Publish date: Posted on
Last updated: October 21, 2023
Keywords #
melasma
pregnancy
OCPs
sun exposure
hydroquinone
Diagnosis #
Melasma is a common skin problem resulting in brown to gray-brown patches on the face. It is more common in women than men, and most commonly occurs on the cheeks, chin, nasal bridge, forehead and the upper lip. Pregnancy and oral contraceptive pills (OCPs) are a common cause of melasma. Melasma can have a significant impact on quality of life, including its effect on emotional well-being.[1,2]
Key Concepts #
- Melasma is a common problem that occurs most often during pregnancy.
- Melasma is characterized by brown to gray-brown patches on the face and rarely on the neck, arms, and other sun-exposed locations.
- Melasma is more prevalent in darker skin types.
- Hydroquinone combined with retinol cream is an effective treatment agent for melasma.
Epidemiology #
Prevalence can vary between 1.5% to 33% depending on the population. Melasma is more common among darker skinned individuals. Up to 50% of pregnant women in the United States develop melasma.[1,2]
Genetics may play a role as 40% of patients report a positive family history. Other factors such as ultraviolet (UV) radiation and hormones are also implicated. UV radiation can stimulate melanocytes to produce excess melanin, giving rise to hyperpigmentation. Estrogen and progesterone from pregnancy or oral contraceptive pills (OCPs) may also stimulate melanocytes which may explain why melasma is rare before puberty. There is an association between thyroid disease and pregnancy-induced or OCP-induced melasma.[1,3]
Clinical Features #
Hyperpigmented macules or patches especially on the cheeks, upper lip, chin, and forehead (sun-exposed areas).
Differential Diagnoses #
- Post-inflammatory hyperpigmentation: this hyperpigmentation occurs as a result of acne, eczema or trauma so a history of one of these conditions may help distinguish it from melasma.
- Drug–induced hyperpigmentation: typical drugs include tetracyclines, antimalarials, and amiodarone which results in dyspigmentation that is more diffuse and less irregular than melasma.
- Pigmented contact dermatitis (Riehl’s melanosis): contact with cosmetic ingredients can result in grey-brown reticular facial pigmentation.
- Poikiloderma of Civatte: pigmentation, atrophic changes, and telangiectasias on the lateral neck may occur due to chronic sun exposure with a different body distribution than melasma.
Diagnostic Workup #
The diagnosis of melasma is clinical in large part and relies on history and physical examination. Wood’s lamp examination may help localize the pigment to the dermis or epidermis. Sometimes it may be reasonable to check thyroid function tests given the appropriate clinical context.
Biopsy is usually not required but may reveal increased melanin deposition in all layers of the epidermis with special staining.
Treatment #
Topical skin-lightening agents, sun protective measures including hats, and daily applications of sunscreen (preferably a zinc/titanium broad-spectrum based one) are effective and considered first-line therapies. Topical bleaching agents are also an option and include topical hydroquinone, azelaic acid, licorice, mandelic acid, mequinol, and kojic acid among others.
Topical retinoids are also effective. Hydroquinone and retinal products are not typically used in pregnant women due to a concern for teratogenic effects. A triple combination therapy called Tri-Luma (hydroquione 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01%) appears to be more effective compared to hydroquinone or retinol alone.[4]
Cessation of birth control pills or hormonal supplements can sometimes be helpful, but not predictably. Avoidance of sun exposure and use of sun protective measures including wearing a sunscreen with an SPF of 30 or higher is recommended.
Second-line therapies include chemical peels and lasers, but the efficacy outcomes are variable.
Slide Viewer #
https://utahderm.med.utah.edu/image-viewer/References #
- Handel AC, Miot LDB, Miot HA. Melasma: a clinical and epidemiological review. Anais brasileiros de dermatologia. 2014;89(5):771-782.
- Pichardo R, Vallejos Q, Feldman SR, et al. The prevalence of melasma and its association with quality of life in adult male Latino migrant workers. International journal of dermatology. 2009;48(1):22-26.
- Lutfi RJ, Fridmanis M, Misiunas AL, et al. Association of melasma with thyroid autoimmunity and other thyroidal abnormalities and their relationship to the origin of the melasma. The Journal of clinical endocrinology and metabolism. 1985;61(1):28-31.
- Taylor SC, Torok H, Jones T, et al. Efficacy and safety of a new triple-combination agent for the treatment of facial melasma. Cutis. 2003;72(1):67-72.
