MELASMA

DEFINITION
Melasma is an acquired pigment disorder,
characterized by symmetrical macular
hyperpigmentation on the face.
Often called chloasma, this disorder was
found in the facial area that extends to the
neck and have sizes that vary

EPIDEMIOLOGY
Darker skin tones
East Asia,West Asia, Southeast Asia.
Hipanic and Black people who lives in a
place that receives prolonged sun
exposure
People with Fitzpatrick skin type IV and
V
30% in middle aged women, men can
also be affected

ETIOLOGY
There many causes of melasma.
Genetic, UV radiation, Thyroid Disease,
Pregnancy, Use of contraceptive pills and
drugs (phenytoin)
Pigmentation occurs due to the excessive
production of melanin

CLASSIFICATIONS
Three types of classification
1. Histology subtypes
A. Epidermis type
It is the most common type
Increased levels of melanin in the
epidermis with only a few of
melanocytes are located on the surface
of the dermis.
Enhances on Wood lamp examination

B. Dermis type
many melanophages can be found
throughout the entire dermis
does not enhance on Wood lamp
examination
C. Mixed type
melanin is increased in the epidermis,
and many melanophages found
throughout the dermis;
Woods lamp examination: spotty

D. Indeterminate type
seen in people with Fitzpatrick type V
or VI skin (skin that very rarely burns or
never burns)
Wood lamp examination is not helpful.

2. Clinical subtypes
A. Centrofacial: involves forehead, cheeks,
upper lip, nose, and chin
B. Malar: involves upper cheek area
C. Mandibular: involves the ramus of the
mandible.

3. Fitzpatrick skin-type classification

Type I: white, always burns easily, never tans
Type II: white, always burns easily, tans minimally
Type III: white, burns minimally, tans gradually
Type IV: light brown, burns minimally, tans well
Type V: brown, rarely burns, tans profusely
Type VI: dark brown or black, never burns, tans
profusely.

ANATOMY

Epidermal
1. Stratum corneum
- layer has many rows of dead cells filled with keratin
-continuously shed and replaced
2. Stratum lucidum
-seen in thick skin of the palms and soles of feet.
3. Stratum granulosum
- 3-5 rows of flattened cells
- nuclei of cells flatten out

4. Stratum spinosum
- melanin granules and Langerhans cell
predominate
5. Stratum basale:
- deepest epidermal layer
- attached to dermis
- mostly columnar keratinocytes
- contain merkel cells and melanocytes

Dermis:
- flexible and strong connective tissue
- elastic, reticular and collagen fibers
- nerves, blood and lymphatic vessels
- oil and sweat glands originate
- two layers: papillary and reticular

1. Papillary layer:
- loose connective tissue with nipple like surface
projection called dermal papilla.
- Contain capillaries
2. Reticular layer:
- collagen fibers offer strength
- holds water

Subcutaneous
- contains adipose tissue and blood vessels

Glands:
Two types of glands exist in the integument.
- Sebaceous glands (oil glands)
- Sudoriferous glands (sweat glands)
1. Sebaceous glands: (holocrine glands)
- connected to hair follicle
- not found on palms and soles of feet
- secretes sebum (fats, cholesterol and
proteins)
- keep hair from drying out, keeps skin
moist

2. Sudoriferous glands: exocrine glands

- millions located throughout the skin
- two types:
i. eccrine:
- Spiral shape
- duct empties on skin surface
- palms and soles of feet
- regulated by cholinergic nerve
- all part of body.

ii. apocrine: axillary and pubic region

- duct empties onto hair follicle
- viscous fluid
- causes body odor when bacteria break it
down
- regulated by adrenergic nerve

Nails:
- Nail plate (body): visible portion
- Nail root: located under cuticle
- Lunula: half moon crescent shaped
white portion under cuticle
- Nail bed: located under nail plate

Hair
1. Vellus hair: all part of body
2. Terminal hair : coarser hair; axillary and
pubic region. Grow in response to sex
hormones

PHYSIOLOGY
1- Protection
- physical barrier that protects underlying tissues
from injury, UV light and bacterial invasion.
2- Regulation of body temperature
- high temperature or strenuous exercise; sweat
is evaporated from the skin surface to cool it
down.
- vasodilation and vasoconstriction regulates
body temp.

