Melasma.

Melasma is a common hypermelanosis

that typically occurs on sun-exposed areas in the face.
The pathogenesis is poorly understood, but genetic
and hormonal influences in combination with UV
radiation are important. Specific precipitants include
birth-control pills, estrogen replacement therapy,
mild ovarian or thyroid dysfunction, ovarian tumors,
cosmetics, nutrition, phototoxic and photoallergic
medications, phototoxic drugs, and medication for
epilepsy.
Melasma is rarely reported before puberty and
is far more common in women, especially those of
reproductive age and often begins or is exacerbated
during pregnancy, explaining the common appellation
“mask of pregnancy.” People with darker skin
types are more frequently affected. The lesions are
brownish macules with irregular borders and symmetric,
photodistribution usually on the face (Fig.
75-17), often coalescing in a reticular pattern. Sun
exposure intensifies the lesions. There are three major
patterns of distribution of the lesions: (1) centrofacial
(63%: forehead, nose, chin, and upper lip), (2) malar
(21%: nose and cheeks), and (3) mandibular (16%:
ramus mandibulae). The anterior chest and dorsal
forearms may also be affected.
From its appearance under Wood’s lamp, melasma
is classically classified into epidermal, dermal, and
mixed. (Epidermal pigmentation is accentuated under
Wood’s lamp, whereas dermal pigmentation is less
apparent.)
Sun protection is central to management. Epidermal
pigmentation is known to be more responsive to
topical treatment than dermal pigmentation. Hypopigmenting
agents such as hydroquinone, tretinoin, azelaic
acid, rucinol, and kojic acid are helpful when used
for prolonged periods. The so-called Kligman formula
is a popular combination of hydroquinone, tretinoin,
and a mild topical corticoid. Chemical peels and laser
therapy may be helpful in the treatment of melasma,
but can also result in further unwanted hyperpigmentation.
Sometimes, melasma slowly disappears after
discontinuation of the hormonal stimulus and/or careful
sun avoidance.165–167
Pregnancy. During pregnancy increased pigmentation
occurs in 90% of women and is most prominent
in darker skin types. Preexisting pigmented lesions
such as nevi and ephelides become darker. Also, recent
scars often darken. In normally pigmented areas, such
as nipples, areolae, and genitalia, the pigmentation
becomes more intense. The linea alba, the median
line on the anterior abdominal wall, often becomes
hyperpigmented during pregnancy and is then called
linea nigra. In a small proportion of pregnant women,
hyperpigmentation occurs in the axillae or the inner
upper thighs. Melasma or “mask of pregnancy” (see
Section “Melasma”) occurs in more than 50% of pregnant
Women