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We have found inconclusive evidence for the effectiveness of topical steroids, topical retinoids, glycolic acid and laser therapy. These are commonly used therapies for melasma in clinical practice and would require further RCTs to validate their use. Lasers offer a potential advantage over conventional therapies because time to clearance can be much reduced. We found only a few studies that looked at patient-based outcomes.

• Limited evidence from a single RCT evaluating the effect of therapeutic sunscreens shows that during the 3-month study period, the majority of women using hydroquinone improved regardless of the addition of sunscreen to their treatment. The study did not describe whether women used other strategies to avoid sunlight.

• Evidence is insufficient to support the use of topical steroids in melasma. There is controversy over the use of topical steroids in melasma.

• An effect of retinoids on melasma has not been shown, but the available studies found that side-effects were common.

• Azelaic acid was found to be superior to 2% hydroquinone in achieving improvement in people with melasma. We found no solid evidence compared azelaic acid with placebo. Azelaic acid was associated with a higher incidence of side-effects.

• Limited evidence from one RCT suggests that hydroquinone plus sunscreen was better than sunscreen and placebo.

• Evidence is insufficient to assess the effects of glycolic acid.

• Overall we found no good evidence of the effects of combined therapies compared with placebo or other preparations. The studies had methodological flaws, including small sample sizes, that compromised the validity of results

• We found insufficient evidence to evaluate the effect of laser therapies in the treatment of melasma.

• We found limited evidence that a combination of vitamins C and E is better than vitamin C alone. We found no evidence of the effects of these therapies compared with placebo.

• No studies have assessed the effect of treatments specifically in men.

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