Melasma

Aka: Melasma, Chloasma, Mask of pregnancy

1. See Also
   1. Hyperpigmentation
   2. Hyperpigmentation in Pregnancy
2. Definition
   1. Chloasma from Greek: "Greenish tint of growing bud"
3. Epidemiology
   1. Women outnumber men by 9:1 ratio
   2. More prominent with darker skin
4. Causes
   1. Pregnancy (affects 70% of pregnant women)
      1. See Hyperpigmentation in Pregnancy
      2. Usually during second and third trimesters
      3. Resolves after delivery
      4. Often darker with subsequent pregnancies
   2. Oral Contraceptives
   3. Phototoxic Reaction (e.g. Phenytoin)
   4. Hyperthyroidism
   5. Liver disease
5. Signs
   1. Hyperpigmented brown flat macular patch
   2. Distribution (usually symmetric)
      1. Cheeks (malar)
      2. Forehead and bridge of nose
      3. Upper lip
   3. Provocative factors (darkening)
      1. Sun Exposure
6. Management: Antepartum
   1. Prevent Sun Exposure with high potency Sunscreen
7. Management: Postpartum
   1. Prevent Sun Exposure with high potency Sunscreen (Titanium dioxide or zinc oxide)
   2. Treatment Approach
      1. Postpartum or post-OCP Melasma often improves in months spontaneously
         1. Observation may be the most prudent approach
      2. Treatments below typically require continued use indefinately for maintenance
   3. Hydroquinone bleaching creams
      1. May be used in combination with Tretinoin (Retin A)
      2. Use for 3-4 weeks
      3. Use with Sunscreen
         1. SPF 50 over the Melasma areas
         2. SPF 15 over other areas of the face
      4. Adverse effects
         1. Hypopigmentation
            1. Use caution in patients with darker skin
         2. Skin sensitizer
            1. Test daily for 2 days on arm first
      5. Preparations
         1. Hydroquinone 2% (Porcelana) is over the counter
         2. Hydroquinone 3-4% is prescription only
            1. Eldopaque available with sun block
         3. Hydroquinone 4%, Tretinoin 0.05%, Fluocinolone 0.01% (Tri-Luma)
            1. Preferred agent by some dermatologists
            2. Torok (2005) Cutis 75:57-62
   4. Keratolytics
      1. Potentiates hydroquinone skin penetration
      2. Reduces pigment over months
      3. Agents
         1. Tretinoin (Retin A) 0.05% to 0.1% cream
         2. Azelaic Acid (Azelex) 20% cream
         3. Adapalene (Differin) 0.1% to 0.3% gel
   5. Chemical Peel
      1. Glycolic Acid 10% peel
      2. Performed by Dermatology
      3. Risk of Hyperpigmentation in darker skin patients
8. References
   1. Habif (1996) Dermatology, p. 622-3
   2. Stambuk in Gabbe (2002) Obstetrics, p. 1283
   3. Plensdorf (2009) Am Fam Physician 79:109-16