Chapter 9

Differential Diagnosis of Melasma

in Brown Skin

Evangeline B. Handog and Maria Juliet Enriquez-Macarayo

9.1  Postinflammatory Hyperpigmentation (PIH)

Postinflammatory hyperpigmentation (Fig. 9.1) presents as asymptomatic

­hyperpigmented macules and patches ranging in color from either tan to dark
brown (epidermal melanin) or gray–blue to gray–brown (dermal melanin) caused
by numerous preceding cutaneous insults such as drug and phototoxic reactions,
infections, physical injury or trauma, allergic reactions and inflammatory dis-
eases [1].
PIH can occur at any age with no gender preference. Epidermal PIH can result
from acne, insect bites, pyodermas, atopic dermatitis, psoriasis and pityriasis rosea.
It generally resolves over time, although fading may require months or years in
darkly pigmented individuals [2].
On the other hand, dermal PIH has been associated with dermatoses character-
ized by degeneration of the basal layer of the epidermis and inflammation at the
dermal-epidermal junction such as lupus erythematosus and fixed drug eruptions.
Resolution is slower and longer than epidermal PIH, and treatment is a challenge.

E.B. Handog (*)

Department of Dermatology, Asian Hospital and Medical Center,
2205 Civic Drive, Alabang, Muntinlupa City, Philippines, 1780
e-mail: vangee@handog.net
M.J. Enriquez-Macarayo
Department of Dermatology, Angeles University Foundation Medical Center,
Pampanga, Philippines

© Springer India 2017 71

E.B. Handog, M.J. Enriquez-Macarayo (eds.), Melasma and Vitiligo in Brown Skin,
DOI 10.1007/978-81-322-3664-1_9
72 E.B. Handog and M.J. Enriquez-Macarayo

Fig. 9.1 Postinflammatory
hyperpigmented patches in
an elderly Filipino female
with dermatomyositis
(Courtesy of the Research
Institute for Tropical
Medicine, Philippines)

9.2  Exogenous Ochronosis

Exogenous ochronosis is an uncommon disorder characterized by dark brown to

black or blue-black hue (Fig. 9.2) caused by the deposition of microscopic,
ochre‑colored pigment in the dermis [3, 4].
It has been seen as a result of hydroquinone use among dark-skinned individuals.
The condition, however, may also develop from the use of antimalarials and
­products containing resorcinol, phenol, mercury and picric acid [1]. Skin irritation
and vigorous friction may be contributory as well. Histopathology is definitive, with
the banana-shaped ochronotic fibers in the dermis.

9.3  A
 cquired Bilateral Nevus of Ota-Like Macules
(ABNOM)

Acquired bilateral nevus of ota-like macules are multiple, speckled blue-brown and/
or slate-gray macules occurring bilaterally on the malar regions (Fig. 9.3) or less
commonly on the forehead, upper eyelids, cheeks and nose. The mucosa is not
involved [5]. ABNOM typically affects middle-aged Asians, particularly Chinese
9  Differential Diagnosis of Melasma in Brown Skin 73

Fig. 9.2  Dark bluish-black

pigmentation on the cheeks
of a Filipino female after
prolonged used of
hydroquinone-containing
OTC products (Courtesy of
the Research Institute for
Tropical Medicine,
Philippines)

Fig. 9.3 Speckled
brown-gray macules on the
malar regions in an Asian
patient (Courtesy of the
National Skin Centre,
Singapore)

and Japanese, with age range of 20–70 years [1, 5]. They are thought to increase in
thickness with advancing age [6].

