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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 114-120

Unmasking dermoscopic evaluation of melasma: findings of a cross-sectional study in central India


1 Department of Dermatology and STD, D. Y. Patil Medical College, Kolhapur, Maharashtra, India
2 Department of Community Medicine, AFMS, New Delhi, India
3 Department of Consultant Anaesthesiology, Rainbow Children Hospital, Bangalore, Karnataka, India
4 Department of Medical Informatics, AFMS, New Delhi, India

Date of Submission01-Mar-2022
Date of Decision05-May-2022
Date of Acceptance07-May-2022
Date of Web Publication26-Aug-2022

Correspondence Address:
Yoganand J Phulari
Department of Dermatology and STD, D. Y. Patil Medical College, Kadamwadi, Kolhapur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_42_22

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  Abstract 


Background: There exists a wide range of variations in skin tone around the world, with Asian and Indian subjects showing a greater susceptibility toward pigmentation disorder. Objective: This study was carried out with the objective to assess the clinical and dermoscopic findings among different types of melasma in a single center of Central India. Materials and Methods: A cross-sectional study was carried out among patients with clinical features of melasma attending the outpatient department at multispecialty hospital with a sample size of 100. A prestructured pro forma was used to collect the baseline data. Clinical and dermatological examination was done after taking a detailed history. Clinical pattern of melasma such as centrofacial, malar, and mandibular was noted. The areas of melasma were examined using a contact polarized Dermlite DL4 3rd Gen Dermoscope attached to an iPhone. Results: The mean age of study participants was 38.15 years with a standard deviation of 6.93. Seventeen percentage were of male gender. Thirty-one percentage of the female patients had a history of oral contraceptive pill (OCP) usage, and 22% of the female patients had a history of menstrual abnormalities. Fitzpatrick skin Type IV was the most commonly affected skin type. Centrofacial type of melasma is the most common clinical type and reticuloglobular pattern is the commonly seen pattern on dermoscopy. The color of dermoscopy was predominantly brown in malar (52.2%) and mandibular (57.1%) and mixed in Centrofacial (45.7%), which was followed by 26.1%–28.6% mixed color in malar and andibular types and 41.4% brown color in centrofacial type. The difference in the color of dermoscopy (P = 0.48), presence of telangiectasia on dermoscopy (P = 0.23), pattern of dermoscopy (P = 0.15), and mean Melasma Severity Index scores with different clinical types was not statistically significant. Similarly, the association between different clinical types of melasma with duration of sun exposure (P = 0.33) and topical photo protection (P = 0.34) was also not statistically significant. Conclusion: Our study findings concluded that melasma is common in women in the age group of 27–56 years range. Exposure to sunlight and the hormonal changes (due to OCP usage) were those among the various factors influencing the development of melasma. Centrofacial melasma was the most common pattern seen in our study group. Epidermal melasma features on dermoscopy were reticuloglobular patterns with a brownish hue, while the features of dermal melasma were irregular patterns with a bluish hue and mixed melasma had irregular patchy brown pigmentation. Perifollicular globules and telangiectasia were also seen.

Keywords: Clinical, dermoscopy, melasma


How to cite this article:
Sreenath S, Phulari YJ, Hiremath RN, Ghodke S, Raj R. Unmasking dermoscopic evaluation of melasma: findings of a cross-sectional study in central India. Clin Dermatol Rev 2022;6:114-20

How to cite this URL:
Sreenath S, Phulari YJ, Hiremath RN, Ghodke S, Raj R. Unmasking dermoscopic evaluation of melasma: findings of a cross-sectional study in central India. Clin Dermatol Rev [serial online] 2022 [cited 2022 Dec 3];6:114-20. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/2/114/354754




  Introduction Top


There exist a wide range of variations in skin tone around the world, with Asian and Indian subjects showing a greater susceptibility toward pigmentation disorder.[1],[2] Facial pigmentation is a major cosmetic and psychological concern. Indian society has shown an increasing demand toward fairness. This is evident from the fact that India comprises one of the largest global markets for fairness skin products.[3] Facial hyperpigmentary disorders include a common group of conditions that are characterized by hyperpigmented lesions on the face. The causes mainly comprise melasma, exogenous ochronosis, lichen planus pigmentosus, Riehl's melanosis, and various miscellaneous conditions. 20%–30% of middle-aged women present with melasma in India. The prevalence of postinflammatory hyperpigmentation is more than 70% in both men and women aged <35 years; this percentage was found to decrease to <10% after the age of 50 years.[4] Conditions such as lichen planus pigmentosus, cosmetic dermatosis, ashy dermatosis, and lesions of benign and malignant skin tumors are difficult to differentiate clinically. This poses a significant diagnostic and therapeutic challenge for dermatologists. This led to the advent of a new diagnostic technique, dermatoscopy.

