Melasma

Case: Kim’s face has dark-brown spots.

Kim, an otherwise well, 40-year-old woman of Southeast Asian origin presented with dark-brown patched face of more than 6 months duration without pruritus (Figure 1). She is a mother of 3 with the youngest child of 5 years old. She is a non-smoker and non-alcohol consumer. On examination she is systemically well. The face showed slightly darkish-brown hyperpigmented macules and patches, involving bilateral cheeks, forehead with glabella, mandible and chin.

Fig.1 Kim’s facial hyperpigmentation

Question 1.

What further history would be helpful in determining the aetiology of Kim’s facial hyper pigmentation? and What specifically would you look for on examination?

Answer 1.

It is important to enquire about risk or aggravated factors for skin discolouration such as any medications used, particularly oral contraceptive pills, photosensitive drugs/agents (eg, minocycline/ doxycycline, antiepileptics, light-sensitive cosmetics). Furthermore, asking allergy history, occupation and sun exposure, family history of skin disorders including melasma, and ± prior treatment of the site are also useful.

A brief relevant physical examination focusing on the pigmented lesions- colouration, border with ± elevation, location and pattern of distribution is recommended. Wood-lamp and dermatoscope examination may aid to evaluate depth of pigment infiltration as well as confirmation of diagnosis, if it is available.^1,2 Wood-lamp will demonstrate increased pigmentation in which enhancement of hyperpigmented skin (accentuation of pigment) with border contrast for epidermal melasma, and unchanged for dermal melasma will be shown; Dermatoscopic features include brownish reticulo-globular pigment network with brown or grey granules (dots) and telengiectasias.^1,2

Further information:

Kim stated, she was not utilising any medication and cosmetic agent. She had no known allergy but her mother has had a similar condition. Kim is a part-time TAFE student with no other work.

Question 2.

What conditions would you include in your differential diagnosis for Kim, and what is the most likely diagnosis based on Kim’s clinical information?

Answer 2.

The differential diagnoses for facial hyperpigmentation can be broad and are listed in table one in order of common occurrence. Female gender, age, and the pattern of hyperpigmentation patches on the face with long duration favoured melasma as the most likely diagnosis in this case.

Question 3.

What is Melasma and its epidemiology?

Answer 3.

Melasma, historically also termed Chloasma, is a common acquired pigmentary disorder, characterised by brown or light dark-brown pigmentation symmetrically involving the face- cheeks, forehead, nose, upper lip, chin and jawline. They may start with macules and later become large patches with ill-defined border and has no pruritus.

Melasma commonly affect women of colour skin, photo type III – V (Asian, Middle East, Mediterranean African and Hispanics/Latin America), with mostly childbearing aged 20 – 40 years. Men are rarely affected with 1:9 (M:F). Overall prevalence varies between 9% and 40% with higher rate in Southeast Asian and South Asian women.^1,5 Melasma can be subdivided into:^6,7

A. Based on clinical morphology (clinical patterns)

1. Centrofacial: involving cheeks, forehead, upper lip, nose, and chin.
2. Malar: Zygomatic and nose (Figure. 2)
3. Mandibular: along mandibular with chin.
4. 1. Extra-facial- involvement of neck and sun-exposed extremities is extremely rare. Some individuals can suffer from the above three patterns together, like in Kim case.

B. Based on depth of pigment infiltration (by wood lamp/dermatoscope, or histology):

1. epidermal type
2. dermal type
3. mixed type (both epidermal and dermal).

Fig 2. Melasma over zygomatic site of 38-year-old lady.

Question 4.

What investigations would you consider for Kim?

Answer 4.

Diagnosis can be made clinically straightforward from history and examination. Biopsy may be considered in doubtful case to differentiate from other conditions.

Question 5.

What is aetiopathogenesis of melasma?

Answer 5.

The cause of melasma is multifactorial and complex. As a result, precise aetiopathogenesis remains unclear. However, the below listed risk factors can be associated with development of melasma, and important to know.

• Sun exposure especially cumulative exposure
• Genetic predisposition (20% – 50% positive family history)^1,8
• Hormonal: hormonal contraception, pregnancy (15%-50% of pregnancy)8
• Photosensitive medications and cosmetic (scented) products use.

Question 6.

What treatment options can you offer Kim?

Answer 6.

The aim of melasma treatment is to diminish the pigmentation by halting the melanocytes proliferation, melanosomes formation and degradation. There are several modalities of treatment as outlined below.^1,5,9

I. General skin care: sun protection is paramount with wide-brimmed hat and use of sunscreen ≥ 30SPF, as UV light can enhance melanin production. Cosmetic camouflage is also useful optionally.

