Mometasone-based triple combination therapy in melasma: is it really safe?

Kligman's triple combination formula has been one of the most popular treatment options in melasma over the last three decades. The original Kligman's formula has been modified in many ways over the years and the most recent modification that has been introduced is a triple combination of 2% hydroquinone, 0.025% tretinoin, and 1% mometasone. The use of this triple combination in patients with melasma has seen a sharp rise over the last few years and with this rampant use the side-effect profile of this triple combination has also come to the fore.

The aim of the present study was to assess the overall safety of the mometasone-based triple combination treatment in the management of melasma.

This retrospective study was performed on 60 patients of melasma who had used a mometasone-based triple combination treatment for at least 3 weeks anytime in the previous 1 year. The patients were given a preformed questionnaire wherein they assessed the overall effect of the triple combination treatment on their melasma during its use as well as after its withdrawal. The patients were specifically asked about the status of their disease as well as the sun sensitivity of their skin before and after the use of triple combination treatment. In addition, the patients were assessed by a single trained dermatologist for the presence of any adverse effects arising out of the triple combination treatment in the form of telangiectasia, hypertrichosis, acne, skin atrophy, etc.

Majority of patients (51.7%) had used the combination treatment well beyond the recommended duration. About one-third (36.7%) of the patients rated their melasma as worse at the time of filling the questionnaire as compared with their disease before the use of triple combination treatment. On clinical examination, the evidence of steroid side effects was seen in 26 patients (43.3%). Steroid-induced telangiectasia was the commonest finding, seen in all of these 26 patients. Steroid-induced skin atrophy, hypertrichosis, and acneiform eruption were seen in 19, 17, and 11 patients, respectively.

The propensity of a mometasone-based triple combination treatment to cause steroid adverse effects on the facial skin should always be borne in mind when the same is prescribed as a treatment option in melasma.