IntroductionMelasma is one of the most common pigmentary disorders seen by dermatologists and often occurs among women with darker complexion (Fitzpatrick skin type IV–VI). Even though melasma is a widely recognized cause of significant cosmetic disfigurement worldwide and in India, there is a lack of systematic and clinically usable treatment algorithms and guidelines for melasma management. The present article outlines the epidemiology of melasma, reviews the various treatment options along with their mode of action, underscores the diagnostic dilemmas and quantification of illness, and weighs the evidence of currently available therapies.MethodsA panel of eminent dermatologists was created and their expert opinion was sought to address lacunae in information to arrive at a working algorithm for optimizing outcome in Indian patients. A thorough literature search from recognized medical databases preceded the panel discussions. The discussions and consensus from the panel discussions were drafted and refined as evidence-based treatment for melasma. The deployment of this algorithm is expected to act as a basis for guiding and refining therapy in the future.ResultsIt is recommended that photoprotection and modified Kligman’s formula can be used as a first-line therapy for up to 12 weeks. In most patients, maintenance therapy will be necessary with non-hydroquinone (HQ) products or fixed triple combination intermittently, twice a week or less often. Concomitant camouflage should be offered to the patient at any stage during therapy. Monthly follow-ups are recommended to assess the compliance, tolerance, and efficacy of therapy.ConclusionThe key therapy recommended is fluorinated steroid containing 2–4% HQ-based triple combination for first line, with additional selective peels if required in second line. Lasers are a last resort.Electronic supplementary materialThe online version of this article (doi:10.1007/s13555-014-0064-z) contains supplementary material, which is available to authorized users.

Chemical peels have been time-tested and are here to stay. Alpha-hydroxy peels are highly popular in the dermatologist’s arsenal of procedures. Glycolic acid peel is the most common alpha-hydroxy acid peel, also known as fruit peel. It is simple, inexpensive, and has no downtime. This review talks about various studies of glycolic acid peels for various indications, such as acne, acne scars, melasma, postinflammatory hyperpigmentation, photoaging, and seborrhea. Combination therapies and treatment procedure are also discussed. Careful review of medical history, examination of the skin, and pre-peel priming of skin are important before every peel. Proper patient selection, peel timing, and neutralization on-time will ensure good results, with no side effects. Depth of the glycolic acid peel depends on the concentration of the acid used, the number of coats applied, and the time for which it is applied. Hence, it can be used as a very superficial peel, or even a medium depth peel. It has been found to be very safe with Fitzpatrick skin types I–IV. All in all, it is a peel that is here to stay.

Microneedling is a simple, inexpensive office procedure with no downtime. It is safe in Indian skin (skin types III-IV). The combined sequential treatment with GA peel caused a significant improvement in the acne scars without increasing morbidity.

Tear trough deformity is a major concern in a lot of individuals seeking periorbital rejuvenation. A prominent tear trough deformity is characterised by a sunken appearance of the eye that results in the casting of a dark shadow over the lower eyelid, giving the patient a fatigued appearance despite adequate rest, and is refractory to attempts at cosmetic concealment. The tear trough deformity is a natural consequence of the anatomic attachments of the periorbital tissues. A variety of techniques have evolved to address this cosmetic issue. Traditional techniques relied on surgical excision of skin, muscle, and fat as well as chemical peels. Treatment is now tailored towards specific anatomic abnormalities and often employs multiple modalities including surgery, botulinum toxin, and replacement of volume. Various original research articles, text book publications and review articles were studied. Data specific to the historical aspect and anatomy of tear trough have been enumerated. Techniques of different authors were analysed and their results and complications have been summarised. The technique of the author has also been described here.

BackgroundMelasma is one of the most common pigment disorders seen by a dermatologist and often occurs among women with darker complexion (skin type IV–VI).AimsThe present study aimed to investigate the epidemiology of melasma in the Indian population and to focus on the regional variability in the demographics, clinical manifestations and factors that precipitate this condition.MethodsThe present multicentric study conducted across four regions in India enrolled patients (>18 years) diagnosed with melasma on Wood’s light examination. Patients were examined to identify the distribution of melasma. Various precipitating and etiological factors for melasma were documented.ResultsThe mean age of the 331 enrolled patients with melasma was 37.2 ± 9.3 years. The prevalence of melasma was higher in females with a female to male ratio of approximately 4:1. The overall population with family history was 31%, highest in the northern region (38.5%) and lowest in the eastern region (18.2%). The two prominent patterns of distribution were centrofacial (42%) and malar (39%). Only 35% of the patients were using sunscreens. Of these, 10% of the patients used sunscreen with SPF >50. The usage of sunscreens was observed to be highest in the north (69%). About 51% of women with multiple pregnancies had a history of melasma when compared with single women (25%) or with no pregnancy (24%).ConclusionsIn conclusion, the result of the study showed that there was a regional variability in the demographics, clinical manifestations and factors that precipitate melasma among patients in India. There was a strong correlation between the family history and prevalence of melasma. Sun exposure is a major precipitating factor in melasma, but only 10% of the patients used sunscreen with SPF >50. Other factors such as concomitant medication, chronicity of disease, multiple pregnancies and use of oral contraceptives might precipitate melasma.Electronic supplementary materialThe online version of this article (doi:10.1007/s13555-014-0046-1) contains supplementary material, which is available to authorized users.