Pigmentation means coloring. Skin pigmentation disorders affect the color of your skin. Your skin gets its color from a pigment called melanin. Special cells in the skin make melanin. When these cells become damaged or unhealthy, it affects melanin production. Some pigmentation disorders affect just patches of skin. Others affect your entire body.

If your body makes too much melanin, your skin gets darker. Pregnancy, Addison's disease, and sun exposure all can make your skin darker. If your body makes too little melanin, your skin gets lighter. Vitiligo is a condition that causes patches of light skin. Albinism is a genetic condition affecting a person's skin. A person with albinism may have no color, lighter than normal skin color, or patchy missing skin color. Infections, blisters and burns can also cause lighter skin.

Melanin is a pigment that determines the color of hair and skin.

Melanocytes are cell found in the stratum basale of the epidermis that produces the pigment melanin.

 

Humans who left Africa and settled in Europe about 40,000 years most likely had dark skin with high levels of melanin, which provides protection against ultraviolet radiation New data confirms that about 8,500 years ago, early hunter-gatherers in Spain, Luxembourg, and Hungary also had darker skin. Skin pigmentation is an adaptation to ultraviolet radiation, with different tones offering different advantages, depending on one’s distance from the equator. As humans migrated to the Northern Hemisphere, they were exposed to less ultraviolet radiation, which also meant less absorption of the Vitamin D needed for strong bones and other important immune functions. In order to compensate for this loss and to allow for greater exposure to ultraviolet radiation, skin pigmentation became lighter.

Vitiligo is not the only disease that causes skin to change color.

Here are a few conditions and what they look like, including vitiligo.

Talk to your health care provider if you think you might have vitiligo or another skin condition.

Excessive pigmentation of the skin, usually as a result of increased epidermal or dermal melanin pigmentation, hypermelanosis. Hyperpigmentation can be localized or generalized. The condition may arise from exposure to light, chemicals or other substances, or from a primary metabolic imbalance.

A condition caused by a deficiency or a loss of melanin pigmentation in the epidermis, also known as hypomelanosis. Hypopigmentation can be localized or generalized, and may result from genetic defects, trauma, inflammation, or infections.

Vitiligo causes white patches on your skin. It can also affect your eyes, mouth, and nose. It occurs when the cells that give your skin its color are destroyed. No one knows what destroys them. It is more common in people with autoimmune diseases, and it might run in families. It usually starts before age 40.

The white patches are more common where your skin is exposed to the sun. In some cases, the patches spread. Vitiligo can cause your hair to gray early. If you have dark skin, you may lose color inside your mouth.

Using sunscreen will help protect your skin, and cosmetics can cover up the patches. Treatments for vitiligo include medicines, light therapy, and surgery. Not every treatment is right for everyone. Many have side effects. Some take a long time. Some do not always work.

A common chronic, noninflammatory and usually symptomless disorder, characterized by the occurrence of multiple macular patches of all sizes and shapes, and varying in pigmentation from fawn-colored to brown. It is seen most frequently in hot, humid, tropical regions and is mostly caused by Malassezia Furfur (formerly Pityrosporum orbiculare).

Pityriasis alba is a common, benign skin disorder occurring predominantly in children and adolescents. The name refers to its appearance: pityriasis refers to its fine scales and alba to its pale color (hypopigmentation). Most patients have a history of atopy, and pityriasis alba may be a minor manifestation of atopic dermatitis. It is characterized by ill-defined macules and patches (or thin plaques), round or oval, often with mild scaling, and sometimes with mild pruritus. The lesions initially may be mildly erythematous, and over time they become hypopigmented. They are most commonly located on the face (especially the cheeks), arms, and upper trunk, and they are more noticeable in people with darker skin types. Sun exposure accentuates the lesions. Patients and parents often are concerned about the cosmetic appearance of the lesions. Pityriasis alba resolves spontaneously, with a gradual return of normal skin pigmentation. Time to complete resolution varies from several months to a few years, although most cases resolve within one year. Reassurance, low-potency topical corticosteroids, and mild emollients are the mainstays of treatment.