9.4  Solar Lentigines

Solar lentigines are characterized by well-circumscribed 1–3 cm pigmented m­ acules

on sun-exposed areas [7, 8]. They can occur in children and adults, especially those
with skin types I to III.
Children who have xeroderma pigmentosum may develop solar lentigines in the
first 6 months of life, after minimal sun exposure. Lesions may vary in color from
light yellow to dark brown. The most common sites of predilection are the face
(Fig. 9.4), hands, forearms, chest, back and shins.
74 E.B. Handog and M.J. Enriquez-Macarayo

9.5  Drug-Induced Hyperpigmentation

Hyperpigmentation caused by toxic agents or medications (Fig. 9.5) accounts for

10–20 % of all cases of acquired hyperpigmentation. The most common causes are
CNS drugs (e.g, chlorpromazine, amitriptyline), antineoplastic agents (e.g., car-
mustine, nitrogen mustard, bleomycin, anthracycline, 5-fluorouracil), anti-­infectious
drugs (e.g., chloroquine, quinacrine, hydroxychloroquine, minocycline, clofazi-
mine, zidovudine), antihypertensive medications (e.g., amiodarone, diltiazem) and
hormones (e.g., oral contraceptives) [1, 5].

Fig. 9.4  Dark brown patch

on the cheekbone area of
an Asian patient (Courtesy
of the National Skin
Centre, Singapore)

Fig. 9.5 Bluish
pigmentation on the face of
a Filipino female,
developed from intake of
minocycline (Courtesy of
the Research Institute for
Tropical Medicine,
Philippines)
9  Differential Diagnosis of Melasma in Brown Skin 75

9.6  Actinic Lichen Planus

It is a rare variant of cutaneous lichen planus, characterized by the development of

lesions on the photodistributed areas (Fig. 9.6a). It is more common in dark-skinned
populations, particularly in young adults [9]. Indurated plaques or papules appear
on the face, neck and the dorsal surface of hands after exposure to ultraviolet (UV)
light [10–12]. Covered areas and mucous membranes are usually spared. In few
cases, discrete, confluent papules and hypermelanotic patches, sometimes assuming
a melasma-like appearance (Fig. 9.6b), may also be seen. The etiology is unknown.

Fig. 9.6 (a) Scaly papules

on the arms of an Asian
male, histopathologically
proven as actinic lichen
planus (Courtesy of the
National Skin Centre,
Singapore). (b)
Hypermelanotic patches on
the midface of a young
Filipino female,
histopathologically proven
as lichen planus (Courtesy
of the Research Institute
for Tropical Medicine,
Philippines)
76 E.B. Handog and M.J. Enriquez-Macarayo

9.7  Erythema Dyschromicum Perstans (Ashy Dermatosis)

Erythema dyschromicum perstans (EDP) is a slowly progressive disease that is more

common in children and young adults, particularly those from Latin America with
skin phototypes III and IV [5]. It has equal prevalence in both sexes [1]. The com-
mon sites of predilection are the neck, proximal upper extremities and trunk [5].
Lesions can follow skin cleavage lines [3]. EDP is characterized by hyperpigmented
macules and patches of variable shape and size with an ashen-gray to brown–blue
color (Fig. 9.7) [13]. A polymorphic eruption may also be seen, presenting as simul-
taneous hypo- and hyperpigmented macules [14]. The lesions are usually asymp-
tomatic; however, minimal pruritus can be present. There is a slow progression of
the lesions over several years, usually without spontaneous regression.

9.8  Riehl’s Melanosis

Also known as female facial melanosis, this condition is more common in middle-­
aged dark-skinned women, particularly Mexicans and Asians [1]. It is characterized
by a rapid onset of a reticular gray-brown to almost black hyperpigmentation on the

Fig. 9.7 Ashen-brown
hyperpigmentation seen on
the face of a young
Filipino female (Courtesy
of The Research Institute
for Tropical Medicine,
Philippines)
9  Differential Diagnosis of Melasma in Brown Skin 77

face (particularly on the forehead, zygomatic area and temples) and neck (Fig. 9.8a, b).
There is no evidence of any inflammation on the skin [15]. It is induced by repetitive
contact with a sensitizer such as fragrances, some pigments and bactericides (carbani-
lides, ricinoleic acids) used in cosmetics and optical w
­ hiteners [16].

