Zenker_revised1.qxp 21/5/09 5:10 pm Page 47
Treating Melasma – A New Dermatological Approach
Table 1: Topical Depigmenting Agents Figure 2: Patient Who Suffered from Chloasma After
Laser Treatment for Over Two Years
Hydroquinone (HQ) (1,4 dihydroxybenzol)
Tretinoin (trans-retinoic-acid)
Before After
Kojic Acid (5-hydroxy-2-(hydroxymethyl)-4-pyrone)
Salicylic acid
Alpha-hydroxy-acid (AHA)
Vitamin C (ascorbic acid)
Figure 1: Principles of Treatment
Bleaching agents
Before After
(combination, concentration and way of delivery)
+
Superficial peeling
(keratinocyte turnover)
Combination therapy
Figure 3: No Pre-treatment, Severe Acne for Five Years,
• Can reduce time to resolution of melasma Superficial Medical Peels with Worsening of the
• Can be safe and effective
Pigmentation, Oral Antibiotics Over Months
Before After
facial areas.
1
It results in pigmentary dischromia or hypermelanosis
of the face, neck and décolleté, and is characterised by well-defined,
relatively symmetrical light brown, brown or grey patches and
macules on sun-exposed facial or bodily areas. Pigment may be
variable in depth; it can occur epidermally, dermally or in both of
these skin layers.
2
The pathophysiology of chloasma is uncertain. It is mostly due
to exposure to sunlight. Chloasma certainly worsens due to
Figure 4: Chloasma Occurred Under Systemic
ultraviolet (UV) exposure and, consequently, is worse in summer.
Chemotherapy Due to a Colorectal Carcinoma,
No Previous Therapy
Furthermore, other causes of melasma are a certain genetic
predisposition, hormonal activity (progesterone),
3
cosmetics, perfume
Before After
and photosensitising agents or medication (e.g. phenytoin, antibiotics
or chemotherapeutic medications). Chloasma can be related to a
certain ovarian or thyroid dysfunction or can occur idiopathically. It is
found in all races, is more common in women, is rare before puberty
and after menopause and is more often found in darker skin types.
Melasma is often linked to the occurrence of acne.
The physical examination consists more or less of a description of the
clinical findings. The typical clincal patterns of melasma in the face are treatment must include the use of sunscreen and abstinence from
centrofacial (63%), malar (21%) and mandibular (16%).
2
In addition, it is cosmetics rich in perfume, tensides and preservatives.
rarely found on the forearms or the decolleté. The intensity of the
pigmentation varies and is darker in darker skin types. In my opinion, chemical peels are one of the preferred indications for
the treatment of this hyperpigmentation. The intensity and depth of
There are not many options available for apparative examinations. chemical peels is very important for the clinical outcome. The deeper
Epidermal pigment can be detected using a Wood’s lamp the peel acts, the more often post-inflammatory hyperpigmentation
(340–400nm). An objective way to detect the location of occurs. Therefore, a chemical peel has to act superficially but as
the pigment would be a punch biopsy. Melanin is increased in the effectively as possible. The addition of bleaching agents is
keratinocytes in the basal and suprabasal layer of the epidermis, in indispensable. The mainstay of treatment remains topical
the superficial and mid-dermis within macrophages or in both layers. depigmenting agents. Hydroquinone (HQ) is most commonly used.
However, the enthusiasm for such an intervention is small. Pharmacotherapy with combinations of HQ, retinoids, glycolic and
salicylic acid peels and/or topical steroids can be promising.
Therapeutic Options
Melasma develops and resolves gradually. The management of Quick fixes with destructive modalities (kryotherapy, medium-depth
skincare for skin tenting to develop chloasma is indispensable. Every chemical peels, lasers and intense pulsed light yield)
4
can lead to
EUROPEAN DERMATOLOGY 47
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