Melasma is a chronic acquired hypermelanotic disorder of the skin characterized by brown macules which are irregular in shape and symmetrically distributed on sun-exposed areas of the body, particularly on the face. It is a common cause of demand for dermatological attention that affects mainly women (especially during the period of menarche). It affects mainly the pigmented phenotypes – Fitzpatrick skin Types III–V. Melasma impacts the quality of life of patients due to its frequent facial involvement[5] affecting their psychological and emotional well-being, which makes them to search for a dermatologist. As it has a very significant impact on appearance, it leads to emotional and psychosocial distress, thus reducing the quality of life of the affected patients.[6] Melasma is diagnosed mainly on a clinical basis. Melasma should be differentiated from other causes of facial hypermelanosis.[6] Biopsy is not routinely performed for the diagnosis of facial melanosis due to the risk of development of pigmentation or scar at the biopsy site and also the reluctance on the part of the patient.[7] Dermatoscopy is a noninvasive and reliable technique used for direct visualization of skin pigmentation and is increasingly being used for the diagnosis of pigmentary disorders. The characteristic dermoscopic patterns visualized on dermoscopy allow early diagnosis of melasma and help to differentiate it from other facial hypermelanoses. In view of the above, we carried out this study to assess the clinical and dermoscopic findings among different types of melasma.


  Materials and Methods Top


A cross-sectional study was carried out among patients with clinical features of melasma attending the outpatient department at multispecialty hospital. The sample size was calculated based on the average yearly number of new patients diagnosed with melasma over the last 3 years in the hospital, adjusted to fulfill the inclusion and exclusion criteria which came out to be 100. Institutional ethical committee clearance was obtained and written informed consent was obtained from all the patients enrolled in the study. Patients on clinical examination showing melasma of postpubertal age and both the sexes were included in the study. Patients who did not give consent and those who had already received topical therapy for melasma and prepubertal age group were excluded. A prestructured pro forma was used to collect the baseline data. Clinical and dermatological examination was done after taking a detailed history. The areas of melasma were examined using a contact polarized Dermlite DL4 3rd Gen Dermoscope attached to an iPhone. Statistical Package for the Social Sciences (SPSS) for Windows Version 22.0 Released 2013. Armonk, NY, USA: IBM Corp., was used to perform statistical analyses.


  Results Top


The mean age of study participants was 38.15 years with a standard deviation of 6.93. Seventeen percentage were of male gender. Thirty-one percentage of the female patients had a history of oral contraceptive pill (OCP) usage, and 22% of the female patients had a history of menstrual abnormalities. Fitzpatrick skin Type IV was the most commonly affected skin type, followed by Type V and Type III [Table 1]. Centrofacial type of melasma is the most common clinical type followed by malar and mandibular types. Reticuloglobular pattern is the commonly seen pattern on dermoscopy, followed by irregular and perifollicular patterns. The color of dermoscopy was predominantly brown in malar (52.2%) and mandibular (57.1%) and mixed in centrofacial (45.7%), which was followed by 26.1% to 28.6% mixed color in malar and mandibular types and 41.4% brown color in centrofacial type. This difference in the color of dermoscopy between clinical types was not statistically significant (P = 0.48) [Table 2].
Table 1: Basic parameters of patients with clinical features of melasma

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Table 2: Association of color, presence of telangiectasia, and pattern on dermoscopy based on the clinical types of melasma using Chi-square test