3-Sensation
- nerve endings and receptor cells that
detect stimuli to temperature, pain,
pressure and touch.
4- Excretion
- sweat removes water and small amounts
of salt, uric acid and ammonia from the body
surface

5- Blood reservoir
- dermis houses an extensive network of
blood vessels carrying 8-10% of total blood
flow in a resting adult.
6- Synthesis of Vitamin D (cholecalciferol)
-UV rays in sunlight stimulate the production
of Vit. D. Enzymes in the kidney and liver
modify and convert to final form; calcitriol
(most active form of Vit. D.) Calcitriol aids in
absorption of calcium from foods and is
considered a hormone.

PATHOMECHANISM OF MELASMA

UV rays destroy Sulphydryl group in

epidermal layer that normally inhibit
tirosinase enzyme for melanogenesis
process.
Use of contraceptive pills may induce
melasma through stimulation of oestrogen
receptor on the melanocyte.

 During pregnancy, melanin stimulating

hormone(MSH) is produced in large amount, as
well as oestrogen and progesterone which are
known to induce melasma.

CLINICAL FEATURES
Melasma presents itself as a symmetrical
hiperpigmentation appearing light brown
to dark brown reticulated macules
Clinical subtypes: a) centrofacial (63%), b)
malar (21%) and c) mandibular (16%)

DIAGNOSIS
A. ANAMNESIS/HISTORY TAKING
Chief complaint: Progressive
hyperpigmentation
Other factors: Pregnancy, Sun exposure,
Contraceptive pills
B. HISTOPATHOLOGY EXAMINATION
Epidermal
Dermal
Mixed

C. Woods Lamp Examination

Epidermal
Dermal
Mixed (Dermal-Epidermal)
Indeterminate

DIFFERENTIAL DIAGNOSIS
A. RIEHLS MELANOSIS
Histopathology : Inflammation infiltrate at
epidermal-dermal and lymphositic
perivascular infiltate
Light brown to dark brown pigmentationn
Forehead, Malar
Due to cosmeticss products, and thus it
is also called Pigmented cosmetic
dermatitis
Patch testing can be done to look for
reaction to components of cosmetics.

B. POST INFLAMMATORY
HYPERPIGMENTATION
A result of patophysiological response
from cutaneus inflammation such as
acne, atopic dermatitis, psoriasis
History : pruritus, dermatitis
Diagnosis is crucial

C. EPHELID
Determined by autosomal dominan gene
More frequent in individuals with blonde or red
hairs, and of Celtic (Scottish, Irish Welsh)
extraction
Hyperpigmentation macules appearing light
brown on sun exposed skins
Pathology lies in the melanosomes; The
melanosomes are longer and rod shaped , and
produced melanin more rapidly when exposed
to the sun.

PREVENTION
Avoid the sun
Example : wearing hat, umbrella, sun block
Avoid some factor that can cause melasma
Example : stop using pill contraception, stop using
cosmetic product
and prevent from using some medicine
(hidantion,
antimalaria, monosiklin)

TREATMENT
1.Sistemik :
-Ascorbic acid/ Vitamin C (1000-1500 mg/day)
-Glutathion (3 x 100 mg/day)
2.Topikal :
Kligman Formula (Whitening cream, Retin-A, Mild
pontent corticosteroids

 Hydroquinone cream 2%-5%

Retinoic acid 0.1%
Azeleic acid 20% for 6 month

3. Advanced treatment
. Chemical peeling
. Laser

PROGNOSIS
Melasma often fades over several months after
you stop taking hormone medicines or your
pregnancy ends. The problem may come back in
future pregnancies or if you use these medicines
again. It may also come back from sun exposure.

Conclusion
Melasma is a complex disorder and various
factors are involved in its pathogenesis,
identification of which will help us in developing
better treatment options with more efficacy,
less side effects and longer periods of
remission.
Newer compounds, especially botanical extracts
and devicebased treatments are being
developed and add to the list of options
available for treatment.

 However, more randomized controlled trials are

needed to evaluate their efficacy compared to the
well known treatments available.

There is also need to define the role of

combination therapy and design protocols to
provide optimum results and prevent relapses

THANK YOU