Melasma

Definition and nomenclature

Melasma is the most common cause of facial melanosis and is
manifested by hyperpigmented macules on the face which become
more pronounced after sun exposure (Figure 88.8a,b) [1,2].
Synonyms and inclusions
• Mask of pregnancy
• Chloasma
Epidemiology
Incidence and prevalence
Common. Increased pigmentation is almost invariable in pregnancy
and is most marked in brunettes. Melasma is frequently
seen in women on oral contraceptives.
Age
Mostly starts between the ages of 20 and 40 years.
Dependent on pregnancy or use of oral contraceptives [3,4].
Sex
F > M.
Up to 10% of cases of melasma occur in men (Figure 88.9).
Ethnicity
More common in light brown skin types, particularly Latin Americans
and those from the Middle East or Asia.
Pathophysiology
Predisposing factors
Several factors have been linked to melasma, among them UV
exposure and hormonal factors appear to be the most significant.
Local or diffuse hyperpigmentation can be seen in a subset of
women, probably due to these hormonal factors. Pregnancy and
oral contraceptives have been linked to increased skin pigmentation.
It has been speculated that this is due to increased levels of
oestrogen and progesterone stimulating the activity of melanocytes
[5]. Melasma is common in the third trimester of pregnancy
when levels of oestrogen, progesterone and MSH are elevated.
Many cases are attributed to pregnancy or the combined oral
contraceptive pill [3,4]. In the context of pregnancy, melasma is
regarded as a normal physiological change, along with darkening of the nipples and linea nigra.
It is not uncommon during the
years of reproductive activity and has been attributed, without
acceptable proof, to a variety of ovarian disorders. The rarity of
melasma in postmenopausal women on oestrogen‐containing
hormone replacement therapy and the fact that men are occasionally
affected suggests that oestrogen alone is not the causative
agent.
Pathology
The mechanism is not fully elucidated, and although MSH may be
involved, it plays a minor part. The plasma concentration of MSH
is normal both in patients with idiopathic melasma [6] and in those
with melasma attributable to oral contraceptives [7]. Oestrogens
and progesterone are involved in the increased pigmentation but
other factors are also implicated [8]. The number of melanocytes is
not increased but they become enlarged and more dendritic, suggesting
a hypermetabolic state. This is reflected by increased melanin
deposition in the epidermis and dermis [8,9].
Despite light microscopic, ultrastructural and immunofluorescence
studies, the condition remains an enigma [1]. An endocrine
mechanism is postulated but the cause of melasma is unknown.
Genetics
No specific genes have as yet been identified but a family history
is common (around 30%). The clinical manifestations are the same
in sporadic and familial cases and is seen particularly in those who
tan readily when exposed to bright sunlight [10].
Environmental factors
Exacerbated by sun exposure, combined oral contraceptives and
other hormone treatments.
Clinical features
Presentation
Melasma is seen predominantly in women. Hypermelanosis
affects mainly the upper lip, the malar regions, forehead and chin
and may be associated with darkening of the nipples, the linea
alba to form the linea nigra, and anogenital skin. Affected skin is
brown in colour. The pigmentary changes are usually bilateral and
are frequently symmetrical.
Differential diagnosis
See Box 88.3.
Classification of severity
Cosmetic problem.
Disease course and prognosis
Variable. The pigmentation usually fades after parturition but may
persist for months or years. It is noted by some women to be more
obvious just prior to menstruation [11]. The pigmentation takes a
long time to fade after discontinuing oral contraception and, as
after pregnancy, it may never fade completely.
Investigations
No investigations necessary.
Wood’s lamp examination can be helpful to identify the depth
of the melanin pigmentation and determine the type of melasma
(epidermal, dermal or mixed). Epidermal melasma normally
appears light brown and shows enhanced colour contrast
with Wood’s lamp examination. Dermal melasma often appears
slightly grey or bluish on gross examination and shows less colour
contrast with Wood’s lamp. Categorization of the type of melasma
is useful because it may help guide treatment options and patient
expectations since dermal melasma is generally less responsive to
therapy, especially to topical modalities [1].
Management
Treatment of melasma can be difficult due to the refractory and
recurrent nature of the condition.
Different skin depigmentation formulations can be used and
contain one or several active compounds. Hydroquinone is the
most extensively studied depigmenting agent for the treatment of
melasma. It inhibits tyrosinase, an enzyme critical to the pigmentproducing
pathway in melanocyte. Topical retinoid therapy has
also been used as monotherapy for melasma but with only moderate
efficacy [12,13].
Triple combination therapy, comprised of hydroquinone, a retinoid
and a corticosteroid, is a highly effective and safe treatment
for melasma. A corticosteroid was introduced to this treatment to
reduce inflammation as it is a side effect of both hydroquinone and
tretinoin. In addition to this advantage, it also inhibits melanocyte
metabolism [13].
Pregnancy‐related melasma tends to improve spontaneously
postpartum and treatment may not be necessary.
First line
A variety of topical treatments are effective at lightening melasma.
Triple therapy with topical hydroquinone, tretinoin and
corticosteroid
(e.g. hydroquinone 4%, fluocinolone acetonide
0.01% and tretinoin 0.05%) is preferred [13,14]. Alternative, dual
therapy (e.g. hydroquinone 2% plus glycolic acid 10%) may be
used but can cause severe irritation [13]. Response to monotherapy
is generally disappointing.