Author : Leonard E, APRN, NP-C, FNP-BC
Board Certified Nurse Practitioner
𝑴𝒆𝒍𝒂𝒔𝒎𝒂, 𝑪𝒂𝒖𝒔𝒆𝒔, 𝒕𝒓𝒆𝒂𝒕𝒎𝒆𝒏𝒕 𝒂𝒏𝒅 𝑴𝒂𝒏𝒂𝒈𝒆𝒎𝒆𝒏𝒕 𝒊𝒏 𝒕𝒉𝒆 𝑷𝒓𝒊𝒎𝒂𝒓𝒚 𝑪𝒂𝒓𝒆 𝑺𝒆𝒕𝒕𝒊𝒏𝒈.
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.
𝑴𝒆𝒍𝒂𝒔𝒎𝒂 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 𝒄𝒉𝒆𝒆𝒌𝒔, 𝒇𝒐𝒓𝒆𝒉𝒆𝒂𝒅, 𝒏𝒐𝒔𝒆, 𝒄𝒉𝒊𝒏, 𝒋𝒂𝒘 𝒂𝒏𝒈𝒍𝒆, 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)
𝐂𝗼𝗺𝗺𝗼𝐧 𝐂𝐚𝐮𝐬𝐞𝐬 / 𝐓𝐫𝐢𝐠𝐠𝐞𝐫𝐬
1. 𝐒𝐮𝐧 𝐞𝐱𝐩𝗼𝐬𝐮𝐫𝐞 ( common in summer and improves in winter)
2. Initiation of common 𝐎𝐫𝐚𝐥 𝐜𝗼𝐧𝐭𝐫𝐚𝐜𝐞𝐩𝐭𝐢𝐯𝐞𝐬) or 𝐡𝗼𝐫𝗺𝗼𝐧𝐚𝐥 𝐫𝐞𝐩𝐥𝐚𝐜𝐞𝗺𝐞𝐧𝐭 𝐭𝐡𝐞𝐫𝐚𝐩𝐲 (*hormones, especially estrogen and progesterone exposure during pregnancy, in birth control pills, or through hormone replacement therapy)
3. 𝐌𝐞𝐝𝐢𝐜𝐚𝐭𝐢𝗼𝐧𝐬 (𝐬𝗼𝗺𝐞 𝐚𝐧𝐭𝐢𝐬𝐞𝐢𝐳𝐮𝐫𝐞 𝐝𝐫𝐮𝐠𝐬/ 𝐚𝐧𝐭𝐢𝗺𝐚𝐥𝐚𝐫𝐢𝐚𝐥 𝐝𝐫𝐮𝐠𝐬)
4. Cosmetics
𝐓𝐫𝐞𝐚𝐭𝗺𝐞𝐧𝐭
Sun protection and sunscreens containing zinc oxide or titanium are most beneficial and must be used for any sun exposure areas.
𝐏𝐡𝐚𝐫𝗺𝐚𝐜𝗼𝐭𝐡𝐞𝐫𝐚𝐩𝐲
𝐇𝐲𝐝𝐫𝗼𝐪𝐮𝐢𝐧𝗼𝐧𝐞 (Melanex) 3% to 4% cream: apply 𝐭𝐰𝐢𝐜𝐞 𝐚𝐭 𝐝𝐚𝐲 (**apply a small amount on the arms to test for hypersensitivity first 𝐛𝐞𝐟𝗼𝐫𝐞 𝐮𝐬𝐢𝐧𝐠); treat for 3 to 12 months
𝐓𝐫𝐞𝐭𝐢𝐧𝗼𝐢𝐧 (Retin-A) 0.05%: apply 𝐭𝐰𝐢𝐜𝐞 𝐚𝐭 𝐝𝐚𝐲. results may be seen in 24 weeks; ***use sunscreen
𝐀𝐳𝐥𝐚𝐢𝐜 𝐀𝐜𝐢𝐝 (Azelex) 20%: apply 𝐭𝐰𝐢𝐜𝐞 𝐚𝐭 𝐝𝐚𝐲 for up to 8 months
Fluocinolone/hydroquinone/tretinoin (Tri-Luma): apply at bedtime is another option
*𝑻𝒓𝒊-𝑳𝒖𝒎𝒂: hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% (𝒃𝒆𝒔𝒕 𝑭𝑫𝑨 𝒕𝒓𝒆𝒂𝒕𝒎𝒆𝒏𝒕)
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 𝐌𝐞𝐥𝐚𝐬𝗺𝐚 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.