Hansen’s disease (also known as leprosy) is an infection caused by bacteria called Mycobacterium leprae. These bacteria grow very slowly and it may take up to 20 years to develop signs of the infection.

The disease can affect the nerves, skin, eyes, and lining of the nose (nasal mucosa). The bacteria attack the nerves, which can become swollen under the skin. This can cause the affected areas to lose the ability to sense touch and pain, which can lead to injuries, like cuts and burns. Usually, the affected skin changes color and either becomes:

• lighter or darker, often dry or flaky, with loss of feeling, or
• reddish due to inflammation of the skin.

If left untreated, the nerve damage can result in paralysis of hands and feet. In very advanced cases, the person may have multiple injuries due to lack of sensation, and eventually the body may reabsorb the affected digits over time, resulting in the apparent loss of toes and fingers. Corneal ulcers and blindness can also occur if facial nerves are affected. Other signs of advanced Hansen’s disease may include loss of eyebrows and saddle-nose deformity resulting from damage to the nasal septum.

Early diagnosis and treatment usually prevent disability that can result from the disease, and people with Hansen’s disease can continue to work and lead an active life. Once treatment is started, the person is no longer contagious. However, it is very important to finish the entire course of treatment as directed by the doctor.

Each year, about 150 people in the United States and 250,000 around the world get the illness. In the past, Hansen’s disease was feared as a highly contagious, devastating disease, but now we know that it’s hard to spread and it’s easily treatable once recognized. Still, a lot of stigma and prejudice remains about the disease, and those suffering from it are isolated and discriminated against in many places where the disease is seen. Continued commitment to fighting the stigma through education and improving access to treatment will lead to a world free of this completely treatable disease.

Leprosy, also called Hansen disease, is a disorder known since ancient times. It is caused by bacteria called Mycobacterium leprae and is contagious, which means that it can be passed from person to person. It is usually contracted by breathing airborne droplets from affected individuals' coughs and sneezes, or by coming into contact with their nasal fluids. However, it is not highly transmissible, and approximately 95 percent of individuals who are exposed to Mycobacterium leprae never develop leprosy. The infection can be contracted at any age, and signs and symptoms can take anywhere from several months to 20 years to appear.

Leprosy affects the skin and the peripheral nerves, which connect the brain and spinal cord to muscles and to sensory cells that detect sensations such as touch, pain, and heat. Most affected individuals have areas of skin damage (cutaneous lesions) and problems with nerve function (peripheral neuropathy); however, the severity and extent of the problems vary widely. Leprosy occurs on a spectrum, in which the most severe form is called multibacillary or lepromatous, and the least severe form is called paucibacillary or tuberculoid. Patterns of signs and symptoms intermediate between these forms are sometimes called borderline forms.

Multibacillary leprosy usually involves a large number of cutaneous lesions, including both surface damage and lumps under the skin (nodules). The moist tissues that line body openings such as the eyelids and the inside of the nose and mouth (mucous membranes) can also be affected, which can lead to vision loss, destruction of nasal tissue, or impaired speech. Some affected individuals have damage to internal organs and tissues. The nerve damage that occurs in multibacillary leprosy often results in a lack of sensation in the hands and feet. Repeated injuries that go unnoticed and untreated because of this lack of sensation can lead to reabsorption of affected fingers or toes by the body, resulting in the shortening or loss of these digits.

Paucibacillary leprosy typically involves a small number of surface lesions on the skin. There is generally loss of sensation in these areas, but the other signs and symptoms that occur in multibacillary leprosy are less likely to develop in this form of the disorder.

In any form of leprosy, episodes called reactions can occur, and can lead to further nerve damage. These episodes can include reversal reactions, which involve pain and swelling of the skin lesions and the nerves in the hands and feet. People with the more severe forms of leprosy can develop a type of reaction called erythema nodosum leprosum (ENL). These episodes involve fever and painful skin nodules. In addition, painful, swollen nerves can occur. ENL can also lead to inflammation of the joints, eyes, and the testicles in men.

Leprosy has long been stigmatized because of its infectious nature and the disfigurement it can cause. This stigma can cause social and emotional problems for affected individuals. However, modern treatments can prevent leprosy from getting worse and spreading to other people. While the infection is curable, nerve and tissue damage that occurred before treatment is generally permanent.

