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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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dermal fibroblasts, which leads to increased levels of soluble stem cell factor and activation of epidermal melanocytes The role of stem cell factor in melasma is poorly understood at this time
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melanosomes and dendritic processes in the hyperpigmented area of the skin39 Dopa reaction has shown increased melanin production within the increased number of melanocytes34
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Histopathology
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In the epidermal form of melasma, which appears light or dark brown or black clinically, the basal and suprabasal layers have a higher than normal level of melanin, which can also be present throughout the epidermis31,4 The melanocytes also appear larger with more noticeable dendritic processes; however, the number of melanocytes is equal to the number in unaffected skin39 In the dermal type of melasma, which appears blue-gray clinically, melaninladen macrophages emerge in a perivascular arrangement in the superficial and middle level of the dermis A mixed form, with both epidermal and dermal components, also commonly occurs Electron microscopy of skin from patients with melasma shows increased
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Epidermal Versus Dermal Disease
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Epidermal melasma is easier to treat than dermal melasma because the melanin is at a higher level in the skin and therefore can be more easily reached by topically applied products Because the epidermal component is amenable to treatment while the dermal component is usually not, it is helpful to determine the extent of the dermal component of the condition in order to accurately predict a patient s treatment response and to provide the patient with the proper expectations A Wood s light or blue light can be used to examine the face at the initial visit to ascertain the extent of the dermal component34 (Fig 13-6) In the epidermal type, the epidermal component will appear darker under Wood s light examination The
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dermal component will be less visible when observed under a Wood s light40 In other words, if the lesions are more pronounced with Wood s light examination, there is a better chance for clinical improvement However, the Wood s light examination did not help to predict the clinical response to peels in a study by Lawrence41 The investigators felt that this occurred because there was such a high number of patients with a mixed epidermal/dermal form of melasma However, the consensus remains that patients in whom epidermal melasma predominates may respond better than those with a large dermal component Therefore, the Wood s examination is still a useful adjunct to determine a patient s prognosis in the treatment of melasma
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CHAPTER 13 SKIN PIGMENTATION AND PIGMENTATION DISORDERS
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Treatment
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The therapeutic objective is to retard the proliferation of melanocytes, inhibit the formation of melanosomes, and, further, promote the degradation of melanosomes42 Treatment options will be discussed in detail in 33, but must include a good high-SPF sunscreen with UVA protection and sun avoidance (Box 13-1) The sunscreen must be worn 24 hours a day Sun avoidance, UVA screens for car and home windows, and protective clothing, such as hats, are a great addition to a topical treatment regimen Topical treatments may include hydroquinone 2% to 4%, low-potency steroids, kojic acid, arbutin, azelaic acid, hydroxy acids, and retinoids Topical tretinoin improves epidermal hyperpigmentation by decreasing tyrosinase activity and melanin production as well as enhancing the desquamation of the epidermis43 Although tretinoin 01% has been studied as a single agent in the treatment of melasma,44,45 the time to improvement is lengthy (10 months, in one study) Therefore, most physicians use a combination of topical products The Kligman formula is a mixture consisting of 01% tretinoin, 50% hydroquinone, 01% dexamethasone, and hydrophilic ointment46 It has been a very popular melasma treatment since its introduction in 1975; however, this formula is currently not commercially available and must be formulated by a pharmacy A prescription combination preparation similar to the Kligman formula that contains hydroquinone 4%, tretinoin 005%, and fluocinolone 001% has been approved by the FDA and is a popular treatment for melasma Most prescription formulas contain 4% hydroquinone; however,
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