Skin Lightening (Melasma & Sunspots) Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Skin Lightening Cream
Check ingredient(s) and strength
Hydroquinone
4%
6%
8%
or
%
Kojic acid
2%
4%
6%
or
%
Vitamin C (ascorbic acid)
0.5%
2%
5%
or
%
Tretinoin
0.01%
0.025%
0.05%
Steroid
Hydrocortisone 1%
Hydrocortisone 2%
Desonide 0.05%
Betamethasone 0.05%
Tranexamic acid
3%
or
%
Other
%
Base
W06 (anhydrous)
Vanishing cream
Cetaphil
Cliniderm
or
An anhydrous base (such as W06) is preferred — hydroquinone and vitamin C oxidize in water-containing bases.
Quantity
gm
Refills
Directions
Apply a thin layer to the affected areas at night. Use
sun protection daily.
More is not better.
These creams work best in short, prescriber-directed courses,
usually with planned breaks. Using a higher strength or
continuing longer than prescribed can backfire —
prolonged hydroquinone use can cause rebound darkening and a
lasting blue-black discolouration of the skin (ochronosis).
Do not increase the strength or extend the course without the
prescriber’s direction.
Prescriber
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Signature