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Telangiectasia was more predominantly seen in centrofacial type (42.9%), followed by malar type with 30.4% and relatively less in mandibular type (14.3%). However, this difference in the presence of telangiectasia on dermoscopy between different clinical types was not statistically significant (P = 0.23). Reticuloglobular pattern was more predominant in malar (52.2%) and centrofacial type (58.6%) as compared to perifollicular pattern in mandibular clinical type (42.9%). However, this difference in the pattern of dermoscopy based on the clinical types of melasma was not statistically significant (P = 0.15). Reticuloglobular pattern was more predominant in malar (52.2%) and centrofacial type (58.6%) as compared to perifollicular pattern in mandibular clinical type (42.9%). However, this difference in the pattern of dermoscopy based on the clinical types of melasma was not statistically significant (P = 0.15). The mean Melasma Severity Index score for malar type was 20.52 ± 9.36, for mandibular type was 15.86 ± 9.82, and centrofacial type was 22.03 ± 9.78. This difference in the mean Melasma Severity Index scores was not statistically significant (P = 0.24) [Table 3]. The association between occurrence of different types of melasma with age, gender groups was not statistically significant (P = 0.70) [Table 4]. Centrofacial type was more predominantly expressed (55%–75%) irrespective of the duration of sun exposure. This was followed by malar type with 20%–30% occurrence and less seen with mandibular type (3.3%–15%). This association between different clinical types of melasma and duration of sun exposure was not statistically significant (P = 0.33). Centrofacial type was more predominantly seen (67.9% to 77.3%) irrespective of the use of topical photoprotection, which was followed by malar type (22.7%–23.1%) and the mandibular type was not present (0%) with use of topical photoprotection as compared to those who did not use of topical photoprotection (9.0%). However, this association between the use of topical photoprotection and clinical types of melasma was not statistically significant (P = 0.34) [Table 5].
Table 3: Association of mean melasma Severity Index scores based on the clinical types of melasma using Kruskal-Wallis test

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Table 4: Association between age, gender, use of topical photo protection with clinical types of melasma using Chi square test

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Table 5: Association between Fitzpatrick Skin Types, Duration of Sun Exposure with clinical types of Melasma using Chi Square Test

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  Discussion Top


Hyperpigmented lesions on the face have always been a distressing symptom to the patient. In the present era, the people have been showing a growing interest in the physical appearance and especially toward fairness in our Indian population. Hence, the number of patients seeking dermatologist care for facial hypermelanosis has been increasing day by day. The field of dermatoscopy has been evolving mainly for the past one decade. In the earlier days, this technique was mainly used by developed countries in order to diagnose and monitor cases of melanoma. But now, the application of this office tool has been extended to developing countries as well. A number of studies and researches are going on regarding the use of dermatoscopy in various inflammatory, noninflammatory, and pigmentary conditions. Our study was an observational which mainly aimed at studying the importance of dermatoscopy in melasma. Melasma was classified into epidermal dermal and mixed based on the depth of melanin in the skin, which was initially examined on Wood's lamp and later confirmed on dermoscopy. Homogeneous reticular network of pigmentation was noticed in majority of the epidermal type of melasma. Dermal type of melasma on dermoscopy showed uniform skin involvement and no areas of sparing with dark brown to gray hyperpigmented lesions were observed. Mixed pattern of melasma on dermoscopy observed reticuloglobular pattern, exaggerated pseudo network with granular pigmentation, arciform structures, exogenous ochronosis, atrophy, and telangiectasias [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]. The dermatoscopic features thus helped to classify melasma into epidermal, dermal, or mixed types and also observed additional features like telangiectasia which aids in designing of optimal treatment for the patients.
Figure 1: Epidermal melasma (malar type of melasma showing brown irregular patches of pigmentation)

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Figure 2: Epidermal melasma features on dermoscopy showing scattered islands of brown pigmentation with scattered dark granules

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Figure 3: Dermal type of melasma showing grayish to dark brown pigmentation

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Figure 4: Dermal melasma features on dermoscopy showing reticuloglobular pattern and telangiectasia

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Figure 5: Mixed type of mandibular melasma showing dark brown irregular patch of hyperpigmentation

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Figure 6: Mixed melasma features on dermoscopy showing a combination of light brown and dark brown pigmentation with globular pattern

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Age

In our study involving 100 patients, the most common age group with melasma was between 31 and 40 years with a mean age of 38.15 years. The youngest patient was 27 years of age and the oldest was 56 years of age. Many of the previous studies reported similar age distribution although Jagannathan et al.[8] in their study found the patients belonging to the age range 20–30 as the most commonly affected. In another study on 140 patients, Yalamanchili et al.,[9] reported the mean age to be 37.13 years and the age range between 31 and 40 years. The test results showed that centrofacial type was more predominantly seen in patients with <40 (70.2%) and >40 years (69.8%), which was followed by malar type with 24.6% and 20.9% and relatively lesser occurrence of mandibular type with 5.3% and 9.3% in <40 and >40 years, respectively.

