3. Case Hx
A 25-year-old woman with Fitzpatrick type IV skin complains of a
darkening of the skin on her cheeks, nose, upper lip and forehead that
began 7 months ago during her first pregnancy.
The lesions are asymptomatic “ not pruritic nor painful “, and they’re
exacerbated by sun exposure.
No history of atopy or other skin diseases.
There’s no history of new cosmetics usage
4. Physical examination
- Well-demarcated, hyperpigmented macules are seen on the cheek,
nose, and upper lip.
- Bilateral, symmetrical, with
irregular shapes smooth surface
and variable pigment intensity.
- Size 4-6 cm
6. Melasma (black spot)
• Acquired light- or dark-brown hyperpigmentation that occurs in the
exposed areas.
• Often affect face
• Aetiology: Sunlight – Hormonal – Genetic predisposition.
• Commonly among :
1- Constitutive brown skin.
2- Whose taking contraceptive pills.
3- Living in sunny climates.
90% are women
9. Pathophysiology
1- Sun exposure
Ultraviolet (UV) light from the sun stimulates the melanocytes production.
In fact, just a small amount of sun exposure can make melasma return after
fading.
This is why melasma often is worse in summer. It also is the main reason why
many people with melasma get it again and again.
2- A change in hormones
When melasma appears in pregnant women, it is called chloasma, or the
mask of pregnancy.
Birth control pills and hormone replacement medicine also can trigger
melasma.
11. Classification
Epidermal Dermal Mixed Indetermined
Comments melanin is
increased in the
epidermis, with
only a few
melanocytes in
the upper
dermis
many
melanophages
throughout the
entire dermis
melanin is
increased in the
epidermis,
many
melanophages
throughout the
dermis
Seen with
people with
Fitzpatrick type
V or VI skin
Wood lamp
examination
Enhanced does not
enhance
spotty
enhancement
Not helpful
12. Clinical manifestation
(It causes brown to gray-brown patches), sharply marginated, roughly
symmetric patches of hyperpigmentation on the face.
(usually on the forehead, malar and mandibular).
Some people get patches on their forearms or neck. This is less common.
13.
14. Melasma risk factors
Pregnant women
Women taking any contraceptives. But commonly oral (estrogen)
Skin type III, IV.
Sun exposure.
Family Hx of melisma
furosemide, ACE-inhibitors, beta-blockers, hydrochlorothiazide, and
anti-seizure medications,
16. Management
Education:
1- Use sun protection daily and compliant to treatment
2- stop OCPs and facia cosmetics
Goals of treatment: curative and prophylactic
A- Hydroquinone ( 1st line)
B- Tretinoin and corticosteroids
C- azelaic acid
D- Kligman formulation (BEST)
Combination of fluocinolone 0.01%, hydroquinone 4%, and tretinoin 0.05%.
17. Hydroquinone:
This medicine is a common first treatment for melasma.
It is applied to the skin and works by lightening the skin. It’s came as a
cream, lotion, gel, or liquid.
Applied every night
18. Tretinoin and corticosteroids:
To enhance skin lightening, dermatologist may prescribe a second
medicine.
This medicine may be tretinoin or a corticosteroid.
Sometimes a medicine contains 3 medicines (hydroquinone,
tretinoin, and a corticosteroid) in 1 cream. This is often called a
triple cream.
19.
20. Other topical (applied to the
skin) medicines:
Dermatologist may prescribe azelaic acid lighten melasma. (Used in
pregnancy)
21. Sun protectors
Agents that protect against UVA include:
oxybenzone, avobenzone, and terephthalylidene dicamphor sulfonic
acid.
Agents that protect against UVB include:
octocrylene, padimate O, octinoxate, and ensulizole.
Follow up: after 3 months.
23. Notes
Epidermal melasma- best therapeutic results.
Dermal melasma – disappointing
Relapse on stopping treatment is common
Maintainance therapy adviced
24. Reference
http://www.dermatology.ca
Ball Arefiev KL, Hantash BM. Advances in the treatment of melasma: a review of
the recent literature. Dermatol Surg. 2012;38:971-984.
Lakhdar H, Zouhair K, Khadir K, et al. Evaluation of the effectiveness of a broad-
spectrum sunscreen in the prevention of chloasma in pregnant women. J Eur
Acad Dermatol Venereol. 2007;21:738-742.
Guinot C, Cheffai S, Latreille J, et al. Aggravating factors for melasma: a
prospective study in 197 Tunisian patients. J Eur Acad Dermatol Venereol.
2010;24:1060-1069.
http://bestpractice.bmj.com/best-practice/monograph/627/follow-
up/prognosis.html
Fitzpatricks Color Atlas and Synopsis of Clinical Dermatology 7th ED
centrofacial, malar, mandibular.
Can affect different areas, such as the forearms and neck.
Solar elastosis, also known as actinic elastosis, is a disorder in which the skin appears yellow and thickened as a result of sun damage
Epidermal most common
Pregnancy melisma increase at third trimester due to increased levels of melanin-stimulating hormone (MSH), post-inflammatory phenomenon, and UV light exposure in pregnant women
Post-inflammatory hyperpigmentation Hyperpigmentation of skin that was previously inflamed due to dermatitis.
Diagnosis is typically made on history of erythema, pruritus, and dermatitis preceding the hyperpigmentation.
Phototoxic reaction Seen in patients exposed to systemic or topical medicines or cosmetics, and then UV radiation.
Disease usually begins abruptly, in contrast to melasma, which develops gradually.
Exogenous ochronosis Skin hyperpigmentation associated with use of the bleaching agent hydroquinone. It is caused by the deposition of polymerised homogentisic acid in the skin.
Historically, this condition follows use of hydroquinone products, and distribution correlates with areas of medicine application.
Most commonly seen in people with Fitzpatrick type V or VI skin who have used hydroquinone-containing preparations of >3% concentration for months to years, and who have had significant UV light exposure without the use of photoprotection. Biopsy reveal golden-yellow to brown deposition of pigment in the dermis.
Erythema dyschromicum perstans Also called ashy dermatosis. Most frequently seen in Hispanic people and can be seen at any age.
Clinically, it presents as multiple blue-grey macules on the neck, chest, and sometimes the face.
The colour and distribution, as well as the lack of association with UV light exposure, help to differentiate it from melisma. Biopsy reveal non-specific, but can show some cell death at the dermal-epidermal junction, as well as pigment incontinence.
hydroquinone 3% solution and 4% cream; azelaic acid 20% cream; and a combination of fluocinolone 0.01%, hydroquinone 4%, and tretinoin 0.05%. Hydroquinone 4% cream can be compounded with 0.05% tretinoin cream or glycolic acid.
Hydroquinone inhibits the activity of the enzyme homogentisic acid oxidase and can cause polymerisation of homogentisic acid, which is then deposited in the skin. The result is a blue-black discoloration of the skin in areas treated with hydroquinone.
This condition is seen primarily in darker-skinned people who use hydroquinone-containing preparations (usually ≥3%) for a period of months to years, and is thought to occur more commonly in those who do not use adequate photoprotection.
This complication is seen most commonly in African countries, where high-concentration hydroquinone-containing products are readily available. If the treating physician encounters this reaction, hydroquinone-containing medicines should be discontinued immediately.
This condition can slowly fade, but is permanent in some cases
