(Liver spots; Moth patches).
Definition. – A single or multiple, circumscribed or diffuse, yellowish, brown or blackish pigmentation of the skin.
Symptoms and Etiology. – Circumscribed patches are well defined, while the diffuse are less so, but both may vary greatly in shape, size and color. They are usually yellowish-brown or fawn colored, but may be a dark brown or black (melanoderma; melasma). The face is the common location for the circumscribed variety while the axillae, genitals, nipples and other relatively deeply colored parts of the skin are most affected in the general form. There are no subjective sensations.
Fig. 94 – Chloasma of four years’ duration. Light-brown pigmentation noted on the hands, arms, face, neck and thighs. Cured with Cimicifuga 3x and the external application of hydrogen peroxide after a year’s persistent use.
There are two varieties; the idiopathic form due to external causes such as local irritants, long continued friction or pressure, excoriations, usually repeated or prolonged heat or cold (chloasma caloricum) or the X-rays; and the symptomatic, due to internal causes including pigmentations associated with diseases of the spleen, liver, suprarenal capsules,
Fig. 95. – Chloasmatic pigmentation of Addison’s disease, presenting a generalized bronzing of the skin. Secondary leukodermic areas were prominent on the chest and upper back, uterus and ovaries, or from pregnancy, Addison’s disease, tuberculosis, malaria, exophthalmic goitre, cancer, hepatic cirrhosis, etc. In these symptomatic types, extensive and excessive color changes are the rule. Pigmentation may be incidental to or follow the lesions of syphilis, leprosy, lichen planus, senile atrophy, pigmented fibroma, psoriasis, lichen ruber, scleroderma, xeroderma pigmentosum, urticaria pigmentosa, and persistent hyperemia or erythema in dependent locations such as may be noted after a varicose eczema of the legs. Chloasma uterinum, a common type, is usually seen during pregnancy although it may be observed in relation to diseases of the uterus and the ovaries. The yellowish brown lesions of this condition are usually located on the forehead, eyelids and cheeks. While many cases fail to show a distinct etiological factor, a general causative agent such as chronic constipation or indigestion, anemia and chlorosis, neurasthenia and other nervous disorders, may be found. Sex has a decided influence because this condition is rare in males.
Pathology. – The morbid process is an accentuation or increase of the normal pigment which is found in the mucous layer of the epidermis. The sympathetic nervous system no doubt plays a large part in the pathological process because many cases of chloasma are related to some disease of the abdominal organs and the pigment function is apparently controlled by the nervous system.
Diagnosis. – Erythemas, due to congestion or inflammation, disappear on pressure and have a red color. Tinea versicolor and erythrasma are fungus disorders in typical locations with fine desquamation, demonstrable by the microscope. Accidental or voluntary stains of the skin and discolorations from chromidrosis can be removed by soap and water or some suitable chemical. Leucoderma will show an apparent increase of pigment at the border but the total or partial absence of normal pigment will be found in some part of the patch.
Prognosis should be guarded because it depends upon some knowledge of the cause and its possible removal. Local applications often have only a temporary effect.
Treatment – Causal measures are to be instituted where etiological factors can be discovered. Thus the treatment of the symptomatic form is usually the treatment of the causal disease. The idiopathic variety will often disappear of itself if the local causative factor be removed. The dermatologist is usually, called upon to relieve the cosmetic blemish. Hence women are the most frequent patients; men seldom care. Externally the treatment is for the same purpose as in freckles and a host of prescriptions have been recommended. Among the best are the following:
Rx Hydrarg. ammon.,
Bismuth. Subnit., aa 3j; 4 @
Adipis, 3j; 30 @ M.
Rx Bismuth. chlor. precip., 3j; 4 @
Barium sulphid., 3iv; 15 @
Cerati simpl., @
Glycerini, aa 3jss; 6 @
M. Sig. – Use externally once daily or less frequently.
Rx Hydrarg. chlor. corrosiv., gr. vj; @ 24
Tinct. benzoin. comp., 3jss; 6 @
Emuls. amygdal. amar. 3iij; 90 @
M. Sig. – Apply night and morning. (Duhring.)
Rx Hydrarg. ammon. 3j; 4 @
Sodae biborat., 3j; 4 @
Ol. rosmarin., mx; @6
Ung. simpl., 3j; 30 @M. (Kaposi)
When the skin becomes red and begins to scale, the above prescriptions should be discontinued and a mid salicylic acid ointment applied. To hide the redness of the surface during the day, a powder of equal parts of magnesium carbonate and talcum may be employed.
Probably mercuric chloride is the most reliable remedy. It may be applied by cataphoresis, a 1/10 per cent. solution being employed, or it may be prescribed in the proportion of from 2 to 4 grains to the ounce of either cologne, tincture of benzoin, Tolu balsam or dilute alcohol. Lactic acid from 20 per cent. to full strength, citric acid 5 per cent. aqueous solution, or hydrogen peroxid may be applied, followed by salicylic acid, 25 per cent. in ointment or collodion. Electrolysis has been used extensively but should never be employed when it is possible to use solidified carbon dioxide. The depth of pressure and duration of the latter application depends upon the location and the extent of chloasma. All methods for the removal of pigment must be carefully applied lest the opposite effect is produced by causing inflammation. Cadmium sulph., Calcarea phos., Lycop., Phosphorus, Nat. ars., Nit. acid, Sepia and Sulphur have been prescribed with success.