II. Medical treatment: includes a wide ranged forms as follows:

• Topical: triple combined topical (hydroquinone (HQ, main component) with retinoid and corticosteroid) is recommended as a first-line and gold-standard treatment due to better effectiveness as well as non-invasive than other modalities;^1,9 To name, Kligman’s formula (HQ 5% + tretinoin 0.05% + dexamethasone 0.1%), or Triluma (HQ 4% + tretinoin 0.05% + fuocinolone acetonide 0.01%), apply once or twice daily over lesion for four weeks and reassess. Treatment will take 3-6 months and adverse effects are minimal such as skin irritation, erythema and post-irritant hyperpigmentation. HQ should not be used during pregnancy.
• Other topical: There are also other useful mono-topical form such as HQ (2-5%), Azelaic acid (5-20%), Kojic acid (1–2%), Cysteamine cream (5%), Ascorbic acid (5–15%), Niacinamide (2-5%), Tranexamic acid (2–5%), Glutathione (2%), Tretinoin (0.025 – 0.5%), and Corticosteroid (mild – mid strength). Of note, the combined treatment or adding an adjuvant generally offers better efficacy and effectiveness.^5,6,9,
• Systemic: Tranexamic acid (TXA), Carotenoids (lutein/zeaxanthin), Glutathione and Polypodium leucotomos extract, of which TXA is widely studied with favourable effect. TXA may be cost-effectively prescribed by GPs in Australasia albeit it is mainly established for menorrhagia. The oral dosage is 500mg daily or twice daily with 3 – 6-month duration. In cases of severe melasma (extensive areas with dermal involvement) or recalcitrance from topical therapy, experts suggested that combined oral TXA and topical (eg. HQ) delivered a better outcome.^5,10 Maintenance topical twice weekly or appropriate frequency is recommended in view of easy relapse after stopping the treatment. The benefits of TXA in melasma treatment outweigh over minor side effects (headaches, epigastric pain, hypomenorrhea, and rare thromboembolic risk);⁶ however person with prompt coagulopathy will require extra caution.

III. Non-pharmacological treatment modalities include micro needling, chemical peeling, dermabrasion, laser and light-based therapies (IPL, PDL, QS-Nd:YAG), with variable responses. These forms, non-cheaper than the above-mentioned regimes should be reserved for cases with failed conventional treatment or patient’s choice, and referral to dermatologist is warranted.

IV. Melasma in pregnancy: may be transient and improve after delivery.⁶ Topical TXA, Azelaic acid and Kojic acid (Category B) are favoured for treatment of melasma during pregnancy if patient wished to be treated.

Kim was treated with oral TXA 500mg daily 6 months with topical Kligman (compounded from pharmacy) daily for 4 weeks, then twice weekly for six months, resulting in optimal outcome (fading of hyperpigmentation).  Note: More novel treatment are expected to emerge, as no single complete satisfactory treatment for melasma has not been established.

Question 7.

What are complications and prognosis/course of melasma?

Answer 7.

Melasma in women can cause psychological morbidity with low self-esteem and aesthetic concern. Although melasma can fade away spontaneously, it will take several years depending on individual’s risk factors and severity of lesion. Recurrent or refractory is relatively common for this chronic disorder.

Resources for health professionals

• DermNet New Zealand, https://dermnetnz.org/topics/melasma
• https://genevadermatology.ch/melasma-for-professionals/

Resources for patients

• https://www.dermcoll.edu.au/atoz/melasma/
• https://www.aad.org/public/diseases/a-z/melasma-treatment

References:

1. Doolan BJ, Gupta M. Melasma. Aust J Gen Pract. 2021 Dec;50(12):880-885.
2. Navya A, Pai V. Comparison of Dermoscope and Woods Lamp as A Tool to Study Melanin Depth in Melasma. Indian Dermatol Online J. 2022 May 5;13(3):366-369.
3. Lyford WH (2020, Apr 27). Melasma. Medscape.https://emedicine.medscape.com/article/ 1068640-differential (accessed 01 Jan 2023).
4. Wang RF, Ko D, Friedman BJ, Lim HW, Mohammad TF. Disorders of Hyperpigmentation. Part I. Pathogenesis and clinical features of common pigmentary disorders. J Am Acad Dermatol. 2022 Feb 10:S0190-9622(22)00251-1.
5. Neagu N, Conforti C, Agozzino M, Marangi GF, Morariu SH, Pellacani G, Persichetti P, Piccolo D, Segreto F, Zalaudek I, Dianzani C. Melasma treatment: a systematic review. J Dermatolog Treat. 2022 Jun;33(4):1816-1837.
6. Mahajan VK, Patil A, Blicharz L, Kassir M, Konnikov N, Gold MH, Goldman MP, Galadari H, Goldust M. Medical therapies for melasma. J Cosmet Dermatol. 2022 Sep;21(9):3707-3728.
7. Wu MX, Antony R, Mayrovitz HN. Melasma: A Condition of Asian Skin. Cureus. 2021 Apr 10;13(4):e14398.
8. Majid I, Aleem S. Melasma: Update on Epidemiology, Clinical Presentation, Assessment, and Scoring. J Skin Stem Cell. 2021;8(4):e120283.
9. González-Molina V, Martí-Pineda A, González N. Topical Treatments for Melasma and Their Mechanism of Action. J Clin Aesthet Dermatol. 2022 May;15(5):19-28.
10. McKesey J, Tovar-Garza A, Pandya AG. Melasma Treatment: An Evidence-Based Review. Am J Clin Dermatol. 2020 Apr;21(2):173-225.

MCQ questions for Melasma

Q. Melasma is more commonly seen in:

a. Caucasian women

b. African women

c. Southeast Asian and South Asian women

d. Northern Chinese women

Correct answer: c

Q. The differential diagnoses for melasma will include:

a. Naevus of Hori

b. Drug-induced pigmentation

c. Post-inflammatory hyperpigmentation

d. All of the above.

Correct answer: d

Q. The correct answer for among the conveniently available treatment modalities to date is:

a. Laser is the best

b. Triple combined topical (hydroquinone + retinoids + corticosteroid) is the first choice.

c. Oral Tranexamic acid is always indicated

d. Hydroquinone 5% cream is better than a combined cream.

Correct answer: b

Author Information

Tim Aung
General Practitioner (FRACGP, FRNZCGP).
Brisbane, Australia.