Delphi consensus on melasma management by international experts and pigmentary disorders society

BACKGROUND: Melasma, an acquired hyperpigmentation disorder, affects individuals of all ethnicities. Its multifactorial aetiology, high recurrence rates and psychosocial impact complicate management and necessitate comprehensive, evidence-based recommendations. OBJECTIVES: The objective was to develop an international consensus on the diagnosis and management of melasma by synthesizing expert opinions and the latest scientific evidence. METHODS: This consensus was developed using a modified Delphi approach. A core group of two senior dermatologists who were experts in pigmentary disorders guided the process, and a diverse panel of 38 dermatologists with a special interest in pigmentary disorders from 11 countries (Australia, Brazil, France, India, Italy, Mexico, Philippines, South Africa, South Korea, Taiwan and the USA) participated in three rounds of surveys and discussions, under the aegis of the Pigmentary Disorders Society (PDS). A literature search of articles published between 2014 and 2024 identified key studies that were graded using the Oxford levels of evidence (2009). Consensus statements were drafted, refined and finalized based on expert feedback. Responses were assessed using a 5-point Likert scale, with predefined thresholds for high (≥75%), moderate (55%-74%) and low (<55%) agreement. RESULTS: The consensus development process started with 34 statements, and at the end of the third round of the Delphi process, 21, 4 and 1 statement reached high, moderate and low consensus, respectively. Key recommendations highlighted photoprotection with broad-spectrum sunscreens as essential, regulated and supervised use of hydroquinone-based triple combination creams as the gold standard, and alternatives such as topical azelaic acid, kojic acid and oral tranexamic acid. Adjunctive procedural therapies, such as chemical peels and microneedling, were suggested to enhance topical efficacy, while lasers were reserved for refractory cases. CONCLUSIONS: These recommendations aim to improve the outcomes of melasma patients globally by integrating expert opinion and evidence-based strategies. Future research should focus on evaluating emerging therapies and optimizing long-term maintenance strategies.