Alkem

{{ Form::open(['url' => '#', 'name' => 'validateForm', 'id' => 'validateForm', 'enctype' => 'multipart/form-data']) }} @csrf

Back

Real-World Prescribing Patterns of Topical Agents and Treatment Outcomes in Melasma: A Retrospective Analysis (MEL-PRO)

BASIC DETAILS

Patient code (Do not write name here) *

Date *

Patient's Age (years)*

Gender *

Male Female

Fitzpatrick Skin Type *

I II III IV V VI

Duration of Melasma (From Diagnosis to Treatment) (months) *

Location of Melasma (check all that apply) *

Forehead Cheeks Upper Lip Chin Neck Others

Treatment - Topical Agent (Check all that apply) *

	Strength	Frequency
Hydroquinone	2% 3% 4% 5%	OD BD TID
Azelaic Acid	20%	OD BD TID
Kojic Acid	1% 2% 3% 4%	OD BD TID
Retinoids	Tretinoin Adapalene Isotretinoin Retino	OD BD TID
Corticosteroids	Hydrocortisone Dexamethasone Mometasone Fluocinolone acetonide	OD BD TID
Ascorbic Acid	5% 25%	OD BD TID
Glycolic Acid	5% 6% 7% 8% 9% 10%	OD BD TID
Salicylic Acid	20% 30%	OD BD TID
Tranexamic Acid	3% 5%	OD BD TID
Triple Combination (4% hydroquinone, 0.05% tretinoin, 0.01% fluocinolone acetonide / 0.1% mometasone furoate)	NA	OD BD TID
Others (please specify)		OD BD TID

Was any additional treatment prescribed? *

If Yes, please tick any of the following No

MASI Score *

Baseline

Follow-Up (3 months posttreatment)

Adverse Event (During Treatment) *

If Yes, specify type (check all that apply) No

@include('user.footer')