• Melasma is an acquired pigment disorder,

characterized by symmetrical macular

hyperpigmentation on the face.
• Often called chloasma, this disorder was found in the
facial area that extends to the neck and have sizes
that vary
• Darker skin tones
• East Asia,West Asia, Southeast Asia.
• Hipanic and Black people who lives in a place
that receives prolonged sun exposure
• People with Fitzpatrick skin type IV and V
• 30% in middle aged women, men can also be
affected
• There many causes of melasma.
• Genetic, UV radiation, Thyroid Disease, Pregnancy,
Use of contraceptive pills and drugs (phenytoin)
• Pigmentation occurs due to the excessive production of
melanin
Three types of classification
1. Histology subtypes
A. Epidermis type
• It is the most common type
• Increased levels of melanin in the epidermis with
only a few of melanocytes are located on the
surface of the dermis.
• Enhances on Wood lamp examination
B. Dermis type
• many melanophages can be found throughout the
entire dermis
• does not enhance on Wood lamp examination
C. Mixed type
• melanin is increased in the epidermis,
• and many melanophages found throughout the
dermis;
• Wood’s lamp examination: spotty
D. Indeterminate type
• seen in people with Fitzpatrick type V or VI skin
(skin that very rarely burns or never burns)
• Wood lamp examination is not helpful.
2. Clinical subtypes
A. Centrofacial: involves forehead, cheeks, upper lip,
nose, and chin
B. Malar: involves upper cheek area
C. Mandibular: involves the ramus of the mandible.
3. Fitzpatrick skin-type classification
Type I: white, always burns easily, never tans
Type II: white, always burns easily, tans minimally
Type III: white, burns minimally, tans gradually
Type IV: light brown, burns minimally, tans well
Type V: brown, rarely burns, tans profusely
Type VI: dark brown or black, never burns, tans
profusely.
Epidermal
1. Stratum corneum
- layer has many rows of dead cells filled with keratin
- continuously shed and replaced

2. Stratum lucidum
- seen in thick skin of the palms and soles of feet.

3. Stratum granulosum
- 3-5 rows of flattened cells
- nuclei of cells flatten out
4. Stratum spinosum
- melanin granules and Langerhans’ cell predominate
5. Stratum basale:
- deepest epidermal layer
- attached to dermis
- mostly columnar keratinocytes
- contain merkel cells and melanocytes
Dermis:
- flexible and strong connective tissue
- elastic, reticular and collagen fibers
- nerves, blood and lymphatic vessels
- oil and sweat glands originate
- two layers: papillary and reticular
1. Papillary layer:
- loose connective tissue with nipple like surface projection called
dermal papilla.
- Contain capillaries

2. Reticular layer:
- collagen fibers offer strength
- holds water
Subcutaneous
- contains adipose tissue and blood vessels
Glands:
Two types of glands exist in the integument.
- Sebaceous glands (oil glands)
- Sudoriferous glands (sweat glands)

1. Sebaceous glands: (holocrine glands)

- connected to hair follicle
- not found on palms and soles of feet
- secretes sebum (fats, cholesterol and proteins)
- keep hair from drying out, keeps skin moist
2. Sudoriferous glands: exocrine glands
- millions located throughout the skin
- two types:
i. eccrine:
- Spiral shape
- duct empties on skin surface
- palms and soles of feet
- regulated by cholinergic nerve
- all part of body.
ii. apocrine: axillary and pubic region
- duct empties onto hair follicle
- viscous fluid
- causes body odor when bacteria break it down
- regulated by adrenergic nerve
Nails:
- Nail plate (body): visible portion
- Nail root: located under cuticle
- Lunula: half moon crescent shaped
white portion under cuticle
- Nail bed: located under nail plate
Hair
1. Vellus hair: all part of body
2. Terminal hair : coarser hair; axillary and pubic region.
Grow in response to sex hormones
1- Protection
- physical barrier that protects underlying tissues from
injury, UV light and bacterial invasion.