Gender

As in all the previous studies, females were more commonly affected with melasma than men in our present study with a male-to-female ratio of 1:3. In our study, 83% of females were affected and 17% of males were affected. This further substantiates the hormonal etiology of melasma. The test results demonstrated that centrofacial type was more predominantly present in both males (64.7%) and females (71.1%), which was followed by malar and mandibular types in males with 17.6% and in females with malar type with 24.1% and relatively lesser with mandibular type (4.8%).

Sunlight exposure

Exposure to sunlight is one of the important factors for the development of melasma. All the patients in our study had a history of sun exposure prior to the development of melasma. Seventy-one percentage of patients resided in an urban area and 29% of patients belonged to a rural area. Twenty percentage of the total patients had sunlight exposure of <1 h/day, 20% of the patients had 1–2 h of sun exposure, and 60% of them had more than 2 h of sun exposure every day. The test results demonstrated that centrofacial type was more predominantly expressed (55%–75%) irrespective of the duration of sun exposure. This was followed by malar type with 20–30% occurrence and less seen with mandibular type (3.3%–15%). The test results showed that centrofacial type was more predominantly seen (67.9% to 77.3%) irrespective of the use of topical photoprotection, which was followed by malar type (22.7%–23.1) and the mandibular type was not present (0%) with the use of topical photoprotection as compared to those who did not use of topical photoprotection (9.0%).

Our study results are consistent with a study by Pawar et al. who in their study found a 100% history of sun exposure.[10] However, Moin et al. in their study found a contrasting result with only 9.80% of their patients having a history of significant sun exposure.[11] The enormous difference between the findings among the studies may be explained probably by the geographical, cultural, and clothing differences in the studies.

Menstrual abnormalities in female patients

Out of 83 female patients in our study, 18 patients, i.e., 22% of females had menstrual abnormalities which are different as compared to observations made by Suthanther et al. where they found only 10.9% of the female patients with menstrual abnormalities in their study.[12]

Oral contraceptive pill usage

Thirty-one percentage of the females gave a history of OCP use prior to the development of melasma as compared to a study done by Jagannathan et al.[8] and Pawar et al.,[10] where only 13.75% and 16.30% of the females had a history of OCP usage, respectively.

Fitzpatrick skin type

Our study was done in the western part of India where most of the patients had Fitzpatrick skin Types 4 and 5. 45% of the patients belonged to Fitzpatrick skin Type 4, 42% of the patients belonged to skin Type 5, and 13% of the patients belonged to skin Type 3, as compared to the study done by Pawar et al.,[10] where 6.67% belonged to Type 3, 83.33% belonged to Type 4, and only 10% belonged to Type 5. The test results showed that centrofacial type was more predominantly expressed with all forms of Fitzpatrick skin types, i.e., Type III, IV, and V (61.5%–76.2%), which was followed by malar type ranging between 16.7 and 38.5% and least expressive in mandibular type with 0.0%–8.9%. However, this association between Fitzpatrick skin types and clinical types of melasma was not statistically significant (P = 0.45).

Distribution of melasma

In our study, the prevalence of centrofacial melasma was 70%, malar Type 23%, and mandibular type being 7% as compared to Yalamanchili et al., (2014),[9] where centrofacial type was 25%, malar type 68%, and mandibular Type 7.1%. In our study, centrofacial melasma was the most common type.

Color of dermoscopic findings

In our study, brown color was the most common color – 45%, followed by mixed (brown and bluish gray) type 40% and bluish gray color being 15%. The test results demonstrated that the color of dermoscopy was predominantly brown in malar (52.2%) and mandibular (57.1%) and mixed in centrofacial (45.7%), which was followed by 26.1% to 28.6% mixed color in malar and mandibular types and 41.4% brown color in centrofacial type.

