MELASMA (CHLOASMA FACIEI) Melasma is characterized by brown patches, typically on the

malar prominences and forehead. There are three clinical patterns: 1) centrofacial, 2) malar, and 3) mandibular. The cenhofacial and malar patterns comprise the majority of patients (Fig. 36-2).The pigmented patches are usually qulte sharply demarcated. It tends to affect darker-complexioned individuals, especially Asians and Hispanics with F~tzpatriclr skln types N and V. It may at times be found on the forearms. Subtle melasma, as identified by ultraviolet (UV) light examination, may be seen in up to 30% of middle-aged Asian females. Melasma occurs frequently during pregnancy and with the ingestion of estrogen, as may occur in oral contraceptives or with hormone replacement therapy (IIRT) at menopause It may also be seen in other endocrinologic disorders. It is seen most frequently in young women, but men make up 10% of reported cases. Use of dilantin may induce melasma. Discontinuing the use of contraceptives rarely dears the pigmentation and it may last for many years after discontinuing them. In contrast, melasma of pregnancy usually clears within a few months of delivery. While melasma has class~callyb een classified as epidermal- o r dermal-based on the presence or absence of Wood's light enhancement, cespectively, most cases show both epidermal and dermal melanin. Dermal melanophages are a normal finding in Aslau sun-exposed skin. Independent of Wood's light findmgs, a therapeutic trial of some form of hypopigmentiig agent should be recommended if the patient requesb it. A number of topical therapies are available. Exposure to sunlight should he avoided and a complete sunblock with broad-spectrum UVA coverage should he used daily. Bleaching creams wrth hydroquinone are the gold standard and are moderately efficacious; they contain from 2% (available over the counter) to 4% hydroquinone, Tretlnoin cream may be added to increase efficacy.While tretinoin alone may reduce melasma, it may also increase pigmentation via its irntant effect. The combination of hydroqu~none and tretinoin,

administered in conjunction with a topical sterold, has been called "Kligman's formula" and is excellent. This is now available as a commercial product,Triluma, used once a day. The efficacy of this product has been reported to be superior to any combination of two of its ingred~ents,w t h a more rapid and complete response with the triple combination. Glycolic a c~dis at times added to hydroquinone to enhance its efficacy. In some pabents with melasma 4% hydroquinune is Insufficient and higher doses of hydroquinone must be compounded. Satelhte pigmentation and local ochronosis are potential complications from use of these higher-concentration preparations. Azelaic acld, kojic acid, N-acetyl-4-cysteminyphenol, 11corice extract, and Arbutin are other therap~esw ~the fficacy, although generally not as effective as hydroquinone. Var~ous surgical procedures such as peels and laser treatment have variable results, with some authors strongly supporting their use and others documenting lack of e f h c y . These variable results may be in part technique dependent.The use of surgical modalities for the treatment of melasma should be approached with caution. Pretreatment with hydroquinone seems to enhance the longtern1 result of some surgical treatments.

Melasma (Figs 39.27 & 39.28) [13] syn. mask of pregnancy; chloasma This common acquired hypermelanosis is seen mainly in women, and occurs exclusively on the sun-exposed skin of the face. The majority of cases are attibuted to pregnancy or the combined oral contraceptive pill. 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 at any time during the years of reproductive activity and has been attributed, without acceptable proof, to a variety of ovarian disorders. The rarity of melasma in post-menopausal women on oestrogen-containing hormone replacement therapy and the fact that men are occasionally affected suggests that oestrogen alone is not the causative agent. Thus, an endocrine mechanism is postulated but its nature is unknown. The hypermelanosis affects the upper lip, cheeks, forehead and chin and becomes more apparent following sun exposure. The areas are brown in colour and are bilateral and frequently symmetrical. In some women it may be noticeable premenstrually. After pregnancy or after stopping oral contraceptives the condition may fade but is often persistent. Melasma-like hyperpigmentation has been reported from use of phenytoin or mephenytoin (hydantoins). Up to 10% of cases of melasma are seen in men, particularly Latin Americans and those from the Middle East or Asia. A variety of topical treatments are effective at lightening melasma [4,5], but these treatments should be combined with assiduous sun-protection measures if the reduced pigmentation is to be maintained.