Post on 01-Jan-2016
MELASMADifferential diagnosis
Dr LE PILLOUER-PROST A, MD Marseilledoclepillouer@free.frDr PASSERON T., CHU Nice
Greek : melas = black
Complex and chronic dysfunction pigmentary system
« acquired hypermelanosis of the face »
Clinical aspectsBrown or blue-gray
macules of the face bilateral and symmetricalIrregular edges
(geographic)Mediofacial +++ : forehead, cheeks, upper lip, nose, chinMalar +/-Mandibular +/-
Stretching test
Wood’s light ? Color contrast
Classical but « Mixed » +++
(superficial and deep depending on areas)
Epidermal
70% Increased contrast
Dermal 10-15% No increased contrast
Mixed 15-20% Variable : usually no increase
Melasma• Women 30-40 years old (9 /10)• Latino and asians, PT III or IV• Familial history (45%)• Frequent diagnosis delay (about 4-5 years)
• Pregnancy onset : 20%• Contraception (estrogens)• Solar exposure +++ • Chronic disease of the melanocytes (several
years)• Winter improvement / summer recurrences • Unfrequent spontaneous remission (10-15%)
Differential diagnosis +++ Acquired bilateral nevus of Ota-like macules :
ABNOM ou Naevus de Hori (JAAD 1984) Postinflammatory hyperpigmentation Riehl’s melanosis Perioral hypermelanosis of Brocq Linea fusca Lichen planus actinicus Exogenous ochronosis Cutaneous metal deposits Drug-induced hypermelanosis
Poikilodermia Civatte Acquired cutaneous brachial dyschromatosis
Acquired bilateral nevus of Ota-like macules : ABNOM ou Hori nevus
EE HL et al. Br J Dermatol. 2006;154:50-3
Blue gray macules, circumscribed, « crumbled »
No improvement during winter nor under topical depigmentant therapy
Resistant « melasmas » +++
Postinflammatory hyperpigmentation (PIHP)
• Hypermelanosis
• Strictly localized to the inflammatory area (thermal burn, chemical, laser…)
• Spontaneous remission (several months or years)
Poïkilodermia (Civatte) / erythrosis coli
Hypermelanosis
+
Erythema and telangiectasiaEpidermal atrophy Follicular papulesSubmental area sparing
Acquired brachial cutaneous dyschromatosis
Middle-aged woman (40 years)Asymptomatic grey-brown macules with geographic borders, interspersed with hypopigmented macules
Dorsum of arms, mostly bilateral
Often with PK de Civatte
No relation ship / estrogens, pregnancy cosmetics
Clinical case
• Mr BAR, 35 years• Asthma, alopecia areata
(teenager)Rhinoplasty Snowboard / SurfTrader
• No drug therapy
• For 18 months• Pigmentation of the lateral
left side of the nose • Sunscreens, topical
depigmentant: inefficient
• Mme H, 52 years old• History
– Hepatitis B (1968)– Ovariectomy (1970)– Hysterectomy (1994) /
hémorragies– Chest cancer (1997)
• Radiotherapy• Nolvadex• Radiotherapy : 2nd cure (2000)• ArimidexNo other drug
• « Facial dark macules »– Onset: after the first
radiotherapy – Reccurrence during the second
• Associated signs : severe asthenia
Clinical case
• Blood tests– Severe hypocorticism
Addison disease– Idiopathic (endocrinology tests)
– Treatment : oral corticoids depending on clinical signs (asthenia +++)
Clinical case
• OUI , 28 years, nurse, PT V
• For 2 years, dark macules on the mandibular areas despite solar eviction, topical triple therapy…
• Questionary : Anxious, asthenia, dry-mouth
• History: nothing, no pills, no drug, no solar exposure
• (Histology + IF) : refusal
• Biological testsDysimmunity
– ACAN– Native Anti-DNA (SS-A et
SS-B)– Latex and WR– No anticardiolipine nor
anticoagulant
• Plaquenil 3/daySunscreenTopical corticotherapyLeucodinine B pommade (mequinol)
Goujerot-Sjrögen disease
Acquired hypermelanosis
• Sun-exposed areas
• No or few improvement during winter
…
• Endocrinopathy– Addison– Hyperthyroidism
• Metabolic– Hemochromatosis– Gaucher disease…
• Deficiency– Pellagra (niacin)– Scurvy (vit C) …
• Drug-induced eruptions
• Infections and parasitism• Tumorales• Post-inflammatoires• Hematology, rheumatic…
• clinical examination : skin and mucous areas
• Questionary, history …
• Endocrinological tests
• ACTH (ISR)• Thyroid (HT)…