About 250,000 new cases of leprosy are diagnosed every year. The condition occurs worldwide, but is most common in India, Brazil, and other areas with warm climates. Between 100 and 250 new cases per year occur in the United States.

World Leprosy Day is observed on the last Sunday of January each year. Established in 1954 by French philanthropist Raoul Follereau, it aims to raise awareness about leprosy (now called Hansen’s disease) and teach people about this ancient disease that is easily curable today. While rare in the United States, many people around the world continue to suffer from this curable disease due to lack of access to basic medical care and continued stigma surrounding the illness.

Leprosy was renamed Hansen’s disease after Norwegian scientist Gerhard Henrik Armauer Hansen, who in 1873 discovered the slow-growing bacterium now known as Mycobacterium leprae as the cause of the illness. It is difficult to catch, and it can take many years to develop symptoms of the disease following an infection. However, people who catch the disease can easily be cured with antibiotics.

Together, we can put a stop to discrimination and stigma against people with Hansen’s disease. We can learn to recognize symptoms and know when to see a physician for diagnosis. Educate yourself and your community and separate the facts from the myths about Hansen’s disease.

Burden of Hansen’s Disease

Around the world:

• The number of new cases reported globally to World Health Organization (WHO) in 2019 was more than 200,000.
• Close to 15,000 children were diagnosed with Hansen’s disease in 2019, more than 40 a day.
• An estimated 2 to 3 million people are living with Hansen’s disease-related disabilities globally.
• In 2019, the countries with the highest number of new diagnoses were India, Brazil, and Indonesia.
• Over half of all new cases of Hansen’s disease are diagnosed in India, which remains home to a third of the world’s poor, a group disproportionately affected by the disease.

In the United States:

• About 150 to 250 cases are reported each year.
• In 2018, 185 new cases were reported to the National Hansen’s Disease Program (NHDP), which coordinates care, research, and information about Hansen’s disease in the U.S.
• Most U.S. cases occur in people who have lived in areas of the world where the disease is still common. Most new cases in 2018 were reported from Arkansas, California, Florida, Hawaii, Louisiana, New York, and Texas.
• In some parts of the southern United States, nine-banded armadillos have been found to carry the bacterium that causes Hansen’s disease. Experts think the armadillos may spread it to people when they handle these animals.

Challenges of Hansen’s Disease

Hansen’s disease mainly affects people in resource-limited countries, especially those who live in crowded conditions. Many have difficulty accessing health care due to high costs of going to the doctor and long distances to reach providers and clinics familiar with Hansen’s disease. Because of this, many of those affected don’t complete treatment or don’t receive it at all, even though the WHO has a program that provides free treatment. Due the continued stigma against people with Hansen’s disease, they may not seek help when first symptoms appear, causing delay in diagnosis and development of disabilities.

Girls and women affected by Hansen’s disease face the added issue of gender and social discrimination, which may also delay detection of the disease. In some countries, the law allows a person to legally divorce a spouse because they are affected by the disease. Unfortunately, this may leave many women destitute, homeless, and unable to care for their children.

Many people living with Hansen’s disease are unable to work due to disability caused by the disease or may face stigma that prevents them from working.

The good news is that Hansen’s disease is curable with antibiotics. Education and improving access to basic health services for all are keys to successful elimination of stigma and disability associated with the illness.

Hansen’s Disease FAQ

There are some misconceptions about Hansen’s disease that continue to cause confusion and fuel stigma and discrimination. Here are seven common questions and answers about the disease so you can get the facts.

What You Can Do to Help

Many people think of leprosy as an ancient disease that was eradicated many years ago. But each year, thousands of men, women, and children all over the world develop this disease. Despite effective treatment, leprosy is one of the world’s most stigmatized diseases, and people living with leprosy-related disabilities in many countries are shunned, denied basic human rights, and discriminated against. The stigma of leprosy affects the physical, psychological, social, and economic well-being of those with leprosy, contributing to the cycle of poverty in the affected regions.

