|Year : 2014 | Volume
| Issue : 2 | Page : 95-99
Melasma in North Indians: A clinical, epidemiological, and etiological study
S Kumar, BB Mahajan, Nidhi Kamra
Department of Skin and VD, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
|Date of Web Publication||15-Dec-2014|
Department of Dermatology, Guru Gobind Singh Medical College and Hospital, Saadiq Road, Faridkot, Punjab
Source of Support: None, Conflict of Interest: None
Background: Melasma is a common, acquired and symmetrical hypermelanosis characterized by more/less dark brownish macules, with an irregular contour, but clear limits, on photoexposed sites. The pathogenesis is unknown, but several clinical patterns and etiological factors have been implicated. Aims: Our present study aims to elucidate the epidemiology, clinical patterns and etiological factors in the causation of melasma in North Indians. Methods: A total of 200 consecutive patients attending the out-patient clinic from September 2013 to February 2104 with the clinical diagnosis of melasma were enrolled for the study. Photographic record was kept to study the clinical patterns. Results: The mean age of patients with melasma was 32.9 years, ranging from 18 to 60 years. Female patients out-numbered male patients, and ratio of female to male patients was 6.14:1. Patients sought medical treatment on an average of 1.79 years after appearance of melasma. 48.84% of female patients and 78.57% of males reported exacerbation with sun exposure. 36.4% of the females reported onset of melasma during pregnancy. Family history was observed in 29.07% of our female patients and 14.28% of males. History of use of mustard oil either for massage or for cooking was given by 54.07% of females and 32.14% of males, while 45.35% of females and 32.14% of males used topical corticosteroids or over-the-counter products for the treatment of melasma. Centro-facial was the most common pattern observed in 76.74% of the female patients while the malar pattern was seen in 85.71% of males. Other patterns we observed were mandibular (3.5%), lateral cheek (1.5%) and brachial (1%). Conclusion: The exact pathogenesis of melasma is unknown. Here in we have tried to elucidate the epidemiology, clinical patterns, and etiological factors in the causation of this pigmentary imperfection.
Keywords: Melasma, North India, pattern
|How to cite this article:|
Kumar S, Mahajan B B, Kamra N. Melasma in North Indians: A clinical, epidemiological, and etiological study. Pigment Int 2014;1:95-9
| Introduction|| |
The term "chloasma" is derived from the Greek word "chloazein" means to "to be green" and "melasma" from the Greek word "melas" meaning black. Since the pigmentation is never green, melasma is an appropriate designation for this condition.  Melasma is a common, acquired and symmetrical hypermelanosis characterized by more/less dark brownish macules, with irregular contour, but clear limits, on photoexposed sites, especially the face, forehead, temples, and more rarely on the nose, eyelids, chin, and upper limbs. 
The reported prevalence of melasma ranges from 8.8% among Latino females in the Southern United States to as high as 40% in South-east Asian population. , Although the exact prevalence in India is not known, it is observed more frequently among individuals with skin Type IV-VI, especially in women of Hispanic, Carribean, and Asian origin, who live in areas of intense ultraviolet radiation (UVR).  Melasma is more common in women of childbearing age, although men also suffer from the condition and account for 10% of the cases. 
There are countless factors involved in the etiology of the disease, but none of them can be mentioned as the only factor leading to its development. These include genetic influences, exposure to UVR, pregnancy, hormone therapy, cosmetics, phototoxic drugs and chemicals (mustard oil), endocrinopathies, emotional factors, anticonvulsive drugs, and others with historic value.  However, it seems that the genetic predisposition and exposure to sun radiation play an important role, considering that melasma lesions are more evident during or shortly after periods of exposure to the sun. 
Melasma may present as freckle-like spots or larger flat brown patches. Several distinct patterns include centro-facial pattern involving forehead, cheeks, nose and upper lips, malar pattern involving cheeks and nose, less common patterns include mandibular pattern, involving ramus of the mandible, lateral cheek and brachial pattern. 
