Melasma Clinical Presentation

Updated: Oct 26, 2018
  • Author: Willis Hughes Lyford, ENS; Chief Editor: William D James, MD  more...
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Patients may inquire about progressive hyperpigmentation of the face, which may be temporally related to pregnancy or to the use of oral contraceptive pills.

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.


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, whereas, dermal pigment is not. 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.

The Melasma Area and Severity Index (MASI) is common outcome measure used to assess melasma patients; however, it previously had not been validated. The goal of a 2010 study was to determine the reliability and validity of the MASI. The authors report that the MASI is a reliable tool for measuring the severity of melasma when compared with the melasma severity scale, Mexameter scores, and area measurements. [10]