Topical Treatments for Melasma and Postinflammatory Hyperpigmentation

C.B. Lynde; J.N. Kraft, MD; C.W. Lynde, MD, FRCPC

Skin Therapy Letter. 2006;11(9):1-6.

Abstract and Introduction

Abstract

Hyperpigmentation disorders of the skin are common and can be the source of significant psychosocial distress for patients. The most common of these disorders are melasma and postinflammatory hyperpigmentation. Sunscreen use and minimizing sun exposure are crucial in all cases. Topical applications are the mainstay of treatment and include phenols, retinoids, corticosteroids, and their combinations.

Introduction

Hyperpigmentation of the skin is a very common problem, with many patients seeking therapies to improve their cosmetic appearance. It is the result of an increase in cutaneous melanin deposition either by increased melanin synthesis or, less commonly, by a greater number of melanocytes. The amount of color change depends on the location of the melanin deposition. Epidermal involvement appears as brown discoloration whereas dermal deposition appears as blue-grey.^[1] Mixed epidermal and dermal depositions appear as brown-grey discolorations. The use of a Wood's lamp can often be very beneficial in determining the location of melanin deposition showing enhancement of color contrast in lesional skin for the epidermal type, but not the dermal types. The mixed type has enhancement in some areas of lesional skin, but not in other areas.^[2] Whether the melanin is deposited in the epidermis or dermis is important therapeutically because dermal hyperpigmentation is much more challenging to treat.^[3]

The most common pigmentation disorders for which patients seek treatment are melasma and postinflammatory hyperpigmentation (PIH). These conditions may have a major impact because disfiguring facial lesions can significantly affect a person's psychological and social wellbeing, contributing to lower productivity, social functioning, and self-esteem.^[4,5]

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Cite this: Topical Treatments for Melasma and Postinflammatory Hyperpigmentation - Medscape - Nov 01, 2006.

Abstract and Introduction
Melasma
Postinflammatory Hyperpigmentation (PIH)
Hyperpigmentation Treatments
Topical Treatments for Melasma
Conclusion
References

Table 1. Differential Diagnosis of Melasma
Condition	Distinguishing Features
Cutaneous Mercury Deposits	• History of mercury containing soaps/creams • Dermatitis may be present
Drug-induced Hyperpigmentation	• History of medication • Hyperpigmentation less patterned and less irregular
Erythema Dyschromicum Perstans	• Gray to blue-brown lesions • Inflammatory phase with rim of erythema occasionally seen • Distribution includes nonsun-exposed areas
Exogenous Ochronosis	• History of hydroquinone application • Banana-shaped, yellow-brown deposits in the dermis
Lichen planus Actinicus	• Fine scale overlying violaceous lesions
Postinflammatory Hyperpigmentation	• History or presence of inflammation with erythema, and/or scaling

Table 2. Melasma Therapies. Similar Therapies are Used Clinically to Treat PIH
Treatments				Quality of Evidence*
Epidermal	Topical	Phenols (e.g., HQ)		B-C
		Retinoids (e.g., Tretinoin)		B-C
		Azelaic Acid		B
		Combination	HQ, Retinoid, Corticosteroid	A-B
			KA & GA	B
			HQ & GA	B
	Chemical Peels	Alpha Hydroxy Acids (GA)		B-C
	Chemical Peels	Salicylic acid		C
	Dermabrasion			E
	Laser Therapy			C-D
Dermal	Pulsed CO₂ laser followed by Q-switched alexandrite laser			C

Note: For all therapies sunscreen use and UV avoidance is important.
*Quality of Evidence⁶
A There is good evidence to support the use of this procedure.
B There is fair evidence to support the use of this procedure.
C There is poor evidence to support the use of this procedure.
D There is fair evidence to reject the use of this procedure.
E There is good evidence to reject the use of this procedure.

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