During World Leprosy Day, we seek to increase public understanding of Hansen’s disease and tackle the social stigma attached to this completely curable disease.

How can you do your part?

• Educate yourself about Hansen’s disease and share with friends and family that leprosy is a curable illness.
• Help depict a positive image of leprosy and increase awareness about it in your community.
• Promote a positive image of leprosy which helps focus on the abilities of the affected individuals rather than disability.
• Search for World Leprosy Day activities online and see what’s happening in your area.

What is Hansen's disease?

Hansen's disease, also known as leprosy, is a complex infectious disease caused by a bacterium. The disease is often mistakenly identified as the "leprosy of the Old Testament," which has been clearly shown not to be Hansen's disease. Hansen's disease is not highly contagious and 95 percent of the human population has a natural immunity. It responds well to treatment and, if diagnosed and treated early, does not cause disability.

The Hansen's disease bacteria infect skin and sometimes other tissues, including the eye, the mucosa of the upper respiratory tract (nose) and the testes. Hansen's disease always involves the peripheral nerves. If untreated, nerve damage can result in crippling of hands and feet and blindness. Early diagnosis and treatment are the keys to preventing Hansen's disease-related disabilities. A person with HD can continue to work and lead an active life.

Hansen’s disease risk

Those at greatest risk are the family of a person who has the disease, but is not being treated. This could be because they are genetically susceptible and/or because they have prolonged contact with the infected individual. A spouse is the least at-risk family member. At greatest risk are children, brothers or sisters, or parents of an individual with untreated Hansen's disease.

Hansen's disease is not passed on from a mother to her unborn baby during pregnancy. Neither is it transmitted through sexual contact.

Is Hansen’s disease contagious?

Yes. However, it is not acquired from casual contact such as shaking hands, sitting next to someone on a bus, or sitting together at a meal. Hansen’s disease is far less contagious than other infectious diseases. More than 95 percent of the human population has a natural immunity to the disease. Healthcare workers rarely contract Hansen’s disease. Most cases of Hansen’s disease respond to treatment and become non-infectious within a very short time.

Treatment of Hansen’s disease

Hansen’s disease is curable using antibiotics. The three most commonly used are Dapsone, Rifampin and Clofazimine. Other antibiotics, such as Clarithromycin, Ofloxacin, Levofloxacin and Minocycline also work well against M. leprae. Dapsone and other Sulfone drugs were discovered to be effective in treating HD at the National Hansen’s Disease Program in 1941. These medications continue to be an important weapon against this disease.

Treatment regimens differ depending upon the form of the disease (see Treatment Guidelines). The National Hansen’s Disease Programs recommends treatment for 1 or two years, depending on the form of disease.

Treatment rapidly renders the disease non-communicable by killing nearly all the bacilli within a few days. These dead bacilli are then cleared from the body slowly, within a variable number of years, so that these dead bacilli may continue to be found in skin biopsies for several years.

Where on body is Hansen’s disease found?

Because the bacteria that cause Hansen's disease like the cooler parts of the body, the skin and its nerves are affected. This can cause dryness and stiffness of the skin. In some cases affected nerves can swell, causing pain. There can be loss of feeling and weakness in the muscles of the hands or feet.

Identifying Hansen’s disease

Hansen's disease in the U.S. is rare, but between 150 and 200 new cases are reported each year.

The first signs of Hansen's disease are usually pale or slightly red areas or a rash on the trunk or extremities. Frequently, but not always, there is an associated decrease in light touch sensation in the area of the rash. A loss of feeling in the hands or feet may also be the first signs of Hansen's disease. These changes in sensation are a valuable clue to diagnosis. Nasal congestion may be a sign of infection, but infection is more often associated with changes of the skin on the face, such as thinning of the eyebrows or eyelashes.

Your doctor can make the diagnosis by doing a test called a skin biopsy, which reveals a particular pathologic pattern and demonstrates the specific "red" staining bacteria. By far the most important diagnostic tool is the biopsy of the rash. There are no reliable ‘blood tests’ for the diagnosis of Hansen’s disease. Although some blood tests are promoted in some countries, they are not used in the United States.

