Case of the Month With Crutchfield Dermatology

Tuesday, July 2, 2013

A 50-year-old woman presents for the evaluation and treatment of brown patches on her dorsal forearms. On examination, she has irregularly shaped brown patches on both forearms. She says these have been developing during the past several years.

She notices they seem to get darker with sun exposure. Careful examination reveals similar, very faint brown patches on her bilateral upper cheeks, forehead and glabellar region, and upper lip. I ask her when she first noticed the patches on her face, and she says, “After my first pregnancy.” Biopsy confirms the suspected diagnosis.

Diagnosis: Melasma

Melasma can occur on various areas of the body — including the arms, as in this case. I tell my patients melasma is a very rapid, uneven suntan. Under the exposure of ultraviolet radiation, sensitized melanocytes aggressively and rapidly produce melanin. In my experience, sensitization is related to pregnancy and/or exogenous hormones, such as birth control pills. I have noticed in a smaller yet significant percentage of patients with birth control pill-associated melasma, if they stop the birth control pills, the melasma will improve.

I also tell patients the cells that produce color in our skin (melanocytes) represent only about 2–3 percent of our total skin cells. I explain that they have long arms like an octopus that feed 40-plus other skin cells around them with little packets of color. Unfortunately, sometimes patients have melanocytes that reside very deep in the skin, and the topical medications we use, including hydroquinone-containing products, to fade melanin can’t penetrate that far.

My initial approach is a good explanation to the patient about using a pea-sized amount of a product containing hydroquinone twice daily for no more than five months. I use a cream compounded with hydroquinone 6 percent, kojic acid 3 percent, tretinoic acid 0.05 percent and hydrocortisone 0.05 percent. After five months, I always give it a two-month break/washout period using an ammonium lactate-containing lotion with a kojic acid product to maintain fading activity. This must be coupled with meticulous sun protection, and I tell patients who are very concerned about the condition to use a double layer of sunscreen.

If topical hydroquinone products are partially successful and the patient needs additional treatment, I use the Skin Active program by NeoStrata with a series of 12 increasing-strength chemical peels done twice monthly for six months. Finally, if that doesn’t work or if patients want to be aggressive initially, I use a system called the Melanage peel. It contains Arbutin (aka arbutase, a glycosylated hydroquinone at approximately 14 percent), vitamin C, Kojic acid, beta-glucosidase and ferulic acid. In my experience, the topical prescription-strength hydroquinone-containing products work about 60 percent of the time, the chemical peels work about 70 percent of the time, and the deep, intense Melanage peel works about 80 percent of the time. I define “works” as patients’ reports that they are happy with the results. Nevertheless, no matter how effective the treatments are, if they are not coupled with meticulous sun protection, the condition will return.

For more information, contact Charles E. Crutchfield III, MD, at Crutchfield Dermatology or visit