![]() ![]() However, non-ablative fractional laser therapy showed more short-term side effects than topical bleaching. #DARK PATCH ABOVE UPPER LIP SKIN#It was concluded that non-ablative fractional laser therapy proved to be safe for the treatment of melasma, including for patients with darker skin types ( Kroon et al., 2011). In a recent paper the traditional triple bleaching procedure was compared with fractional laser therapy at 1550 nm. The stratum corneum was found to be intact after 24 hours, as reported by Hantash et al., (2006) and Laubach et al., (2006). It was reported that these microscopic treatment zones with a diameter less than 100 μm allow extrusion of microscopic epidermal necrotic debris including melanin from the melanocytes through a compromised dermoepidermal junction. At this wavelength the water absorption in the skin is predominant, resulting in multiple small coagulated zones separated by surrounding untreated tissue. Recently, non-ablative fractional laser therapy at 1550 nm was reported as a treatment possibility. Therefore, the use of these devices is controversial. Results of laser therapy and intense pulsed light therapy are generally disappointing and often followed by adverse effects such as postinflammatory hyperpigmentation, especially in dark-skinned patients. The treatment of choice is a still a triple topical bleaching procedure that was first introduced in 1975 as the Kligman formula and consists of hydroquinone, tretinoin and dexamethasone. Conventional treatments include topical bleaching creams and chemical peels. Various treatments are currently available for melasma, but the results are often disappointing. Melasma is difficult to manage because it is refractory to treatment and often recurs. ![]() Other factors predisposing to melasma are pregnancy, systemic drugs, hormonal medications, and cosmetics causing phototoxic or photoallergic reactions. Genetic background, gender and sun exposure seem to be the most important aetiological factors. The pathogenesis of melasma is not fully understood. Melasma is common in women but rare in men. ![]() Melasma is seen in all skin types, but is particularly seen in skin types IV to VI. Melasma is a common pigment disorder, which often causes significant emotional and psychosocial distress in patients and affects the quality of life ( Pawaskar et al., 2007). Svanberg, in Lasers for Medical Applications, 2013 Melasma During pregnancy, treatment should include potent sunscreen and avoidance of ultraviolet radiation and irritant cosmetics. Epidermal pigment (accentuated by Wood's light examination) is most responsive to bleaching with topical hydroquinone creams and tretinoin after pregnancy. Melasma is persistent in approximately 30% of patients, whether induced by pregnancy or estrogen-containing OCPs. Histologically, excessive melanin deposition is seen either in the epidermis or dermal macrophages 2. It usually fades within a year after pregnancy or discontinuation of OCPs. Melasma is thought to be due to hormonal influences, and is worsened by sun exposure. It occurs in the second trimester in three-quarters of pregnant women and in one-third of those taking oral contraceptive pills (OCPs). Although the malar pattern is considered typical, the entire central face is affected in most patients, including the forehead, cheeks, upper lip, nose, and chin. This can occur in three patterns – centrofacial, malar, or mandibular, depending on the distribution of pigmentation. Melasma (formerly called chloasma, or the “mask of pregnancy”) is symmetrical macular hyperpigmentation of the face ( Figure 3.11). Samantha Vaughan Jones, in Obstetric and Gynecologic Dermatology (Third Edition), 2008 Melasma Less commonly used treatments include azelaic acid (Azelex) and chemical peels. In addition, a combination product containing fluocinolone, hydroquinone, and tretinoin (Tri-Luma) is effective. If after several months no lightening has occurred, tretinoin cream 0.1% (Retin-A) may be cautiously applied daily in addition to the use of hydroquinone and a sunscreen. Sunscreens with a SPF of 30 should be used prophylactically. It is applied twice daily to affected areas. A 2% concentration is available over the counter, whereas 4% hydroquinone cream (Eldoquin-Forte) requires a prescription. Hydroquinone, a bleaching agent, is most frequently used to treat melasma. Freckles are smaller and more numerous, and involve the trunk and extremities in addition to the face. For the former, patients have a history of prior dermatitis. Postinflammatory hyperpigmentation and freckles are pigmented macules. The brown pigmentation is often patchy within the macule, giving it a reticulated appearance. They are sharply delineated and involve the malar eminences, forehead, upper lip, and mandible. Macular brown patches of melasma occur symmetrically on the face. Sunlight, pregnancy, and birth control pills exacerbate melasma. ![]()
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