Hansen’s disease and disfigurement

People with Hansen's disease who are diagnosed and treated early avoid many of the complications associated with the disease and experience no disfigurement or disability. Problems with insensitive fingers or toes can be prevented by avoiding injury and infections to these areas, and by taking the Hansen's disease medicines.

Many patients with the tuberculoid or Paucibacillary form of Hansen's disease can even self-heal without benefit of treatment, but it is the standard of care to treat all patients identified with the disease.

Hansen’s disease transmission

The most commonly accepted theory is that Hansen's disease is transmitted by way of the respiratory tract, since large numbers of bacteria can be found in the nose of some untreated patients. The degree of susceptibility of the person, the extent of exposure and environmental conditions are among factors probably of great importance in transmission.

Exposure to Hansen’s disease

If you think you have been exposed to Hansen's disease, you do not need to take any action. Most people have a natural immunity and there is no need for prophylaxis.

We do not yet have a vaccine or a blood or skin test that will tell if you have been exposed or if you have pre-clinical disease, although both of these are active areas of research at the National Hansen's Disease Programs.

Household contacts of people with Hansen's disease should have a thorough physical examination annually for five years. If they develop a questionable skin rash, they should notify their healthcare providers and have the skin rash biopsied to determine whether or not Hansen's disease is present.

Hansen’s disease in the U.S. and the world

In the U.S., there are approximately 6,500 cases on the National Hansen's Disease Programs Registry. This includes all cases reported since the registry began and who are still living. The number of cases with active disease and requiring drug treatment or management is approximately 3,300.

The NHDP compiles a statistical summary of new cases which present in the United States each year. Between 150 and 200 new U.S. cases are reported to the Registry annually.

The World Health Organization, which compiles global Hansen's disease data, registered a total of 296,499 new cases worldwide in 2008. This data indicates a rapid, drastic reduction of the number of cases seen each year for the previous 12 years and have raised questions. See the World Health Organization report, Global Leprosy Situation 2006 (not a U.S. Government Web site, pdf). Such data is very dependent upon operational factors such as the method of case finding (i.e., active screening of high risk groups, vs ‘passive’ case finding – waiting for patients to come to a clinic).

Delayed Hansen’s disease diagnosis

Unfortunately, the rash caused by Hansen's disease often resembles other skin diseases. Hansen's disease is a slowly developing, chronic, infectious disease and 2 to 10 years may elapse before clinical signs and symptoms appear.

Moreover most private sector physicians in the U.S. lack experience with this disease, and do not consider a diagnosis of Hansen's disease, even in a patient who has lived in or migrated from a country where Hansen's disease is prevalent. Often a patient sees several physicians before the correct diagnosis is made, delaying the initiation of treatment even more.

Forms of Hansen’s disease

Classification of this disease is complex, but overall there are two forms. Tuberculoid (or Paucibacillary – few bacilli) is a limited form of the disease that is contagious.
Lepromatous (or Multibacillary – many bacilli) is a more generalized form. Proper classification requires a skin biopsy. These are evaluated at the National Hansen’s Disease Programs at no charge.

Hansen’s disease and tuberculosis

Mycobacterium leprae, the bacillus that causes Hansen's disease is in the same bacterial family as M. tuberculosis, the bacillus that causes tuberculosis. Because of this relationship, the National Hansen's Disease Program conducts extramurally-funded research on tuberculosis. For more information, please see the National Hansen’s Disease Program Research webpage.

Hansen’s disease reaction

Some patients experience what is called a reaction after treatment has begun. This is a response of the immune system to dead or dying bacteria and can cause worsening of the rash or a painful neuritis which can affect sensation and/or strength. Reactions are NOT caused by the treatment, and are NOT a sign that the treatment is working.

Reaction can be mild or severe. If mild, no treatment or only over the counter anti- inflammatory medication may be sufficient. More severe reactions can be harmful to nerves and should be promptly treated by a physician. If you think you are having a reaction of any type, it is best to notify your physician so that he can decide on appropriate treatment.

Scleroderma means hard skin. It is a group of diseases that cause abnormal growth of connective tissue. Connective tissue is the material inside your body that gives your tissues their shape and helps keep them strong. In scleroderma, the tissue gets hard or thick. It can cause swelling or pain in your muscles and joints.

