Melasma

Biology of melanocyte
Dendritic cell at basal layer of epidermis Produce melanin and send to surrounding keratinocyte Epidermal melanin unit (melanocyte:keratinocyte) = 1:36

Biology of melanin
Synthesis from melanosome Transport to keratinocyte via dendritic process of melanocyte

2 type : eumelanin : pheomelanin

Melanin synthesis
Binding

Melanocyte stimulating hormone

Melanocortin 1 receptor
adenylase cyclase

Tyrosinase

cAMP

Melanin synthesis
Tyrosine tyrosinase Dopa Dopa quinone Eumelanin Pheomelanin

Melanin synthesis
MSH MC1R mutation of MC1R

Eumelanin

Pheomelanin

Melanin transfer
Phagocytosis : melanin transfer to dermis : phagocytose by melanophage Endocytosis : melanin transfer to keratinocyte via intercellular space

Melasma
Acquired bilateral symmetrical hypermelonosis Irregular light to gray brown macule and patch Ill defined margin Involved sun exposure area Most common in women

Distribution of melasma
Central facial pattern (63%) : cheek, forehead, nose, chin Malar pattern (21%) : cheek, nose Mandibular pattern (16%) :chin

Cause of melasma
Light : UVA, UVB, visible light Hormone : pregnancy, contraceptive pill

Drug : dilantin, anti-malarial drug, tetracycline, minocycline Cosmetic : perfume, color

Genetic Malnutrition : liver dysfunction, B12 def.

Type of melasma
Epidermal melasma Dermal melasma Mixed epidermal dermal melasma

Epidermal melasma

Light or dark brown color

Melanin deposition in basal, suprabasal layer of epidermis Larger melanocyte with more noticeable dendritic process

Dermal melasma
Blue gray color Perivascular melanophage at superficial and middermis Melanin granule in dermis

Effective therapy
Retard melanocyte proliferation Inhibit melanosome formation Promote melanosome degradation

Treatment
Avoidance Sunscreen Medication : hydroquinone, azelaic acid, retinoic acid Chemical peeling Dermabrasion Laser

Laser treatment for melasma

Target chromophore is melanin Should destroy melanocyte in hair follicle Good in dermal and mix melasma

Laser treatment for melasma

Epidermal melanin removal : lPL, PDL Dermal melanin removal : Q-switched Ruby, Q-switched Alexandrite, Q-switched Nd:YAG Fraxel

Epidermal melanin removal

No recovery time Repigmentation after removal

Dermal melanin removal

Minimal downtime Side effect : transient erythema, hypopigmentation Repigmentation from melanin in melanophage

Fraxel
Epidermal and dermal ablation MEND formation and eliminated through skin Induce melanophage disruption and release melanin granule into dermis Downtime 3-7 d Long term improvement