Responses by Benjamin Barankin, MD, FRCPC, Toronto

Q: What are the best treatment modalities for the management of melasma (other than hydroquinone skin-lightening topicals)?—Charles Copeland, MD, Whitby, Ont.

The treatment of melasma has historically included the “gold standard” hydroquinone alone or in combination with topical retinoids and topical steroids (Kligman’s or Modified Kligman’s formulas). Other topical options include the use of ascorbic acid/vitamin C, alpha lipoic acid, niacinamide (vitamin B3), kojic or glycolic acid and/or potassium azeloyl diglycinate. These topical compounds can be compounded by specialized compounding pharmacies. Other options for melasma include the use of lasers (e.g. IPL, Fractional lasers), chemical peels and/or microdermabrasion.

References: 1. Rendon M, Berneburg M, Arellano I, Picardo M. Treatment of melasma. J Am Acad Dermatol. 2006;54(5 Suppl 2):S272-S281. 2. Espinal-Perez LE, Moncada B, Castanedo-Cazares JP. A double-blind randomized trial of 5% ascorbic acid vs. 4% hydroquinone in melasma. Int J Dermatol. 2004; 43(8):604-607. 3. Wang CC, Hui CY, Sue YM, Wong WR, Hong HS. Intense pulsed light for the treatment of refractory melasma in Asian persons. Dermatol Surg. 2004;30(9):1196-1200. 4. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: a pilot study. Dermatol Surg. 2005;(12):1645-1650.

Q: Can Dovonex be safely used on the face for psoriasis?—Alok Sood, MD, Toronto

Calcipotriol (Dovonex) is a vitamin D3 analogue that inhibits cell proliferation and enhances cell differentiation in the skin of patients with psoriasis. Face involvement with psoriasis is more common in children, adults with severe psoriasis, and along the hairline of those with scalp psoriasis. Make sure the diagnosis is not seborrheic dermatitis. It is more common than psoriasis on the face and manifests as erythematous patches, with yellow greasy scale favoring the eyebrows and nasolabial folds. This condition would not respond to topical calcipotriol.

The use of calcipotriol allows us to reduce the use of topical steroids (“steroid-sparing”) on the face and/or the dosage and duration of systemic medications. The main side effect on the face, as well as intertriginous areas, would be mild irritation. For this reason, topical calcipotriol cream is often recommended in the morning and a mild topical steroid or topical calcineurin inhibitor (e.g., topical tacrolimus [Protopic]) in the evening. It is important to apply calcipotriol at different times from other agents due to stability issues. Calcipotriol has also been used successfully with vitiligo, including the face.

References: 1. Farber EM, Nall L. Childhood psoriasis. Cutis 1999;64(5):309-314. 2. Scott LJ, Dunn CJ, Goa KL. Calcipotriol ointment. A review of its use in the management of psoriasis. Am J Clin Dermatol 2001;2(2):95-120. 3. Gargoom AM, Duweb GA, Elzorghany AH, Benghazil M, Bugrein OO. Calcipotriol in the treatment of childhood vitiligo. Int J Clin Pharmacol Res 2004; 24(1):11-14.