Symptoms of scleroderma include

• Calcium deposits in connective tissues
• Raynaud's phenomenon, a narrowing of blood vessels in the hands or feet
• Swelling of the esophagus, the tube between your throat and stomach
• Thick, tight skin on your fingers
• Red spots on your hands and face

No one knows what causes scleroderma. It is more common in women. It can be mild or severe. Doctors diagnose scleroderma using your medical history, a physical exam, lab tests, and a skin biopsy. There is no cure, but various treatments can control symptoms and complications.

Your adrenal glands are just above your kidneys. The outside layer of these glands makes hormones that help your body respond to stress and regulate your blood pressure and water and salt balance. Addison disease happens if the adrenal glands don't make enough of these hormones.

A problem with your immune system usually causes Addison disease. The immune system mistakenly attacks your own tissues, damaging your adrenal glands. Other causes include infections and cancer.

Symptoms include

• Weight loss
• Muscle weakness
• Fatigue that gets worse over time
• Low blood pressure
• Patchy or dark skin

Lab tests can confirm that you have Addison disease. If you don't treat it, it can be fatal. You will need to take hormone pills for the rest of your life. If you have Addison disease, you should carry an emergency ID. It should say that you have the disease, list your medicines and say how much you need in an emergency.

Introduction

Melasma is a common skin problem caused by brown to gray-brown patches on the face. Most people get it on their cheeks, chin, nose bridge, forehead, and above the upper lip. It is more common in women than men. Pregnancy is a common cause of melasma. It also affects woman taking oral contraceptives and hormones.

Etiology

Etiologic factors include genetic influences, ultraviolet (UV) radiation, pregnancy, hormonal therapies, cosmetics, phototoxic drugs, and antiseizure medications.

Melasma stimulates melanocytes by the female sex hormones estrogen and progesterone, producing more melanin pigments when the skin is exposed to the sun.

Genetic

Genetic predisposition may be a major factor in the development of melasma.

• Melasma is more common in females than in males.

• Persons with light-brown skin types from regions of the world with high sun exposure are more prone to the development of melasma.

• Approximately 50% report a positive family history of the condition. Identical twins have been reported to develop melasma.

Sunlight Exposure

UV radiation can cause lipids peroxidation in cellular membranes, resulting in free radicals which could stimulate melanocytes to produce excess melanin.

• Sunscreens that block UV-B radiation (290-320 nm) do not block the longer wavelengths of UV-A and visible radiation (320-700 nm) which also stimulate melanocytes to produce melanin.

Hormonal Influences

Hormones may play a role in developing melasma in some individuals.

• The mask of pregnancy is known to occur in obstetric patients. The exact mechanism is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone levels are normally increased during the third trimester of pregnancy and may be a factor.

• Patients with melasma who are nulliparous have no increased levels of estrogen or MSH but show elevated levels of estrogen receptors within the lesions. In addition, melasma with estrogen- and progesterone-containing oral contraceptive pills and diethylstilbestrol treatment for prostate cancer have been observed.

• A woman who is postmenopausal and given progesterone may develop melasma, while those who are given estrogen alone do not; this implicates progesterone as playing a primary role in the development of melasma.

Thyroid Disease

There is a four-fold increase in thyroid disease in melasma patients.

• There is an association between the development of melasma and the presence of melanocytic nevi and lentiginous nevi.

• This would indicate a relationship between the development of melasma and the presence of pigmentation.

Epidemiology

Persons of any race can be affected. Melasma is more common in darker skin types than in lighter skin types, and it is particularly more common in light brown skin types. Women are affected nine times more than men. Melasma is rare before puberty and more common in reproductive years. Melasma is present in 15% to 50% of pregnant patients. The prevalence varies between 1.5% and 33% depending on the population.

Pathophysiology

The most important factor is exposure to sunlight. UV radiation induces production of alpha-melanocyte–stimulating hormone and corticotropin as well as interleukin 1 and endothelin 1, which contributes to increased melanin production by intraepidermal melanocytes. Prolonged UV exposure-induced dermal inflammation and fibroblast activation upregulate stem cell factors in the melasma dermis, resulting in increased melanogenesis.