Though there are a number of studies describing the epidemiology and etiological factors, there is a paucity of studies on melasma in North Indians. Our study is aimed at studying the epidemiology, clinical pattern and etiological factors associated with melasma in North Indian population.
| Methods|| |
Two hundred consecutive patients attending the dermatology out-patient department (OPD) between September 2013 and February 2014 of tertiary care hospital with a clinical diagnosis of melasma were enrolled for the study.
The demographic data regarding age, sex, duration of melasma, and family history were noted. The data of various provocative factors such as sun exposure, pregnancy, oral contraceptive pills, cosmetics, use of mustard oil and history of use of topical corticosteroids (TCS) were recorded.
Clinical evaluation was done and depending upon the distribution of lesions, they were classified under centro-facial, malar, mandibular, lateral cheek and brachial patterns. All the methods carried out were in accordance with ethical standards of the institute and approval.
| Results|| |
There were 173 females and 27 males with an age range of 18-60 years. Most common age group affected was 20-39 years (64%). It was more common in women, with a female to male ratio of 6.4:1 approximately. The mean age of presentation was 32.9 years, and average duration of its presence was 1.79 years. A positive family history was observed in 50 (29.07%) of females and 4 (14.28%) of males.
Of the 200 patients, 84 (48.84%) of females and 22 (78.57%) of males gave history of their melasma exacerbation during sun exposure. Out of 173 female patients, 63 (36.4%) of them reported their onset of melasma during pregnancy. Only 7.5% of the female patients took oral contraceptive pills during the disease process in our study. 30 patients (15%) used make-up on a regular basis. History of use of mustard oil in cooking/body massage was present in 93 (54.07%) of females and 9 (32.14%) of male patients. 78 (45.35%) of female patients and 8 (28.57%) of males reported use of TCS/over-the-counter (OTC) products in the past [Table 1].
|Table 1: Dermographic distribution aetiological factors of study population|
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According to the pattern of melasma, the centro-facial pattern was the most common [Figure 1]; seen in 132 (76.74%) of females and 4 (14.28%) of males; malar pattern was the next most common observed in 24 (85.71%) of males and 24 (16.23%) of females [Figure 2]. Other patterns observed were mandibular [Figure 3] (3.5%), lateral cheek [Figure 4] (1.5%) and brachial (1%) [Figure 5]. In males most common pattern observed was malar (85.71%) [Table 2].
|Figure 1: Centro-facial pattern of melasma in middle-aged elderly female|
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| Discussion|| |
Melasma is an acquired hyper-pigmentary disorder of the skin. It is the most common pigmentary disorder in Indian population.  In a survey of 2000 black patients seeking dermatologic care in private practice, the third most commonly cited skin disorder was pigmentary problem of which post inflammatory hyper-pigmentation, melasma and vitiligo were diagnosed most often. 
The average age of melasma patients was 32.9 years in our study, compared to 33.45 years reported in a study from the eastern population and 42.3 years, reported in a study from Singapore.  Melsma is more common in women. We found melasma in 14% of men, compared to 19.87% in the study from the eastern population of India and 4.4% in a study from Singapore.  This study showed that the average duration of melasma was 1.79 years that is lower than reported in other studies. A genetic predisposition is a major factor in the development of melasma. Identical twins have been reported to develop melasma when exposed to similar environmental conditions.  This is supported by our study as positive family history was observed in 29.07% of our female patients and 14.28% of males that was in correlation with previously reported studies.
The interaction of hormones and UVR can be illustrated in melasma. UVR on human skin induces the production of alpha-melanocyte stimulating hormone (α-MSH) and adrenocorticotropic hormone (ACTH) in melanocytes and keratinocytes. α-MSH stimulates the activity of tyrosinase and in vivo melanin synthesis and the synthesis of melanocytes through melanocortin 1 receptor (MC1-R).  Other reports indicate that the irradiation of melanocytes with UVR increases MC1-R mRNA levels. Moreover, the synthesis of many epidermal factors, including α-MSH, ACTH and endothelin-1, is increased by the exposure to UVR, suggesting an important influence of these mediators on the response of melanocytes to sunlight.  In our study, 78.57% of male patients and 48.84% of females had sun exposure, which they felt was an aggravating factor. This was slightly more in relation to previously reported studies because majority of our patients were outdoor workers. 
