Published on March 13, 2014
Comprehensive overview of “Melasma” Wood’s lamp may not be accurate and Fligman’s formula still the best March 2014 Almansouri Daifallah MD
Outcomes • Terminology: – Origin: – Arabic: – French: – Synonym: • Definition. • Etiology • Risk factors • Epidemiology • Pathophysiology • Dermatopathology • Local Symptoms • Systemic symptoms: • Signs • Investigation, and DDx, • DDx • Complications • Prognosis • Psychological impact • Guidelines • Priscription table of 1st line medication dose • 2 commonest and 2 most serious side effects: • Patient education • Progression, severity and response assessment methods
Terminology – Origin: • chloasma: Greek; chloázein to be green. • Melasma: Greek; melas means black. – Arabic: – French: mélasma – Synonym: Chloasma faciei, mask of pregnancy “melasma gravidarum”, melasma addiso´nii.
Definition • An acquired hypermelanosis (sharply demarcated brown macules) often secondary to sun light and/or hormonal changes that oxidize tyrosine to melanin.
Etiology • Unknown • Possible factors: – Sun light: most important – Hormonal: • LH and female sex hormones e.g. OCP and pregnancy, HRT, menopause. • Hypothyroidism: melasma patient 4X will have thyroid abnormalities. • Addisonni melasma – Medication: salicylic acid, oxidized linoleic acid, photosensitizing agents, antisiezure, diphenylhydantoin.
Risk factors • Racial: dark skin and black (Fitzpatrick skin types III and V) • Female. • Age: elderly. • Genetic. • Environmental: strong solar radiation radiation
Epidemiology • 8-40% • 14.5% in Arab-American • In Hail 2.88% of skin diseases • Two peaks: infant after 2 wks + 20s -30s. • F>M: 5-9>1
Pathophysiology: 1- Sun light 2- Hormones
• Sun-light cause elevated levels of nitric oxide via the NF-κB pathway. Sun • nitric oxide stimulates tyrosinase activity of melanocytes In Melanocyte • Tyrosinase convert Tyrosine -> melanin increasing local melanin production hyperpigmentation NB. no increase in melanocyte number, but the melanocytes themselves were larger and had more prominent dendritic processes.
• MSH, ACTH, lutei-nizing hormone (LH), and follicle-stimulating hor-mone (FSH) increase melanocyte size and tyrosinase production
Dermatopathology • In epidermis: • Highly dendritic melanocytes • Melanin deposited (key feature and requires Masson Fontana stain) in basal and suprabasal cells • In dermis: • melanophage. • Solar elastosis in dermis (Verhoeff-van Gieson stain) (b) Perilesional normal skin, pigmented (c) Lesional: Epidermal hyperpigmentation.
Symptoms and signs Symptoms • Cosmetic concern only. Aggravated by: • Sun exposure Signs • Skin: symmetrical light or dark brown or even black hyperpegmented macules has serrated, irregular, and geographic borders.
Where? Sun exposed areas: • Forehead, cheeks , nose bridge, upper lip (moustache-like melasma), chin, V -neck. moustache-like melasma
Investigations • Diagnosis is clinically: pattern +risk factors. • Wood lamps: intensification of epidermal type. • TFT: to exclude hypothyrodism. • Biopsy: rarely.