9.9  Ephelides

Ephelides or freckles are characterized by small light brown macules appearing on

the sun-exposed skin (Fig. 9.9) [1, 8]. It is more common in fair-skinned popula-
tions and those with red or blond hair and Celtic ancestry. Onset is usually in early
childhood and may or may not disappear later in life.
The table below shows a summary of the differential diagnoses to be considered
when dealing with pigmented lesions presenting mostly on the face (Table 9.1).

a b

Fig. 9.8 (a) Reticulated reddish-brown patch on the forehead and (b) neck of a Filipina female
(Courtesy of Dr. Johannes F. Dayrit, Philippines)

Fig. 9.9  Small brown

macules, of different hues,
dispersed mostly on the
cheeks of an Asian female
(Courtesy of the National
Skin Centre, Singapore)

Table 9.1  Differential diagnoses summary
Diagnosis
Postinflammatory
hyperpigmentation
Exogenous ochronosis [17,
18]
Aquired bilateral nevus of
ota-like macules (ABNOM)/
Hori’s nevus
Solar lentigines
Drug-induced
hyperpigmentation
Actinic lichen planus [21]
Age/sex
Any age, no gender
Rare disease
No known age or sex
predilection
Predominantly among females
Mean age is 45.8 years among
males and 45.9 among females
[19]
Median age at onset is
30 years [15]
Children and adults
10–20 % of acquired
hyperpigmentation; no age or
sex predilection
Mostly younger than 30 years
Mean of 14 years
No sex predilection
History Distribution
History of trauma Site of previous trauma
Prolonged use of Photodistributed along
hydroquinone (2–5 %) sites of contact with
worsened by keratolytic causative agent
agents and sun exposure Face, neck, back, dorsum
of extremities
symmetrically distributed
Become bluer with age Zygomatic area, forehead,
among women temporal area, nasal radix,
upper eyelid
Zygomatic – most
common among women
Forehead – most common
among men
History of sun exposure Sun-exposed parts
History of drug intake Sun-exposed areas
and sun exposure
Usually noted in spring Face, dorsal aspect of the
or summer hands and outer aspect of
Among photosensitive the forearms
individuals
Mainly in tropical areas
78
Color/lesion
Brown/dark gray
Brown gray or blue black
Brown, blue, slate gray [20]
May vary in color
Bluish gray
Atrophic – with
hyperpigmentation
Dyschromic type – white
angular papules and plaques on
the neck and dorsa of hands
Classic plaque-like – violaceous
papules
Pigmented type – resembles
melasma seen in the face and
neck
E.B. Handog and M.J. Enriquez-Macarayo
Erythema dyschromicum
perstans [22, 23]
Riehl’s hypermelanosis [22]
Ephelides [1, 2]
Unrelated to age and sex
Not related to age and sex
Develop during early
childhood then regress with
age
Slowly progressive Symmetric over the trunk, Color may vary from different
May be pruritic arms, neck and face shades of gray to lead
May occur on any body Developing lesions may have
part except the scalp, raised reddish border
palms, soles, mucous
membranes
Develops rapidly Face Brownish gray
Sites previously in Highly pronounced on the
contact with allergens, forehead and temples
especially cosmetics
Associated with positive
patch tests to cosmetics
or components
Fair-skinned individuals Face, dorsal aspects of the Light to dark brown
with Celtic ancestry arms and upper trunk
Become more visible at
spring and summer, can
9  Differential Diagnosis of Melasma in Brown Skin
fade during winter
79
80 E.B. Handog and M.J. Enriquez-Macarayo