High estrogen and progesterone levels have been implicated in causing the melasma, based on frequent association of melasma with pregnancy, use of oral contraceptive pills and hormone replacement therapy in postmenopausal women. However, the mechanism of this interaction has not been fully elucidated. In vitro studies have shown that cultured human melanocytes express estrogen receptors (ERs) with higher expression in the facial areas as compared with other regions. This receptor distribution may explain the preferential location of melasma.  Estradiol increases the levels of tyrosinase, tyrosinase-related protein 1 and tyrosinase-related protein 2, the enzymes involved in human eumelanogenesis.  Although, estrogen has been hypothesized to be central in the pathogenesis only few studies have been done to support the view. In our study, 36.4% of our female patients reported onset of melasma during pregnancy, which is higher than reported in previous studies (22.4%). History of use of oral contraceptives was present only in 15 (7.5%) of patients, but none reported precipitation/exacerbation of melasma with them.
Use of heavy cosmetics, perfumes, etc., that contain psoralen derivatives or hexachlophane which is photodynamic may cause hyper-pigmentation of the face.  In our study, 15% of patients gave a history of regular use of heavy makeups. This association was previously reported by Grimes in 1995.
About 54.07% of females and 32.14% of males in our study reported use of mustard oil, either as a massaging oil/in cooking. In a study carried out by Sarkar et al. [Table 3] use of mustard oil was observed in 43.9% of men and 31.4% of women.  Difference in observed values was because we also included the use of mustard oil in cooking while in other study only topical application of mustard oil was considered as aggravating factor. Mustard oil is derived from the seeds of the mustard plant, which belong to family Brassicaceae.  It is composed of fatty acids like oleic acid, linoleic acid and erucic acid. Erucic acid is considered toxic. Mustard oil is used for body massage and cooking mainly in northern states of India, in chief contrast to coconut oil used in Southern States.  Contact hypersensitivity occurs because of allyl isothio-cyanate, a chief antigen in mustard oil, capable of inciting contact dermatitis.  It is also a common photosensitizer in the setup of North Indians. This can lead to the appearance of facial pigmentation. Although it was used by large number of patients in our study, its role in the causation of melasma is still unclear and needs to be substantiated by further studies.
In our study, 45.35% of females and 28.57% of males gave history of use of TCS alone and OTC products, and precipitation of melasma by the same. Most of the patients reported temporary lightening, followed by hyper-pigmentation on withdrawal of the product.
According to the pattern of melasma centro-facial was most common observed in 76.74% of the female patients. In men the malar pattern was observed to be most common (85.71%). This is substantiated by most of the studied done in India and abroad. However, study from Singapore reported the malar pattern in 89% of patients.,  Furthermore, an author from South India observed the malar pattern to be most common.  This variation in results might be due to regional and environmental differences. We observed mandibular pattern in 3.5% of patients. Other rare patterns observed were lateral cheek and brachial pattern of pigmentation.
Limitations of our study were inability to delineate the epidermal/dermal type of melasma and inability to relate the association of melasma with various endocrinal diseases because of poor socio-economic status of the patients attending the OPD.
Future research is required to further substantiate the role of hormones (particularly in the context with ER, progesterone receptor status of facial skin) and allergens like mustard oil in causation of melasma.
| Conclusion|| |
Thus to conclude melasma is one of the most common unesthetic dermatoses that leads to great demand for specialized dermatological care. It is much more common in women than men. The main causative factors amongst our patients appeared to be sun exposure, use of mustard oil, TCS/OTC products, pregnancy and familial diathesis. Relationship of melasma with use of mustard oil and hormones needs to be substantiated further. Most common pattern observed in North Indian females was centro-facial, while in males the malar pattern appeared to be most common.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]