Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?  

I wouldn't if they're not bothered, but I would think to look into their HCQ book levels... we know that certain doses of HCQ are more effective in controlling disease activity than others, and that of course, higher levels may be associated with adverse effects, not just in the skin.

1. I would check a trough whole blood HCQ level. Nathalie Costedoat-Chalumeau and her colleagues found higher levels in patients who developed skin pigmentation (Jallouli et al., PMID 23824340), but actual levels were not reported. Petri et al also showed that levels above 1200 ng/mL were associated...