What is your approach to treating patients with melasma that does not respond to hydroquinone-based topical therapies?

This is my Melasma algorithm:

1. Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen
2. Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare)
3. Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/...

Depends on the reason one is not responding. For example, one of our approaches for treating patients that are not responding to hydroquinone is a product called Cyspera. This cream helps to decrease melanin pigment within the skin without the use of HQ or Retinol. Easy to apply, leave on uncleaned ...