Classification 1: Area based • Centrofacial (commonest), malar, mandibular, brachial (acquired brachial cutaneous dyschromatosis). malar centrofacial mandibular brachial
Classification 2: histologically based • by Wood’s light examination !!!/ physical examination:
• Deep Vs. Superficial
Other Classifications • Etiology based: senile, gravidarum, adissonni. • Pattern based: erythrosis pigmentosa faciei (inflamed melasma),
Management I. Remove the cause: a) Minimize sun exposure: apply sunscreen (titanium dioxide and/or zinc oxide with hight SPF), make-up that contains sunscreen, use wide- brimmed hat . b) Discontinue hormonal contraception. II. Remove the extra melanin: a) Fist line: Bleaching agents: (Kligman’s formula= Tretinoin + Hydroquinone+steroid) 1. Hydroquinone (2-4%) “the gold standard” 2. Tretinoin cream 3. Steroid: to quickly to fade the colour and reduce the likelihood of a contact dermatitis of previous agents e.g. hydrocortisone, b) Second line: chemical peeling for superficial melasma ONLY and may change it to post-inf-peg.: glycolic acid, low-concentration TCA, and salicylic acid. c) Third: Intense pulsed light and fractional Laser: both are effective and quick but both give inconsistent result. FL may cause complications d) Fourth: Surgical peeling may cause scars, inflammation, pigmentation, …..etc. III. Palliative: Cosmetic camouflage: Mineral makeup; titanium and zinc
Prescription Spec IndicatidurationfrequencydoseRouteMedication Fligman’s formula : prepared called trimula or mix the following in hydrophilic oinyment OR (ethanol+propylene gycol 1:1)instead. Stop flucinolone after 4 weeks and continue others once/weekly for 6 months 6 weeksOnce daily at evening left on for 30 min before sleep Creamfluocinolone acetonide 0.01% hydroquinon e 4% tretinoin 0.05% Bleaching and reduce irritation Once dailycreamAscorbic acid (C) 0.1% Life longEvery 2 hoursHigh SPF (>30)lotionSunscreen (contain titanium dioxide and/or zinc oxide )
2nd line: peeling agents Till achievement of desired result 4-6 sessions / 3-6 wks 20 minutesIPL Till achievement of desired result Every 4-6 weeks Starting from 30% up to 70% Glycolic acid Kojic acid 3nd line: lights Fractional laser Alternative: Alternative
Medication SE ManagementSEContra- indications Medication • stinging and redness in 25% • Conc >4% will may cause satellite pigmentation and local ochronosis (a bluish grey discolouration)) Sick child or < 2yr Hydroquinone (2-4%) Stop immediately. TeratogenicPregnancytretinoin TC complicationsPregnancy; Cat CHydrocortisone acetate Stop iterythema, scaling, dryness, stinging or burning, edema, and hypo- or hyperpigmentation Fractional laser All are temporaryRedness, pain, swelling, pigmentation and rarely burn. IPL
Hydroquinone Side Effect • Exogenous ochronosis( ): Blue-gray discoloration of the skin with characteristic pin-point, caviar-like papules
Mechanism of bleaching agents
Complications • significant negative impact on patients’ quality of life and assessed using MelasQoL.
DDx DifferentiationDisease HxPostinflammatory pigmentation lentigo Hx+ EX: diffuse and less irregularDrug-induced pigmentation; amiodarone, tetracycline Papular lesion + histologyLichen planus Naevus of Ota TSHHypothyrodism Solar lentigines, Clinical examinationEphelides (freckles) On neck and sparing of the submental .Poikiloderma of Civatte Amiodarone-induced pigmentation |Postinflammatory pigmentation |Pigmented contact dermatitis (Riehl's melanosis)
Freckles • clusters of concentrated melanin in fair skin.
Poikiloderma of Civatte • thin skin with telangiectasia • sparing of the submental area is characteristic.
Follow Up and Prognosis • Response assessment: MASI scoring= area*homogenicity*darkness = 0-48 • 8% of melasma gravidarum noted spontaneous remission. • Monitor for exogenous onchronosis and skin atrophy for long term treatment.
Summary • Risk factors(sun/hormone/Fx) + symmetrically distributed hyperpigmented macules on face and neck = melasma. • TTT: Frigman’s formula and sun protection. • Recurrance is high • Never use monoben-zylether of hydroquinone
References: • http://www.camberwellskin.com.au/images/melasma%20upper%20lip.jpg • https://www.dermquest.com/MediaLibrary/3364572/melasma_2.jpg • http://www.locateadoc.com/pictures/gallery/melasma-treatment-before-fullsize-21100-40168.jpg • http://www.jcasonline.com/articles/2013/6/3/images/JCutanAesthetSurg_2013_6_3_139_118403 _f1.jpg • http://www.ijdvl.com/viewimage.asp?img=ijdvl_2013_79_3_367_110798_f1.jpg • http://dermnetnz.org/ • European Handbook of Dermatological Treatments • Vaneeta M. Sheth, Amit G. Pandya, Melasma: A comprehensive update: Part II, Journal of the American Academy of Dermatology, Volume 65, Issue 4, October 2011, Pages 699-714, ISSN 0190- 9622, http://dx.doi.org/10.1016/j.jaad.2011.06.001. (http://www.sciencedirect.com/science/article/pii/S0190962211006281) • http://www.uptodate.com/contents/melasma?source=search_result&search=melasma&selectedTi tle=1~44 • http://www.dermatlas.org/browse • Andrew's Diseases of the Skin: Clinical Dermatology • Fitzpatrick's Dermatology in General Medicine, Eighth Edition, All information, data and images in this presentation are the property of the following references and were assembled in this presentation for nonprofit educational purposes
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