II. Definition
- Chloasma from Greek: "Greenish tint of growing bud"
III. Epidemiology
- Women outnumber men by 9:1 ratio
- More prominent with darker skin (skin types 4-6)
IV. Causes
- Pregnancy (affects 70% of pregnant women)
- See Hyperpigmentation in Pregnancy
- Usually during second and third trimesters
- Resolves after delivery
- Often darker with subsequent pregnancies
- Oral Contraceptives
- Phototoxic Reaction (e.g. Phenytoin)
- Hyperthyroidism
- Liver disease
V. Signs
- Progressive Macular, nonscaling hypermelanosis on skin that is sun exposed
- Hyperpigmented brown flat Macular patch
- Epidermal Melasma: Light brown coloration, enhances under Woods Lamp
- Dermal Melasma: Gray, does not enhance under Woods Lamp (predicts treatment refractory)
- Distribution (usually symmetric)
- Face (typically in one of 3 patterns: centrofacial, malar or mandibular)
- Cheeks (malar)
- Forehead and bridge of nose
- Upper lip
- Other regions
- Dorsal Forearms
- Face (typically in one of 3 patterns: centrofacial, malar or mandibular)
- Provocative factors (darkening)
VI. Management: General (non-pregnancy related)
- Approach
- Sunscreen
- SPF 50 over the Melasma areas
- SPF 15 over other areas of the face
- Treatments must be continued indefinately to maintain effect
- Sunscreen
- Combination agents
- Hydroquinone 4%, Tretinoin 0.05%, Fluocinolone 0.01% (Tri-Luma)
- Most effective, but adverse effects include erythema and peeling (in up to 40%)
- Torok (2005) Cutis 75:57-62 [PubMed]
- Hydroquinone 4%, Tretinoin 0.05%, Fluocinolone 0.01% (Tri-Luma)
- Hydroquinone bleaching creams
- May be used in combination with Tretinoin (Retin A)
- Use with Sunscreen (see above)
- Adverse effects
- Hypopigmentation
- Use caution in patients with darker skin
- Skin sensitizer
- Test daily for 2 days on arm first
- Hypopigmentation
- Preparations
- Hydroquinone 2% (Porcelana) is over the counter
- Hydroquinone 3-4% is prescription only
- Eldopaque available with sun block
- Keratolytics
-
Chemical Peel
- Glycolic Acid 10% peel
- Performed by Dermatology
- Risk of Hyperpigmentation in darker skin patients
- Variably effective (Tri-Luma is preferred instead)
VII. Management: Pregnancy Related
- Antepartum
- Prevent Sun Exposure and use high potency Sunscreen
- Do not use any of the topicals above (Teratogenic)
- Reassure, that Melasma fades gradually after delivery (but may recurr with future pregnancies)
- Postpartum
- Prevent Sun Exposure with high potency Sunscreen (Titanium Dioxide or Zinc Oxide)
- Treatment Approach
- Postpartum or post-OCP Melasma often improves in months spontaneously (90% of cases)
- Observation may be the most prudent approach
- Treatments above typically require continued use indefinately for maintenance
- Delay start for at least 2-3 months after delivery to allow for natural fading
- Postpartum or post-OCP Melasma often improves in months spontaneously (90% of cases)
VIII. References
- Habif (1996) Dermatology, p. 622-3
- Stambuk in Gabbe (2002) Obstetrics, p. 1283
- Erlandson (2023) Am Fam Physician 107(2): 152-8 [PubMed]
- Plensdorf (2009) Am Fam Physician 79:109-16 [PubMed]
- Plensdorf (2017) Am Fam Physician 96(12): 797-804 [PubMed]
- Rivas (2013) Am J Clin Dermatol 14(5): 359-76 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| Definition (NCI) | Symmetrical patches of tan or brown discoloration on the skin of the face that darken with sun exposure.(NICHD) |
| Concepts | Disease or Syndrome (T047) |
| MSH | D008548 |
| ICD10 | L81.1 |
| SnomedCT | 201280001, 156434007, 36209000 |
| English | Chloasma, Chloasmas, Melasma, Melasmas, CHLOASMA, Chloasma NOS, melasma (chloasma faciei), melasma, chloasma faciei, melasma (diagnosis), Chloasma NOS (disorder), Melasma (disorder), Chloasma (disorder), chloasma, Chloasma, NOS, Melasma, NOS |
| Portuguese | CLOASMA, Cloasma, Melasma |
| Spanish | CLOASMA, Cloasma, cloasma, SAI, cloasma, SAI (trastorno), cloasma, melasma (trastorno), melasma, Melasma |
| Dutch | abnormale huidpigmentering, chloasma, Chloasma, Melasma |
| French | Mélasme, Chloasma, Mélasma, CHLOASMA, Masque de grossesse |
| German | Melasma, Chloasmen, CHLOASMA, Chloasma [Melasma], Chloasma, Melasmen |
| Japanese | メラニン沈着, 肝斑, ﾒﾗﾆﾝﾁﾝﾁｬｸ, ｶﾝﾊﾝ, ｶﾝﾊﾟﾝ |
| Czech | Melasma, Chloasma, chloasma, melasma |
| Korean | 기미 |
| Hungarian | Melasma, Chloasma |
| Italian | Melasma, Cloasma |
| Norwegian | Kloasme, Melasma |
