Melasma Clinical Presentation

Updated: Apr 27, 2020
  • Author: Willis Hughes Lyford, MD; Chief Editor: William D James, MD  more...
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Presentation

History

Patients may inquire about progressive hyperpigmentation of the face, which may be temporally related to pregnancy or to the use of oral contraceptive pills. In the vast majority of cases, it is asymptomatic.

Some patients may report extrafacial melasma, but this very rarely presents in isolation and usually patients also exhibit findings on their sun-exposed face.

Intense or long-term exposure to sunlight worsens the condition and may precipitate melasma, but because the development of pigmentation is often insidious, patients may not recognize the association.

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Physical Examination

The macular hyperpigmentation of melasma is commonly tan to brown. Blue or black may be evident in patients with dermal melasma. The distribution is one of three patterns. Centrofacial involves the forehead, cheeks, nose, upper lip, and chin. Malar involves solely the nose and the cheeks. Mandibular affects the ramus of the mandible. It is unclear why certain characteristic areas of the face are most commonly involved, but it is believed that sebaceous gland density and activity in these regions may be involved. A rare pattern confined to the forearms is seen in women receiving exogenous progesterone and in Native Americans.

The excess melanin can be visually localized to the epidermis or the dermis by use of a Wood lamp (wavelength, 340-400 nm). Epidermal pigment is enhanced during examination with a Wood light and generally appears well-circumscribed with accentuation of borders. Dermal melanosis, on the other hand, tends to be less well-defined. Clinically, a large amount of dermal melanin is suspected if the hyperpigmentation is bluish black. In individuals with dark-brown skin, examination with a Wood light does not localize pigment, and these patients are thus classified as indeterminate.

Dermoscopy can also play a key role in the diagnosis of melasma and in identifying the level of pigment deposition. Dermoscopy findings include prominent vascularity and telangiectasias, accentuation of the pseudoreticular pigmentary network, and pigment structures including owl's eye structures. Dermoscopy may also be used for assessing melasma severity. [15]

The Melasma Area and Severity Index (MASI) is a common outcome measure that is validated as a tool to measure facial hyperpigmentation. It takes into account an area-weighted pigmentation score and pigment homogeneity across the cheeks, chin, and forehead. [16] It has now been correlated to the Melasma Severity Score, a global score incorporating patient assessment of their condition with rater's objective assessment. These tools are mainly used as objective measures in clinical trials.

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Complications

There are no known medical complications associated with melasma. It does not carry an increased risk of melanoma or nonmelanoma skin cancers.

The psychosocial burden of melasma can be an important consideration for many patients. Patients are often quite displeased or distressed with the appearance of melasma and can become frustrated by the challenges of treatment and its tendency to recur if strict preventive measures are not used. Self-image and self-esteem may suffer as a result of this condition. Physicians should be cognizant of this component of evaluating and treating patients with melasma. The Melasma Quality of Life Scale (MelasQOL) is a validated tool to provide quantification of melasma’s impact on a patient's quality of life. [17] The results do not correlate with the MASI score referenced earlier.

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