instruction: hello doctor I am 32 year old female my past medical history includes rosacea 15 years perioral dermatitis years melasma and hyperpigmentation in the upper cheeks for three years and add I am currently under noritate occasional elidel during flare up and adderall 5 my daily my hyperpigmentation on my upper cheeks has been progressively getting worse over the last several months the pigmentation is well demarcated with areas of normal skin I work indoors and the most sun I get on a daily basis is my short 15 minutes car ride from home to work I cannot pinpoint the cause of the hyperpigmentation and melasma I am not on any type of birth control and do not believe the source to be hormonal I am hesitant to try lightening agents as I have had adverse effects in the past I am going to trace back the pigmentation for you and maybe you can help me out before three years I applied noritate and diana to my face my skin in general was fine I had only one area of pigmentation on my face right side of face inch as that was noticeable I asked a dermatologist if there was anything that I could do to lighten it she gave me tri luma I decided to put the tri luma on the affected area and also a few freckles on my upper cheeks the next day I became extremely red and out of fear of triggering my rosacea I dropped tri luma immediately then after a month I stopped taking diana because I moved back to a colder climate and my face was getting too dry after some eight months the area of pigmentation right side of cheek was started getting darker so I decided to give another try for tri luma I again applied it to the larger area of pigmentation and to the tiny freckles on my upper cheeks the decision to apply it to the freckles was purely a cosmetic decision the next day those freckles turned into full blown pigmentation I immediately stopped the tri luma and the pigmentation in those areas has basically been there up to present day at that time a local dermatologist had suggested me to apply some cortisone cream to the areas to lighten them up the pigmentation subsided very minimally I did not apply the cortisone cream thereafter the pigmentation from this point waxed and waned in intensity up until two months back then it has remained prominent there were a few times during this two year span where my perioral dermatitis flared up and I was told to restart diana which also made the pigmentation worse I was unsure whether the diana was bringing the pigmentation to the surface or whether it was in fact making it worse I went to two dermatologists who had differing views of stop diana and keep using diana I decided to stop as it appeared to be getting noticeably worse again I do not know if this was a whole process of bringing the pigmentation to the surface or not please share your thoughts
output: hello well here I discuss everything one by one for further information consult a dermatologist online