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Melasma ( Hyperpigmentation skin disorder ) Causes , Treatment and Management

Updated: Jun 27, 2021

Author : Leonard E, APRN, NP-C, FNP-BC

Board Certified Nurse Practitioner

๐‘ด๐’†๐’๐’‚๐’”๐’Ž๐’‚, ๐‘ช๐’‚๐’–๐’”๐’†๐’”, ๐’•๐’“๐’†๐’‚๐’•๐’Ž๐’†๐’๐’• ๐’‚๐’๐’… ๐‘ด๐’‚๐’๐’‚๐’ˆ๐’†๐’Ž๐’†๐’๐’• ๐’Š๐’ ๐’•๐’‰๐’† ๐‘ท๐’“๐’Š๐’Ž๐’‚๐’“๐’š ๐‘ช๐’‚๐’“๐’† ๐‘บ๐’†๐’•๐’•๐’Š๐’๐’ˆ.


Melasma is a more general term referring to hyperpigmentation of certain areas of the skin (regardless of pregnancy status) as a result of sun exposure and hormonal influences. It is usually more common in women than in men. First-line treatments are prescription skin bleaching creams (hydroquinone) and strict sun avoidance. Studies are being done to examine the benefit of laser therapy and salicylic acid peels every 2 to 8 weeks.

๐‘ด๐’†๐’๐’‚๐’”๐’Ž๐’‚ is considered a chronic disease that is characterized as the presence of majorly symmetrical, macular hyperpigmentation (bronzing) in sun- exposed areas, such as over the ๐’„๐’‰๐’†๐’†๐’Œ๐’”, ๐’‡๐’๐’“๐’†๐’‰๐’†๐’‚๐’…, ๐’๐’๐’”๐’†, ๐’„๐’‰๐’Š๐’, ๐’‹๐’‚๐’˜ ๐’‚๐’๐’ˆ๐’๐’†, and above the upper lip

These Irregular dark-brown macules and patches with well-defined margins, are seen most often in women of reproductive age with a darker complexion; can appear with pregnancy which is called (e.g., chloasma)

๐‚๐—ผ๐—บ๐—บ๐—ผ๐ง ๐‚๐š๐ฎ๐ฌ๐ž๐ฌ / ๐“๐ซ๐ข๐ ๐ ๐ž๐ซ๐ฌ


1. ๐’๐ฎ๐ง ๐ž๐ฑ๐ฉ๐—ผ๐ฌ๐ฎ๐ซ๐ž ( common in summer and improves in winter)


2. Initiation of common ๐Ž๐ซ๐š๐ฅ ๐œ๐—ผ๐ง๐ญ๐ซ๐š๐œ๐ž๐ฉ๐ญ๐ข๐ฏ๐ž๐ฌ) or ๐ก๐—ผ๐ซ๐—บ๐—ผ๐ง๐š๐ฅ ๐ซ๐ž๐ฉ๐ฅ๐š๐œ๐ž๐—บ๐ž๐ง๐ญ ๐ญ๐ก๐ž๐ซ๐š๐ฉ๐ฒ (*hormones, especially estrogen and progesterone exposure during pregnancy, in birth control pills, or through hormone replacement therapy)


3. ๐Œ๐ž๐๐ข๐œ๐š๐ญ๐ข๐—ผ๐ง๐ฌ (๐ฌ๐—ผ๐—บ๐ž ๐š๐ง๐ญ๐ข๐ฌ๐ž๐ข๐ณ๐ฎ๐ซ๐ž ๐๐ซ๐ฎ๐ ๐ฌ/ ๐š๐ง๐ญ๐ข๐—บ๐š๐ฅ๐š๐ซ๐ข๐š๐ฅ ๐๐ซ๐ฎ๐ ๐ฌ)


4. Cosmetics

๐“๐ซ๐ž๐š๐ญ๐—บ๐ž๐ง๐ญ

Sun protection and sunscreens containing zinc oxide or titanium are most beneficial and must be used for any sun exposure areas.

๐๐ก๐š๐ซ๐—บ๐š๐œ๐—ผ๐ญ๐ก๐ž๐ซ๐š๐ฉ๐ฒ


๐‡๐ฒ๐๐ซ๐—ผ๐ช๐ฎ๐ข๐ง๐—ผ๐ง๐ž (Melanex) 3% to 4% cream: apply ๐ญ๐ฐ๐ข๐œ๐ž ๐š๐ญ ๐๐š๐ฒ (**apply a small amount on the arms to test for hypersensitivity first ๐›๐ž๐Ÿ๐—ผ๐ซ๐ž ๐ฎ๐ฌ๐ข๐ง๐ ); treat for 3 to 12 months

๐“๐ซ๐ž๐ญ๐ข๐ง๐—ผ๐ข๐ง (Retin-A) 0.05%: apply ๐ญ๐ฐ๐ข๐œ๐ž ๐š๐ญ ๐๐š๐ฒ. results may be seen in 24 weeks; ***use sunscreen

๐€๐ณ๐ฅ๐š๐ข๐œ ๐€๐œ๐ข๐ (Azelex) 20%: apply ๐ญ๐ฐ๐ข๐œ๐ž ๐š๐ญ ๐๐š๐ฒ for up to 8 months

Fluocinolone/hydroquinone/tretinoin (Tri-Luma): apply at bedtime is another option

*๐‘ป๐’“๐’Š-๐‘ณ๐’–๐’Ž๐’‚: hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% (๐’ƒ๐’†๐’”๐’• ๐‘ญ๐‘ซ๐‘จ ๐’•๐’“๐’†๐’‚๐’•๐’Ž๐’†๐’๐’•)


In fact, the only topical ointment currently approved by the US Food and Drug Administration (FDA) for the treatment of melasma is a triple-combination cream, a composite of hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% (Tri-Luma).

Comparative studies of the effectiveness of the triple-combination cream versus topical HQ suggest that the combination cream is faster and more effective at reducing melasma pigmentation, but it does carry a slightly increased risk of an adverse reaction.

2010 study found that the triple-combination cream is safe and effective when used intermittently or continuously for up to 24 week



Treatment of ๐Œ๐ž๐ฅ๐š๐ฌ๐—บ๐š can include combi- nations of a retinoic acid and hydroquinone, beta- hydroxy acid peels, and various laser and intense pulsed light photorejuvenation treatments.

*A 24-hour skin patch test to rule out an allergy to any bleaching agent should be done before use. The patient should be advised to avoid the eye area and to use the cream cautiously in sensitive areas such as the nose and the lips.



References


Dunphy, L. M., Winland-Brown, J. E., & Thomas, D. J. (2015). Chapter 7. Skin Problems. In Primary care: The art and science of advanced practice nursing (4th ed., pp. 152-153). F A Davis Company.

Fenstermacher, K., & Hudson, B. T. (2015). Chapter 5. Skin Conditions. Disorders of pigmentation. In Practice guidelines for family nurse practitioners (4th ed., p. 168). W B Saunders Company.



Goroll, A. H., & Mulley, A. G. (2014). Chapter 180. Evaluation of Disturbances in Pigmentation. In Primary care medicine: Office evaluation and management of the adult patient (7th ed., pp. 3377-3388). Lww.

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