Pattern on dermoscopy

In the present study, reticuloglobular pattern was the commonly found – 55%, followed by irregular pattern – 30% and perifollicular pattern – 15% as compared to Yalamanchili et al., (2014),[9] where 95% was reticuloglobular pattern and 97% was perifollicular pattern. The test results showed that reticuloglobular pattern was more predominant in malar (52.2%) and centrofacial type (58.6%) as compared to perifollicular pattern in mandibular clinical type (42.9%). However, this difference in the pattern of dermoscopy based on the clinical types of melasma was not statistically significant (P = 0.15). Thirty-eight percentage of the patients had telangiectasia in this study. The test results showed that telangiectasia was more predominantly seen in centrofacial type (42.9%), followed by malar type with 30.4% and relatively less in mandibular type (14.3%).

Mean melasma area and severity index score

The test results showed that the mean Melasma Severity Index score for malar type was 20.52 ± 9.36, for mandibular type was 15.86 ± 9.82, and centrofacial type was 22.03 ± 9.78. This difference in the mean Melasma Severity Index scores was not statistically significant (P = 0.24), as compared to Yalamanchili et al., (2014),[9] where the mean melasma area and severity index score was found to be 5.7.

As per the case report discussion by Sonthalia et al.,[13] in most of the extensively described literature, melasma dermoscopic features have mostly been mentioned in comparison to other facial melanoses. Reticular or pseudoreticular as common in deeper melasmas is the basic pattern[9] and the pigment suggests mainly of depth of melasma[14] although there are articles contesting it.[15] Dermoscopic pictures apart from being more treatment compliant is also a valuable tool in follow-up of melasma treatment.[16]

Nanjundaswamy et al.[17] in their findings showed characteristic wave-like pattern with dermal type presenting as gray color, epidermal type presenting with light brown color, and mixed type presented with dark brown color in middle-aged people and had statistical significance association. The explanation given by the authors is that during the initial stage, only epidermis had pigment deposition because of external factors, and age progression and various other factors such as multiple treatment regimens with hormonal influences led to the finally mixed type of melisma.


  Conclusion Top


Our study findings concluded that melasma is common in women in the age group of 27–56 years range. Exposure to sunlight and the hormonal changes (due to OCP usage) were those among the various factors influencing the development of melasma. Centrofacial melasma was the most common pattern seen in our study group. Epidermal melasma features on dermoscopy were reticuloglobular pattern with a brownish hue, while the features of dermal melasma were irregular pattern with a bluish hue and mixed melasma had irregular patchy brown pigmentation. Perifollicular globules and telangiectasia were also seen. Our study recommends to carry out studies at multiple centers and with a large sample size to see the association of various variables with different clinical types which were not statistically significant in our study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Hourblin V, Nouveau S, Roy N, de Lacharrière O. Skin complexion and pigmentary disorders in facial skin of 1204 women in 4 Indian cities. Indian J Dermatol Venereol Leprol 2014;80:395-401.  Back to cited text no. 4
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Jagannathan M, Sadagopan K, Ekkarakudy J, Anandan H. Clinicoepidemiological study of patients with melasma in a tertiary care hospital – A prospective study. Int J Sci Stud 2017;4:117-20.  Back to cited text no. 8
    
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Pawar S, Khatu S, Gokhale N. A clinico-epidemiological study of melasma in pune patients. Pigment Disord 2015;2:2376-0427.  Back to cited text no. 10
    
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Moin A, Jabery Z, Fallah N. Prevalence and awareness of melasma during pregnancy. Int J Dermatol 2006;45:285-8.  Back to cited text no. 11
    
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Suthanther CB, Bubna AK, Sankarasubramanian A, Veeraraghavan M, Rangarajan S, Muralidhar K. A clinical study of melasma and assessment of Dermatology Life Quality Index at a tertiary health care center in South India. Pigment Int 2016;3:77.  Back to cited text no. 12
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Ibrahim ZA, Gheida SF, El Maghraby GM, Farag ZE. Evaluation of the efficacy and safety of combinations of hydroquinone, glycolic acid, and hyaluronic acid in the treatment of melasma. J Cosmet Dermatol 2015;14:113-23.  Back to cited text no. 16
    
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