References

1. Lapeere H, Boone B, De Schepper S, Verhaeghe E, Van Gele M, Ongenae K, et al.

Hypomelanoses and hypermelanoses. In: Wolff K, Goldsmith L, Katz S, Gilchrest B, Paller A,
Leffel D, editors. Fitzpatrick’s dermatology in general medicine. 8th ed. New York: McGraw-­
Hill, Inc; 2012. p. 804–26.
2. Chang M. Disorders of hyperpigmentation. In: Bolognia JL, Jorizzo JL, Schaffer JV, editors.
Dermatology. 3rd ed. China: Elsevier Saunders; 2012. p. 1049–50.
3. Kulandaisamy S, Mohan Thappa M, Gupta D. Exogenous ochronosis in melasma: a study
from South India. Pigm Int. 2014;1:17–22.
4. Sharma S, Rao R. Exogenous ochronosis masquerading refractory melasma. Our Dermatol
Online. 2014;5(4):398–400.
5. Bolognia JL, Schaffer JV, Duncan K, Ko C. Disorders of pigmentation. In: Dermatology
essentials. China: Elsevier Inc.; 2014. p. 496–501.
6. Min Park J, Tsao H, Tsao S. Acquired bilateral nevus of Ota-like macules (Hori nevus): etio-
logic and therapeutic considerations. J Am Acad Dermatol. 2009;61(1):88–92.
7. Grichnik JM, Rhodes AR, Sober AJ. Benign neoplasias and hyperplasias of melanocytes. In:
Goldsmith L, Katz S, Gilchrest B, Paller A, Lefell D, editors. Fitzpatricks’s dermatology in
general medicine. 8th ed. New York: McGraw-Hill, Inc; 2012. p. 1406.
8. Plensdorf S, Martinez J. Common pigmentation disorders. Am Fam Physician. 2009;79(2):
109–16.
9. Verhagen AR, Koten JW. Lichenoid melanodermatitis. A clinicopathological study of fifty-one
Kenyan patients with so-called tropical lichen planus. Br J Dermatol. 1979;101(6):651–8.
10. Salman SM, Kibbi AG, Zaynoun S. Actinic lichen planus. A clinicopathologic study of 16
patients. J Am Acad Dermatol. 1989;20(2 Pt 1):226–31.
11. Kim GH, Mikkilineni R. Lichen planus actinicus. Dermatol Online J. 2007;13(1):13. http://
escholarship.org/uc/item/98k4v2zx. Accessed: 17 Feb 2016.
12. Meads SB, Kunishige J, Ramos-Caro FA, Hassanein AM. Lichen planus actinicus. Cutis.
2003;72(5):377–81.
13. Bahadir S, Cobanoglu U, Cimsit G, Yayli S, Alpay K. Erythema dyschromicum perstans:
response to dapsone therapy. Int J Dermatol. 2004;43(3):220–2.
14. Torrelo A, Zaballos P, Colmenero I, Mediero IG, de Prada I, Zambrano A. Erythema dyschro-
micum perstans in children: a report of 14 cases. J Eur Acad Dermatol Venereol.
2005;19(4):422–6.
15. Serrano G, Pujol C, Cuadra J, Gallo S, Aliaga A. Riehl's melanosis: pigmented contact derma-
titis caused by fragrances. J Am Acad Dermatol. 1989;21:1057–60.
16. Khanna N, Rasool S. Facial melanoses: Indian perspective. Ind J Dermatol Venereol Leprol.
2011;77:552–64.
17. Martins VMR, de Sousa ARD, Portela ND, Tigre CAR, Gonçalves LMS, Filho RJLC.

Exogenous ochronosis: case report and literature review. Bras Dermatol. 2012;87(4):633–6.
18. Gandhi V, Verma P, Naik G. Exogenous ochronosis after prolonged use of topical hydroqui-
none (2%) in a 50-year-old Indian female. Ind J Dermatol. 2012;57(5):394–5.
19. Wang BQ, Shen ZY, Fei Y, Li H, Liu JH, Xu H, et al. A population-based study of acquired
bilateral nevus-of-Ota-like macules in Shanghai, China. J Invest Dermatol. 2011;131:358–62.
20. Lee WJ, Lee GY, Won KW, Won CH, Lee MW, Choi JH, Chang SE. Comparison of acquired
bilateral nevus of Ota-like macules in men and women. Ind J Dermatol Venereol Leprol.
2014;80(4):313–9.
21. Choi K, Kim H, Kim H, Park Y. A case of actinic lichen planus. Internet J Dermatol. 2009;8(1).
http://ispub.com/IJD/8/1/12894. Accessed 17 Feb 2016.
22. Rabinovitz HS, Barnhill RL. Benign melanocytic neoplasms. In: Bologna JL, Jorrizo JL,
Schaffer JV, editors. Dermatology. 3rd ed. China: Elsevier Saunders; 2012. p. 1851–83.
23. Convit J, Kerdel-Vegas F, Rodriguez G. Erythema dyschromicum perstans: a hitherto unde-
scribed skin disease. J Invest Dermatol. 1961;36:457–62.