Histopathology

Melanin is increased in the dermis or epidermis or both. Epidermal melanin is located in the keratinocytes in the basal and suprabasal areas. Dermal melanin also is found in the superficial and mid dermis within the macrophages congregating around small, dilated vessels. Inflammation is sparse or absent.

History and Physical

Melasma occurs in sun-exposed areas as an acquired hypermelanosis, presenting as symmetrically distributed hyperpigmented macules which can be confluent or punctate. It is worse in areas that receive excessive sun exposure, including the cheeks, the upper lip, the chin, and the forehead.

Evaluation

No laboratory tests are indicated although some studies suggest mild abnormalities in thyroid function are associated, specifically pregnancy- or oral contraceptive pill-associated melasma. In these cases, it is reasonable to consider checking thyroid function tests. Wood lamp examination helps to localize the pigment to the dermis or epidermis.

Treatment / Management

The best treatment is a topical combination of hydroquinone cream and avoidance of sun or estrogen exposure. In addition to the avoidance of sun exposure, discontinuing the use of high-SPF sunscreens (50 or higher) can prevent the development of melasma. First-line therapy for melasma consists of effective topical therapies, mainly in the form of triple combinations (hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01%) and when triple combinations are unavailable or when patients have hypersensitivity to them, then dual ingredients or single agents be considered.

Chemical peels and lasers may yield unpredictable results and are associated with adverse effects including epidermal necrosis, postinflammatory hyperpigmentation, and hypertrophic scars. These interventions are second-line therapies and used only if the topical medication has failed. In experienced hands, chemical peels and lasers are usually safe and may produce results faster than topical medications.

Skin Peels These procedures carry a risk of adverse outcomes. Peels use glycolic or salicylic acid-based compounds which may increase turnover of hyperpigmented keratinocytes.

• They often begin as a monthly treatment using low concentration formulas and progress to weekly applications at higher concentrations.

• Lightening agents are usually used in conjunction with superficial peels for better results.

• Skin peels should only be used after a trial of therapy with at least one skin-lightening agent.

• Close monitoring of skin depigmentation is necessary, and therapy should be halted if alterations in pigmentation in the surrounding skin are noted.

Lasers

The efficacy of lasers for the treatment of melasma has been associated with undesired cosmetic results. Their use should be considered in cases of extensive disease that is refractory to laser use as it may actually worsen the condition.

Differential Diagnosis

The differential diagnoses include:

• Actinic Lichen Planus

• Acanthosis Nigricans

• Discoid Lupus Erythematosus

• Drug-Induced Photosensitivity

• Exogenous Ochronosis

• Frictional Melanosis

• Mastocytosis

• Nevi of ito and Ota

• Pigmented Contact Dermatitis

• Poikiloderma of Civatte

• Postinflammatory Hyperpigmentation

Prognosis

Melasma has no associated mortality or morbidity. No cases of malignant transformation or association with the increased risk of melanoma or other malignancies have been reported. Patients with melasma actually are considered to have less risk for melanoma.

The dermal pigment may take longer to resolve than the epidermal pigment because no effective therapy is capable of removing dermal pigment. However, treatment should not be withheld simply because of a preponderance of dermal pigment. The source of the dermal pigment is the epidermis, and, if epidermal melanogenesis can be inhibited for long periods, the dermal pigment will not replenish and will slowly resolve.

Resistant cases or recurrences of melasma occur often and are certain if strict avoidance of sunlight is not rigidly heeded.

Pearls and Other Issues

Patients should avoid the routine use of cosmetics on sensitive skin. Vigorously rubbing triple creams on hyperpigmented areas may worsen the situation. Ochronosis can occur with prolonged exposure to creams with potent steroids.

Melasma should be distinguished from post-inflammatory hyperpigmentation, actinic lichen planus, and hydroquinone-induced exogenous ochronosis.

Patient education should include strict sun avoidance as this is essential for resolution and may prevent recurrence of melasma. Melasma patients should apply bleaching creams to dark areas only. Resolution with strict sun avoidance and topical bleaching creams can take many months; patients should be educated to expect slow but gradual lightening.

