Derm Dx: Brown patches on the face - Clinical Advisor

Derm Dx: Brown patches on the face

Slideshow

  • Melasma1_0513 Derm Dx

  • Melasma2_0513 Derm Dx

A 45-year-old Hispanic female presents to the dermatology clinic distressed about brown patches on her face. She first noticed the spots after the birth of her second child at the age of 30 years. Since then she feels that the pigmentation has darkened and become more extensive.

Melasma is a very common skin disorder. All races are affected, but increased severity has been noted in more darkly pigmented populations such as Southeast Asians, Hispanics and blacks. Both men and women are affected, however female patients more commonly...

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Melasma is a very common skin disorder. All races are affected, but increased severity has been noted in more darkly pigmented populations such as Southeast Asians, Hispanics and blacks. Both men and women are affected, however female patients more commonly seek treatment. 

The pathogenesis of melasma is not completely characterized, but ultraviolet sun exposure is certainly the primary trigger. Female hormones are a secondary trigger for melisma. Therefore it is often seen in the setting of pregnancy, oral contraceptive use and hormone replacement therapy. Fortunately, melasma associated with pregnancy often resolves. However, melasma associated with exogenous hormone therapy rarely improves spontaneously. 

The pigmentation of melasma consists of well-demarcated brown patches. The common locations are the malar cheek, forehead, upper lip, mandible and dorsal forearms. 

Melasma is very challenging to treat. Patient education regarding sunlight avoidance is of utmost importance. This includes use of broad-spectrum sunblock, broad-rimmed hats, tinted car windows, shielding the skin with an umbrella on daytime walks and other modalities of sun-protection. 

Topical therapy with a hydroquinone based bleaching cream is the gold standard of treatment and has been demonstrated to be efficacious. Hydroquinone in combination with a topical corticosteroid and topical retinoid is more efficacious that hydroquinone monotherapy. 

Several surgical procedures may be effective in treating melasma, but all patients must continue to practice strict sun protection before and after the procedures. Additionally, patients are often pretreated with hydroquinone cream prior to the procedure in order to help prevent the risk of paradoxical post-procedural hyperpigmentation.

Chemical peels with glycolic acid and salicylic acid are commonly used treatment. There are multiple laser modalities that have been reported to be effective.  Fractional resurfacing is a modality used in our practice with moderate results. 

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.

References

  1. Bolognia J, Jorizzo JL, Rapini RP. “Chapter 66: Disorders of Hyperpigmentation.” Dermatology. St. Louis: Mosby/Elsevier, 2008.
  2. James WD, Berger TD, Elston DM et al. “Chapter 36: Disturbances of Pigmentation.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
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