What could be the cause and appropriate management for a 56-year-old female presenting with black pigmentation on her face?

Black Pigmentation on Face in 56-Year-Old Female

Most Likely Diagnosis: Melasma

The most likely diagnosis is melasma, a common acquired hypermelanosis affecting middle-aged women, characterized by symmetric brown to gray-brown patches on sun-exposed facial areas. 1, 2, 3

Clinical Features Supporting Melasma

• Age and gender profile: Melasma predominantly affects reproductive-age and middle-aged women, with your patient fitting this demographic perfectly 3, 4
• Typical presentation: Brown to bluish-gray patches with well-demarcated or ill-defined borders on sun-exposed facial areas 5
• Common locations: Cheeks (most common at 43.6%), T-zone (33.1%), and malar regions 5

Key Etiologic Factors to Assess

• UV exposure history: Present in 62.2% of melasma cases 5
• Hormonal factors: Pregnancy history, oral contraceptive use, hormone replacement therapy 3, 4, 6
• Genetic predisposition: Family history present in 43.6% of cases 5
• Medications: Phototoxic drugs, anti-seizure medications 4, 6
• Thyroid dysfunction: Should be evaluated 4

Diagnostic Workup

Wood's Lamp Examination

• Essential for determining melanin depth 3, 5
• Epidermal melasma: Brown/black color that enhances under Wood's lamp
• Dermal melasma: Blue color with no enhancement
• Mixed type: Variable enhancement (common in darker skin types V-VI) 3

Dermoscopic Findings

• Brown reticular pseudonetwork (73.3% of cases) 5
• Increased vascularity and telangiectasia (51.7%) 5
• Brown clods (33.1%) 5

Important Differential Diagnoses to Exclude

Post-Inflammatory Hyperpigmentation

• History of preceding inflammatory skin condition 7
• Less symmetric distribution pattern
• May occur anywhere trauma or inflammation occurred

Drug-Induced Hyperpigmentation

• Temporal relationship with medication initiation 7
• May have different distribution pattern

Peutz-Jeghers Syndrome (If Perioral)

• Critical to exclude if pigmentation involves lips and buccal mucosa 8
• Look for: Pigmented macules 1-5 mm on vermilion border of lips (94%), buccal mucosa (66%), hands (74%), feet (62%) 8
• Associated with gastrointestinal hamartomatous polyps and increased cancer risk 8
• Pigmentation typically appears in infancy, not at age 56 8

Laugier-Hunziker Syndrome

• Acquired pigmentation in young/middle-aged adults 8
• Can involve conjunctiva and longitudinal melanonychia 8
• No gastrointestinal involvement 8

Evidence-Based Treatment Algorithm

Step 1: Foundation (All Patients)

Strict sun protection is mandatory and forms the foundation of all melasma treatment 1, 2

• Broad-spectrum sunscreen SPF 50+ 2
• Reapply every 2-3 hours during outdoor exposure 2
• Wide-brimmed hats and UV-protective clothing 2
• Avoid peak UV hours (10 AM to 4 PM) 2

Step 2: First-Line Topical Therapy (8-12 Weeks Trial)

Hydroquinone remains the most effective FDA-approved topical bleaching agent for melasma 1, 9, 6

Hydroquinone-Based Regimens

• Triple combination therapy (hydroquinone + tretinoin + corticosteroid): Superior efficacy compared to monotherapy 1, 3
• Hydroquinone 4% alone 9, 6
• Compounded formulations containing hydroquinone and depigmenting agents 1

Critical Hydroquinone Warnings (FDA Label)

• Contains sodium metabisulfite: May cause anaphylactic reactions in sulfite-sensitive individuals 9
• Risk of exogenous ochronosis: Gradual blue-black darkening, more common in Black patients but can occur in Caucasians and Hispanics 9
• Must use with broad-spectrum sunscreen: Product contains no sunscreen; failure to protect can cause repigmentation 9

Alternative First-Line Agents

• Tretinoin (retinoic acid) 1, 3, 7
• Azelaic acid 3, 7
• Combination regimens preferred over monotherapy 3

Step 3: Add Oral Tranexamic Acid (If Inadequate Response)

Oral tranexamic acid 250 mg twice daily is an evidence-based treatment option 1, 2

• More effective than topical tranexamic acid 2
• Can be combined with topical therapies 1
• PRP combined with oral tranexamic acid shows 90.48% efficacy vs. 73.68% for tranexamic acid alone 2

Step 4: Advanced Procedural Treatments (Refractory Cases)

Intradermal platelet-rich plasma (PRP) injections are the most effective treatment for melasma, showing superior results to all other therapies including tranexamic acid injections 2

PRP Treatment Protocol

• Four intradermal treatment sessions every 2-3 weeks 2
• Microinjections 1 cm apart 2
• Follow-up evaluation one month after last treatment 2
• Mean mMASI score reduction: 53.66% with PRP-TXA combination 2
• Significantly higher patient satisfaction compared to other modalities 2

Chemical Peels (Adjunctive)

• Superficial and medium-depth peels effective in combination regimens 3, 7
• Use with extreme caution in darker skin types: Risk of post-inflammatory hyperpigmentation 7, 6
• Frequent applications of superficial peels particularly effective and well-tolerated in dark-skinned patients 7

Step 5: Maintenance Therapy (Essential)

Melasma is a chronic condition with high recurrence rates; maintenance therapy is mandatory 2

• Continue strict sun protection indefinitely 2
• Intermittent use of topical agents 2
• Maintenance PRP treatments every 6 months 2

Common Pitfalls to Avoid

Treatment Errors

• Discontinuing treatment too early: Melasma requires long-term maintenance 2
• Inadequate sun protection: Single most important factor in treatment failure 1, 2
• Using hydroquinone without sunscreen: Will cause repigmentation 9
• Aggressive chemical peels in dark skin: High risk of post-inflammatory hyperpigmentation 7, 6

Diagnostic Errors

• Missing Peutz-Jeghers syndrome: If pigmentation involves lips/buccal mucosa, must evaluate for GI polyps and cancer risk 8
• Not performing Wood's lamp examination: Essential for determining melanin depth and guiding treatment 3, 5
• Ignoring medication history: Drug-induced hyperpigmentation requires different management 7

Monitoring for Complications

• Watch for exogenous ochronosis: Blue-black darkening with hydroquinone use, more common in Black patients 9
• Screen for sulfite allergy: Before prescribing hydroquinone-containing products 9
• Assess thyroid function: Thyroid dysfunction is an etiologic factor 4

Treatment Selection Based on Severity

Mild to Moderate Melasma

1. Strict sun protection + triple combination topical therapy 1, 3
2. If inadequate response at 8-12 weeks: Add oral tranexamic acid 1, 2

Moderate to Severe or Refractory Melasma

1. Strict sun protection + topical therapy + oral tranexamic acid 1, 2
2. Add PRP injections (4 sessions every 2-3 weeks) 2
3. Consider adjunctive superficial chemical peels (with caution in darker skin) 3, 7

Maintenance (All Patients)

• Lifelong sun protection 2
• Intermittent topical agents 2
• PRP every 6 months if needed 2