Melasma usually persists for several years. It may present as odd streaking on the face, causing cosmetic disfigurement. Pregnancy-related melasma may persist for several months after delivery, and melasma related to hormonal treatments may persist for long periods after stopping oral contraceptives. Recurrences are common, particularly after re-exposure to the sun.9 Response to the treatment can be variable, although dermal type melasma is less responsive than epidermal type (see below). The benefits of treatment may not be apparent for many months. Treatment is often unsatisfactory and has been associated with side-effects such as local irritation, scarring, contact dermatitis and residual patches of lighter colour on the skin - so-called "confetti pigmentation". Hydroquinone, one of the common depigmentation agents, has been particularly associated with exogenous ochronosis (deposit of brown, blue or black pigmentation in the skin and cartilage seen in sufferers of alkaptonuria, which is a rare inherited metabolic disorder) from prolonged use of strong concentrations.14
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