma (more responsive to treatment than dermal type). Azelaic acid is an alternative especially in pregnancy-related melasma. Kojic acid is used as adjunct.
Reference: Neena Khanna Illustrated Synopsis of Dermatology & STD, 6th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.