2- Regulation of body temperature

- high temperature or strenuous exercise; sweat is
evaporated from the skin surface to cool it down.
- vasodilation and vasoconstriction regulates body
temp.
3-Sensation
- nerve endings and receptor cells that detect stimuli to
temperature, pain, pressure and touch.

4- Excretion
- sweat removes water and small amounts of salt, uric
acid and ammonia from the body surface
5- Blood reservoir
- dermis houses an extensive network of blood vessels
carrying 8-10% of total blood flow in a resting adult.

6- Synthesis of Vitamin D (cholecalciferol)

-UV rays in sunlight stimulate the production of Vit. D.
Enzymes in the kidney and liver modify and convert to
final form; calcitriol (most active form of Vit. D.)
Calcitriol aids in absorption of calcium from foods and is
considered a hormone.
• UV rays destroy Sulphydryl group in epidermal layer
that normally inhibit tirosinase enzyme for
melanogenesis process.

• Use of contraceptive pills may induce melasma through

stimulation of oestrogen receptor on the melanocyte.
• During pregnancy, melanin stimulating hormone(MSH) is
produced in large amount, as well as oestrogen and
progesterone which are known to induce melasma.
• Melasma presents itself as a symmetrical
hiperpigmentation appearing light brown to dark
brown reticulated macules

• Clinical subtypes: a) centrofacial (63%), b) malar

(21%) and c) mandibular (16%)
A. ANAMNESIS/HISTORY TAKING
• Chief complaint: Progressive hyperpigmentation
• Other factors: Pregnancy, Sun exposure,
Contraceptive pills

B. HISTOPATHOLOGY EXAMINATION
• Epidermal
• Dermal
• Mixed
C. Wood’s Lamp Examination
• Epidermal
• Dermal
• Mixed (Dermal-Epidermal)
• Indeterminate
A. RIEHL’S MELANOSIS
• Histopathology : Inflammation infiltrate at
epidermal-dermal and lymphositic perivascular
infiltate
• Light brown to dark brown pigmentationn
• Forehead, Malar
• Due to cosmeticss products, and thus it is also called
Pigmented cosmetic dermatitis
• Patch testing can be done to look for reaction to
components of cosmetics.
B. POST INFLAMMATORY HYPERPIGMENTATION
• A result of patophysiological response from cutaneus
inflammation such as acne, atopic dermatitis,
psoriasis
• History : pruritus, dermatitis
• Diagnosis is crucial
C. EPHELID
• Determined by autosomal dominan gene
• More frequent in individuals with blonde or red
hairs, and of Celtic (Scottish, Irish Welsh) extraction
• Hyperpigmentation macules appearing light brown
on sun exposed skins
• Pathology lies in the melanosomes; The melanosomes
are longer and rod shaped , and produced melanin
more rapidly when exposed to the sun.
• Avoid the sun
Example : wearing hat, umbrella, sun block

• Avoid some factor that can cause melasma

Example : stop using pill contraception, stop using cosmetic
product
and prevent from using some medicine (hidantion,
antimalaria, monosiklin)
1.Sistemik :
-Ascorbic acid/ Vitamin C (1000-1500 mg/day)
-Glutathion (3 x 100 mg/day)

2.Topikal :
• Kligman Formula (Whitening cream, Retin-A, Mild pontent
corticosteroids
• Hydroquinone cream 2%-5%

• Retinoic acid 0.1%

• Azeleic acid 20% for 6 month

3. Advanced treatment

• Chemical peeling

• Laser
• Melasma often fades over several months after you stop taking
hormone medicines or your pregnancy ends. The problem may
come back in future pregnancies or if you use these medicines
again. It may also come back from sun exposure.
• Melasma is a complex disorder and various factors are
involved in its pathogenesis, identification of which will help
us in developing better treatment options with more efficacy,
less side effects and longer periods of remission.

• Newer compounds, especially botanical extracts and

devicebased treatments are being developed and add to
the list of options available for treatment.
• However, more randomized controlled trials are needed to
evaluate their efficacy compared to the well known treatments
available.

• There is also need to define the role of combination therapy

and design protocols to provide optimum results and prevent
relapses