1. MELASMA Differential diagnosis
Greek : melas = black
Complex and chronic dysfunction pigmentary system
« acquired hypermelanosis of the face »
Dr LE PILLOUER-PROST A, MD Marseille
Dr PASSERON T., CHU Nice

2. Clinical aspects Brown or blue-gray macules of the face
bilateral and symmetrical
Irregular edges (geographic)
Mediofacial +++ : forehead, cheeks, upper lip, nose, chin
Malar +/-
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

3. 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%)

5. 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

6. Acquired bilateral nevus of Ota-like macules : ABNOM ou Hori nevus
Blue gray macules, circumscribed, « crumbled »
No improvement during winter nor under topical depigmentant therapy
Resistant « melasmas » +++
EE HL et al. Br J Dermatol. 2006;154:50-3

7. Postinflammatory hyperpigmentation (PIHP)
Hypermelanosis
Strictly localized to the inflammatory area (thermal burn, chemical, laser…)
Spontaneous remission (several months or years)

8. Postinflammatory hyperpigmentation (PIHP)

9. Poïkilodermia (Civatte) / erythrosis coli
Hypermelanosis +
Erythema and telangiectasia
Epidermal atrophy
Follicular papules
Submental area sparing

10. 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

11. Linea Fusca

12. Perioral hypermelanosis of Brocq

13. Differential Diagnosis Clinical cases

14. Clinical case Mr BAR, 35 years Asthma, alopecia areata (teenager)
Rhinoplasty
Snowboard / Surf
Trader
No drug therapy
For 18 months
Pigmentation of the lateral left side of the nose
Sunscreens, topical depigmentant: inefficient

15. Same lesions on tighs and buttocks
with PIHP

16. Same lesions on tighs and buttocks
with PIHP
Eczema

17. Clinical case Mme H, 52 years old History « Facial dark macules »
Hepatitis B (1968)
Ovariectomy (1970)
Hysterectomy (1994) / hémorragies
Chest cancer (1997)
Radiotherapy
Nolvadex
Radiotherapy : 2nd cure (2000)
Arimidex
No other drug
« Facial dark macules »
Onset: after the first radiotherapy
Reccurrence during the second
Associated signs : severe asthenia

18. Other folds hyperpigmentation

19. Blood tests Addison disease Severe hypocorticism
Idiopathic (endocrinology tests)
Treatment : oral corticoids depending on clinical signs (asthenia +++)

20. 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

22. Goujerot-Sjrögen disease
(Histology + IF) : refusal
Biological tests
Dysimmunity
ACAN
Native Anti-DNA (SS-A et SS-B)
Latex and WR
No anticardiolipine nor anticoagulant
Plaquenil 3/day
Sunscreen
Topical corticotherapy
Leucodinine B pommade (mequinol)

23. 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)…

24. Marseille
Vieux-Port
Notre-Dame de La Garde