2014 Comprehensive overview of melasma; Wood’s lamp may not be accurate and Fligman’s formula still the best

1. Comprehensive overview of
“Melasma”
Wood’s lamp may not be accurate and Fligman’s formula still the best
March 2014
Almansouri Daifallah MD

2. 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

3. 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.

4. Definition
• An acquired hypermelanosis (sharply
demarcated brown macules) often secondary
to sun light and/or hormonal changes that
oxidize tyrosine to melanin.

5. 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.

6. Risk factors
• Racial: dark skin and
black (Fitzpatrick skin
types III and V)
• Female.
• Age: elderly.
• Genetic.
• Environmental: strong
solar radiation radiation

7. 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

8. Pathophysiology:
1- Sun light
2- Hormones

9. • 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.

10. • MSH, ACTH, lutei-nizing hormone (LH), and
follicle-stimulating hor-mone (FSH) increase
melanocyte size and tyrosinase production

11. 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.

12. 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.

13. Where?
Sun exposed areas:
• Forehead, cheeks
, nose
bridge, upper lip
(moustache-like
melasma), chin, V
-neck.
moustache-like melasma

14. Investigations
• Diagnosis is clinically: pattern +risk factors.
• Wood lamps: intensification of epidermal
type.
• TFT: to exclude hypothyrodism.
• Biopsy: rarely.

15. Classification 1: Area based
• Centrofacial
(commonest), malar, mandibular, brachial
(acquired brachial cutaneous dyschromatosis).
malar centrofacial mandibular brachial

16. Classification 2: histologically based
• by Wood’s light examination !!!/ physical examination:

17. • Deep Vs. Superficial

18. Other Classifications
• Etiology based: senile, gravidarum, adissonni.
• Pattern based: erythrosis pigmentosa faciei
(inflamed melasma),

19. 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

21. 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 )

22. 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

23. 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

24. Hydroquinone Side Effect
• Exogenous ochronosis( ): Blue-gray
discoloration of the skin with characteristic
pin-point, caviar-like papules

25. Mechanism of bleaching agents

26. Complications
• significant negative impact on patients’ quality
of life and assessed using MelasQoL.

27. 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)

28. Freckles
• clusters of concentrated melanin in fair skin.

29. Poikiloderma of Civatte
• thin skin with telangiectasia
• sparing of the submental area is characteristic.

30. 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.

31. 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

32. 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,
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