Derm Cases · Dermatology / Pigmentary disorders / Women's health
OSCE — centrofacial brown patches: melasma diagnosis and stepwise therapy
An 8-minute OSCE station on melasma recognition, triggers, Wood's lamp depth typing, photoprotection including visible light, topical regimens, and cautious use of oral tranexamic acid and procedures.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on melasma recognition, triggers, Wood's lamp depth typing, photoprotection including visible light, topical regimens, and cautious use of oral tranexamic acid and procedures.
Brief (to candidate)
A 36-year-old multiparous woman with Fitzpatrick IV skin has bilateral symmetrical brown facial patches on cheeks, forehead and upper lip for 2 years, worse after sun and during pregnancy. She wants "laser only." You have 8 minutes to confirm melasma, explain drivers, and set a safe stepwise plan.
[5]Candidate instructions
- State the clinical diagnosis and typical distribution patterns.
- Name major triggers (UV/visible light, hormones, genetics).
- Use Wood's lamp concepts for epidermal/dermal/mixed typing.
- Build a tiered treatment plan starting with photoprotection.
- Counsel limits of lasers and hydroquinone duration.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Acquired bilateral symmetrical facial hyperpigmentation on sun-exposed areas (centrofacial, malar, mandibular patterns); common in women FST III–IV[5][6] |
| Triggers / pathogenesis | UV and visible light, hormonal factors (pregnancy, OCP), genetic predisposition, local melanocyte hyperactivity and dermal changes — chronic relapsing course expected[5] |
| Depth typing | Wood's lamp: epidermal accentuation (better topical response) vs dermal (less accentuation, harder) vs mixed — sets expectations, not absolute biopsy need in classic disease |
| Foundation Rx | Strict photoprotection (broad-spectrum; visible light/iron oxide tinted sunscreens often discussed); discontinue optional hormonal triggers if appropriate after counselling |
| Topicals | Hydroquinone (± triple combination classic), tretinoin, azelaic acid, other pigment inhibitors; time-limit HQ to reduce exogenous ochronosis risk[1][2][6] |
| Second line | Oral tranexamic acid in selected non-contraindicated patients; peels/energy devices only after foundation therapy and by experienced operators (PIH risk)[1][2] |
| Safety communication | Not "laser first"; relapse common; stop continuous HQ >~6 months without review; exclude unilateral/rapid mimics |
Model key actions
- Diagnose classic melasma and prioritise photoprotection + topical regimen before procedures.[6]
- Discuss relapsing natural history and set realistic expectations.[2]
- Avoid unsupervised long-term hydroquinone and high-risk lasers as first steps.
Common errors
- Jumping to laser as first-line.
- Missing photoprotection of visible light.
- Continuous hydroquinone without ochronosis warning.
- Calling Addison or drug pigmentation "melasma" without systemic review.
References4ShowHide
- [1]Neagu N, Conforti C, Agozzino M, et al. Melasma treatment: a systematic review. The Journal of dermatological treatment, 2022.PMID 33849384
- [2]Gan C, Rodrigues M. An Update on New and Existing Treatments for the Management of Melasma. American Journal of Clinical Dermatology, 2024.PMID 38896402
- [5]Ali L, Al Niaimi F. Pathogenesis of Melasma Explained. International Journal of Dermatology, 2025.PMID 40022484
- [6]McKesey J, Tovar-Garza A, Pandya AG. Melasma Treatment: An Evidence-Based Review. American Journal of Clinical Dermatology, 2020.PMID 31802394