Enhancing Healthcare Team Outcomes

Melasma is a benign skin disorder that has no morbidity. The key reason why some patients seek treatment is aesthetic. Fortunately, melasma resolves on its own in most cases. Thus, healthcare workers including nurse practitioners, dermatologists, and primary care providers should educate the patient on avoiding the sun and discontinuing the trigger medications. There are dozens of treatments for melasma and none is superior to the other. In fact, some treatments like the laser may worsen the condition.

Patients who seek no treatment and avoid the sun will notice that the rash usually disappears in a few months.

Disorders of increased melanin pigmentation that develop without preceding inflammatory disease.

Ocular albinism is a genetic condition that primarily affects the eyes. This condition reduces the coloring (pigmentation) of the iris, which is the colored part of the eye, and the retina, which is the light-sensitive tissue at the back of the eye. Pigmentation in the eye is essential for normal vision.

Ocular albinism is characterized by severely impaired sharpness of vision (visual acuity) and problems with combining vision from both eyes to perceive depth (stereoscopic vision). Although the vision loss is permanent, it does not worsen over time. Other eye abnormalities associated with this condition include rapid, involuntary eye movements (nystagmus); eyes that do not look in the same direction (strabismus); and increased sensitivity to light (photophobia). Many affected individuals also have abnormalities involving the optic nerves, which carry visual information from the eye to the brain.

Unlike some other forms of albinism, ocular albinism does not significantly affect the color of the skin and hair. People with this condition may have a somewhat lighter complexion than other members of their family, but these differences are usually minor.

The most common form of ocular albinism is known as the Nettleship-Falls type or type 1. Other forms of ocular albinism are much rarer and may be associated with additional signs and symptoms, such as hearing loss.

Oculocutaneous albinism is a group of conditions that affect the coloring of the hair and eyes. Individuals affected by oculocutaneous albinism have very light skin and light-colored irises; they may also have vision problems such as decreased sharpness of vision, rapid eye movements (nystagmus), crossed eyes (strabismus), or increased sensitivity to light (photophobia). All types of oculocutaneous albinism are caused by gene mutations that are inherited in an autosomal recessive manner. Treatment includes covering the skin from sun exposure by using sunscreen and protective clothing and attending to vision problems by wearing glasses.

The most common form of cutaneous mastocytosis (MASTOCYTOSIS, CUTANEOUS) that occurs primarily in children. It is characterized by the multiple small reddish-brown pigmented pruritic macules and papules.

Birthmarks are abnormalities of the skin that are present when a baby is born. There are two types of birthmarks. Vascular birthmarks are made up of blood vessels that haven't formed correctly. They are usually red. Two types of vascular birthmarks are hemangiomas and port-wine stains. Pigmented birthmarks are made of a cluster of pigment cells which cause color in skin. They can be many different colors, from tan to brown, gray to black, or even blue. Moles can be birthmarks.

No one knows what causes many types of birthmarks, but some run in families. Your baby's doctor will look at the birthmark to see if it needs any treatment or if it should be watched. Pigmented birthmarks aren't usually treated, except for moles. Treatment for vascular birthmarks includes laser surgery.

Most birthmarks are not serious, and some go away on their own. Some stay the same or get worse as you get older. Usually birthmarks are only a concern for your appearance. But certain types can increase your risk of skin cancer. If your birthmark bleeds, hurts, itches, or becomes infected, call your health care provider.

Moles are growths on the skin. They happen when pigment cells in the skin, called melanocytes, grow in clusters. Moles are very common. Most people have between 10 and 40 moles. A person may develop new moles from time to time, usually until about age 40. In older people, they tend to fade away.

Moles are usually pink, tan or brown. They can be flat or raised. They are usually round or oval and no larger than a pencil eraser.

About one out of every ten people has at least one unusual (or atypical) mole that looks different from an ordinary mole. They are called dysplastic nevi. They may be more likely than ordinary moles to develop into melanoma, a type of skin cancer. You should have a health care professional check your moles if they look unusual, grow larger, change in color or outline, or in any other way.