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The British Association of Dermatologists patient information leaflet on melasma (March 2012) refers to creams that reduce the activity of the pigment-forming cells in the skin and lists hydroquinone creams as the most commonly used.

However, when my GP looked in the BNF (in August 2013) he could not find hydroquinone creams listed. I was prescribed azelaic acid instead - which has had no result after using it twice a day for a month.

Please can you advise:

a) are hydroquinone creams available in the NHS and can GPs prescribe them or do they have to be prescribed by a dermatologist?

b) on average how long do these creams (e.g. azelaic acid or hydroquinone creams) need to be used in order to see a result? (I am unsure of the balance between concluding ineffective treatment early to avoid possible side effects for no gain and persisting for long enough to see a result).

Thank you.

Hydroquinone can be prescribed by GPs but most would not be confident enough to prescribe it because of possible side effects and not something most GPs treat. It is not an easy condition to treat and is understandably distressing. Oestrogens, either from the contraceptive pill or HRT can cause it to become more obvious.

The big problem with Melasma, or Chloasma as it is sometimes called, is the effect of sunlight. Azaleic acid cream which should be 20% strength (Skinoren) can be effective if the skin is not very dark and should take a month or two for significant effect. However if you do not use sunscreens (factor 30 or above) regularly and not just on bright days, the pigmentation will either not go or will return very quickly.

Thank you Dr Kownacki and Dr Murad for your replies.

Dr Kownacki - I have been using the 15% strength of azelaic acid (Finacea gel) - is this not strong enough to see an effect and should I go up to a product that is 20% strength (e.g. Skinoren as you suggested) for a month or so before concluding that it's not working?

You commented that GPs can prescribe hydroquinone creams but that most would not feel confident to do so. Given that my GP could not find hydroquinone in the BNF, please can you advise me of a product name or section of the BNF? (He looked both online and in the paper version).

Finally, would it be appropriate to ask my GP for a referral to a dermatology clinic so that they could prescribe it instead?

Many thanks for your help

Clare

Finacea is indicated for Rosacea so Skinoren with 20% is likely to be more effective but not a cure.
There is a combination product called Pigmanorm which is cheaper and similar to the Kligman's depigmenting cream but I find it may only be available from hospital pharmacies. So I am afraid you will need a referral to get such a treatment if it is considered appropriate. I am sorry if I misled you but such mixtures can cost the NHS huge amounts because they have to be mixed up specially for each individual.
Do not forget the need to keep out of the sun which in turn might require vitamin D oral supplements.