Topical Treatments for Melasma and Postinflammatory Hyperpigmentation
C.B. Lynde; J.N. Kraft, MD; C.W. Lynde, MD, FRCPC
Abstract
Hyperpigmentation disorders of the skin are common and can be the source of significant psychosocial distress for patients. The most common of these disorders are melasma and postinflammatory hyperpigmentation. Sunscreen use and minimizing sun exposure are crucial in all cases. Topical applications are the mainstay of treatment and include phenols, retinoids, corticosteroids, and their combinations.
Hyperpigmentation disorders of the skin are common and can be the source of significant psychosocial distress for patients. The most common of these disorders are melasma and postinflammatory hyperpigmentation. Sunscreen use and minimizing sun exposure are crucial in all cases. Topical applications are the mainstay of treatment and include phenols, retinoids, corticosteroids, and their combinations.
Introduction
Hyperpigmentation of the skin is a very common problem, with many patients seeking therapies to improve their cosmetic appearance. It is the result of an increase in cutaneous melanin deposition either by increased melanin synthesis or, less commonly, by a greater number of melanocytes. The amount of color change depends on the location of the melanin deposition. Epidermal involvement appears as brown discoloration whereas dermal deposition appears as blue-grey.
Hyperpigmentation of the skin is a very common problem, with many patients seeking therapies to improve their cosmetic appearance. It is the result of an increase in cutaneous melanin deposition either by increased melanin synthesis or, less commonly, by a greater number of melanocytes. The amount of color change depends on the location of the melanin deposition. Epidermal involvement appears as brown discoloration whereas dermal deposition appears as blue-grey.
Mixed epidermal and dermal depositions appear as brown-grey discolorations. The use of a Wood's lamp can often be very beneficial in determining the location of melanin deposition showing enhancement of color contrast in lesional skin for the epidermal type, but not the dermal types. The mixed type has enhancement in some areas of lesional skin, but not in other areas. Whether the melanin is deposited in the epidermis or dermis is important therapeutically because dermal hyperpigmentation is much more challenging to treat.
The most common pigmentation disorders for which patients seek treatment are melasma and postinflammatory hyperpigmentation (PIH). These conditions may have a major impact because disfiguring facial lesions can significantly affect a person's psychological and social wellbeing, contributing to lower productivity, social functioning, and self-esteem.
Melasma
Melasma is a common acquired pigmentary disorder that occurs mainly in women (more than 90% of cases) of all racial and ethnic groups, but particularly affects those with Fitzpatrick skin types IV-VI. While the cause of melasma is unknown, factors include: a genetic predisposition, ultraviolet light exposure, and estrogen exposure. Estrogen is thought to induce melasma as it often develops during pregnancy, with use of oral contraceptives, and with hormone replacement therapy (HRT) in postmenopausal women. Melasma in pregnancy usually clears within a few months of delivery.
Discontinuation of oral contraceptives or HRT, in combination with adequate sun protection, may also result in melasma clearance, although there is a paucity of literature with regard to HRT and the clearance of this condition. Melasma presents as brown to grey macules and patches, with serrated, irregular, and geographic borders. The pigmented patches are usually sharply demarcated and symmetrical. Melasma has a predilection for sun-exposed areas. The three major patterns of distribution are: centrofacial (cheeks, forehead, upper lip, nose, and chin) (66% of cases), malar (cheeks and nose) (20% of cases) and mandibular (rami of the mandible) (15% of cases). See Table 1 for the differential diagnosis.
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The most common pigmentation disorders for which patients seek treatment are melasma and postinflammatory hyperpigmentation (PIH). These conditions may have a major impact because disfiguring facial lesions can significantly affect a person's psychological and social wellbeing, contributing to lower productivity, social functioning, and self-esteem.
Melasma
Melasma is a common acquired pigmentary disorder that occurs mainly in women (more than 90% of cases) of all racial and ethnic groups, but particularly affects those with Fitzpatrick skin types IV-VI. While the cause of melasma is unknown, factors include: a genetic predisposition, ultraviolet light exposure, and estrogen exposure. Estrogen is thought to induce melasma as it often develops during pregnancy, with use of oral contraceptives, and with hormone replacement therapy (HRT) in postmenopausal women. Melasma in pregnancy usually clears within a few months of delivery.
Discontinuation of oral contraceptives or HRT, in combination with adequate sun protection, may also result in melasma clearance, although there is a paucity of literature with regard to HRT and the clearance of this condition. Melasma presents as brown to grey macules and patches, with serrated, irregular, and geographic borders. The pigmented patches are usually sharply demarcated and symmetrical. Melasma has a predilection for sun-exposed areas. The three major patterns of distribution are: centrofacial (cheeks, forehead, upper lip, nose, and chin) (66% of cases), malar (cheeks and nose) (20% of cases) and mandibular (rami of the mandible) (15% of cases). See Table 1 for the differential diagnosis.
DOWNLOAD COMPLETE PDF HERE
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