Journal of Clinical and Aesthetic Dermatology

FEB 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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58 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2018 • Volume 11 • Number 2 R E V I E W dermatitis, toxic melanoderma, lichen planus pigmentosus, frictional melanosis, acanthosis nigricans, and maturational pigmentation. Certain other conditions such as nevus of Ota, nevus of Hori, freckles, solar lentigo, and Becker's melanosis might also create confusion, especially when these conditions are bilateral. Further, these conditions can coexist with melasma and should be identified before prescribing treatment. Pigmentary demarcation lines (PDL) are an important differential and might be confused with melasma. 1 A detailed medical history, thorough clinical examination of the skin, dermoscopy, and histopathology are helpful in arriving at the correct diagnosis. INVESTIGATIONS Woods lamp examination, dermoscopy, mexametry, confocal microscopy, and HPE of a skin biopsy specimen are helpful tools for distinguishing melasma from other dermatological conditions. Wood's lamp examination highlights the difference in pigmentation of the affected skin and type of accentuation helps to classify the type of melasma. Another emerging diagnostic modality is dermoscopy, a simple noninvasive modality. The standard dermoscopic findings of melasma include a fine brown reticular pattern superimposed on a background of faint light brown structureless areas. Further, a vascular component can also be seen in a large number of patients. 47 Melanin in the superficial epidermis presents as a dark brown, well-defined pigment network, with shades of light brown and irregularity within the network. Sparing of the appendegeal openings is seen when melanin is located in the lower layers of the epidermis. A blue or bluish-gray color is seen in dermal melasma when pigment is located in the dermis. 48 The objective melanin content can be measured with a narrowband reflectance spectrophotometer (Mexameter®, CK Electronics, Cologne, Germany) or in vivo reflectance confocal microscopy. 49 MANAGEMENT Many clinicians might assume that their male patients are not as concerned about the appearance of their skin as women are and that they will be reluctant to follow a stringent skin care plan. However, clinicians should bear in mind that if a male patient is seeking treatment for a dermatological condition, such as melasma, then cosmesis might at least be of partial concern to him, and thus the patient might be very motivated to adhere to a prescribed treatment regimen. To encourage the greatest degree of treatment adherence, clinicians should take into careful consideration each patient's individual needs when creating treatment regimens, as preferences and expectations might differ greatly among men and their female counterparts . For example, use of products with strong fragrances or an oily base or use of camouflaging agents might not be acceptable to some patients. Additionally, some patients might find the idea of applying skin care products several times a day or even once daily unappealing, and clinicians should be aware of this before developing their treatment plans. Additionally, patient counseling is an integral component of melasma management, and clinicians should educate their patients on its causes, prevention and treatment methods, and recurrence rates. Sun avoidance is the most important part of melasma treatment, both for current improvement and future prevention of recurrence. The use of broad spectrum sunscreens (UVA and UVB) along with an inorganic sunscreen (physical block) like zinc oxide or titanium dioxide with a minimum sun protection factor of 15 should be encouraged. 50 Regardless of sex, physicians should counsel all patients regarding protection from sun exposure, with emphasis on optimal and regular application of sunscreen and use of hats and clothing that block the sun. Physicians must be extra attentive to male patients, who have shown to be less successful in adhering to sunscreen application guidelines. 51 There is a paucity of literature on treatment of melasma in men. Most of the guidelines for melasma have been based on studies done predominantly in women. The management recommendations for men are similar to those for women, and there are no separate recommendations for the men. Various treatment options for melasma include the use of topical and oral depigmenting agents, chemical peels, and surgical modalities, such as dermabrasion and lasers. Although hydroquinone (HQ) and triple combination creams (HQ+retinoic acid [RA]+corticosteroid [CS]) remain the gold standard of treatment, alternate treatment options for topical use include dual combinations (HQ+RA, CS+RA; HQ +CS), kojic acid, azelaic acid, arbutin, mequinol, ascorbic acid, tranexamic acid, rucinol, lignin peroxidase, orchid extracts, and licorice extract. Other therapeutic modalities include chemical peels along with laser light therapies. In a study by Keeling et al, 25 five men with melasma were treated with a combination of 2% mequinol and 0.01% retinoic acid solution, which resulted in complete clearance in four patients and moderate improvement in one patient at 12 weeks. Medical treatment is the mainstay of management of melasma in men, and combinations of modalities can be used to optimize results. According to a literature review by Krupashankar et al, 50 topical therapy with triple combination cream should be the first line of treatment for patients with melasma. Monotherapies and dual therapies have lower efficacy, slower onset of action, and are recommended to patients unable to access triple therapy or who have sensitivity to the ingredients. Another important component in the armamentarium against melasma are chemical peels, such as glycolic acid, mandelic acid, lactic acid, jessners peels, trichloroacetic acid, and retinoid peels. However, caution should be exercised in using peels for melasma in darker skin types, as there are higher rates of adverse effects like irritation and post-inflammatory hyperpigmentation. 52 Laser and light treatment used for treating melasma include Q-switched neodymium: yttrium-aluminum-garnet (QS Nd: YAG) laser (1064,532nm), Q switched ruby (694nm), Q switched alexandrite (755nm), copper bromide laser, erbium: YAG laser, 1550nm erbium- doped fractional laser, and intense pulsed light. 53 Among these, the nonablative1550nm fractional laser is approved by the United States Food and Drug Administration (FDA) for the treatment of melasma and is associated with decreased downtime and lower risk of complications. 54 Various studies have reported conflicting results with lasers in the treatment of melasma. Although lasers can produce rapid and significant results in some patients, adverse effects such as irritation, post-inflammatory hyperpigmentation, mottled hypopigmentation, and rebound hyperpigmentation can occur, particularly in dark-skinned individuals. There is no consensus in the literature regarding the safety, efficacy, or durability of laser-based treatments and, thus, they are not considered

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