DESCRIPTION
Acquired brown hyperpigmentation of the face and neck in genetically predisposed women.

HISTORY

1. A common complaint in women of African, Hispanic, and Asian descent. Roughly 10% of cases occur in men.
2. The forehead, malar eminences, upper lip, and chin are most frequently affected.
3. Pigmentation develops slowly and is more prevalent after sunlight exposure. Prolonged heat exposure may contribute to this condition as well.
4. Melasma occurs during the second or third trimester of pregnancy and in some women taking oral contraceptives or other exogenous estrogens. Usually after pregnancy or with discontinuation of contraceptives, the pigment fades slowly over months.

PHYSICAL FINDINGS

1. Symmetric macular eruption of brown hyper­pigmentation. The intensity of the color varies, with deeper pigmentation in darker-skinned people. Color is usually uniform but may be blotchy.
2. The edges of the patches can be irregular but well defined.
3. No signs of inflammation.

TREATMENT

• Patients must be made aware that treatment requires several weeks and strict sun protection. Minimize sun exposure at midday and encourage wearing of hats. Sunscreens of at least SPF 30 containing avobenzone, Mexoryl, or physical blockers such as titanium dioxide or zinc oxide that block both ultraviolet A and B should be worn daily.
• Combination products containing tretinoin, hydroquinone, and fluocinolone (Tri-Luma) may be more effective and more convenient. This is applied once each day for 8 weeks and may be used intermittently for up to
  1 year.
• Over the counter hydroquinone products are at 2% concentrations (Porcelana). Prescription products include 3% (Melanex) and 4% (Claripel, Lustra, Eldoquin Forte, and Solaquin Forte). Hydroquinone can be an irritant and a sensitizer
• Tretinoin is also effective as monotherapy. Tretinoin cream 0.025%, 0.05%, 0.1% (Retin-A) and tretinoin emollient cream 0.05% (Renova) enhance the effectiveness of hydroquinones. EpiQuin Micro contains 4% hydroquinone and retinol.
• Azelaic acid  (Finacea gel)  is safe during  pregnancy.
• Superficial peels with glycolic acid hasten the effects of tretinoin and hydroquinone.