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)

Postinflammatory hyperpigmentation (PIHP)

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

Linea Fusca

Perioral hypermelanosis of Brocq

Differential Diagnosis

Clinical cases

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

Same lesions on tighs and buttockswith PIHP

Same lesions on tighs and buttockswith PIHP

Eczema

• 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

Other folds hyperpigmentation

• 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)…

MarseilleVieux-PortNotre-Dame de La Garde