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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 77-82

A clinical study of melasma and assessment of Dermatology Life Quality Index at a tertiary health care center in South India


Department of Dermatology, Sri Ramachandra University, Chennai, India

Date of Web Publication27-Dec-2016

Correspondence Address:
Dr. A K Bubna
Assistant Professor, Department of Dermatology, Sri Ramachandra University, Chennai - 600 116
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5847.196298

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  Abstract 

Background: Melasma is a common acquired hypermelanosis, notorious for its recalcitrant nature. Though benign in nature, it could significantly affect the quality of life in some patients. Therefore, apart from pharmacologic management in cases of resistant melasma, the need for psychologic counseling would be imperative to improve the quality of life in such patients.
Aim: To analyze the clinical patterns of melasma along with all other demographic parameters followed by Wood’s lamp (WL) examination, Melasma Area and Severity Index (MASI) scoring and assessment of Dermatology Life Quality Index (DLQI) in all the participants of our study.
Methods: A prospective, observational and descriptive study done over a period of 7 months in 175 freshly diagnosed females with melasma above 18 years of age.
Results: Majority of the patients with melasma were in the 31–40 year age group (44%), followed by 21–30 (26.9%) and 41–50 (16.6%) years. The duration of melasma in most of our patients was below 1 year. Sunlight (48.5%) appeared to be the major precipitating factor followed by cosmetics (22.2%). A significant association with hypothyroidism was demonstrated amongst our participants. A positive family history was noted in 54.85% of the study subjects. The dermal variant was the most common type of melasma that was observed. The mean MASI score observed was 5.3 and the mean DLQI seen in our study was 1.46.
Conclusion: Melasma is common in middle-aged females. Solar radiation constitutes a major risk factor for melasma. Hypothyroidism appears to have a significant association with melasma. It is important to evaluate the DLQI in all patients with melasma to holistically manage these patients.

Keywords: Clinical, dermatology life quality index, melasma


How to cite this article:
Suthanther C B, Bubna A K, 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;3:77-82

How to cite this URL:
Suthanther C B, Bubna A K, 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 [serial online] 2016 [cited 2020 Jan 26];3:77-82. Available from: http://www.pigmentinternational.com/text.asp?2016/3/2/77/196298

C. B. Suthanther, A. K. Bubna
Both authors 1 and 2 have contributed equally for the compilation of the manuscript and therefore are entitled equally for first authorship.



  Introduction Top


Melasma is a chronic, acquired hyperpigmentary condition of the skin characterized by blotchy, brown macules generally with a symmetric pattern of distribution, over photo-exposed parts of the body, mainly the face, and usually involving Fitzpatrick skin types III–V.[1] Melasma constitutes approximately 1–4% of our Dermatology outpatient load in total and affects nearly all ethnic groups with an increased propensity amongst Asians and Hispanics.[2],[3] Constant exposure to solar radiation has been implicated to play a major role in the development of melasma, though other precipitants such as cosmetics and phototoxic drugs cannot be ignored.[4] This clinical entity, though easily diagnosable, a concrete treatment culminating in permanent resolution still remains an enigma. In cases associated with a high Melasma Area and Severity Index (MASI) score the disorder could even considerably affect patient psychology. Therefore while managing melasma, apart from the therapeutic management a good psychological support also warrants introduction of appropriate holistic patient management. Therefore it is essential to evaluate the Dermatology Life Quality Index (DLQI) in all melasma patients.


  Methods Top


This was a prospective, observational and descriptive hospital based study done in the department of Dermatology of our institute from January to July 2013. It was conducted to analyze the clinical patterns of melasma, the age distribution and precipitating factors for the same, which was followed by melasma assessment using the MASI score and evaluating the DLQI in these patients. The study population included 175 freshly diagnosed female patients with melasma, above the age of 18 years, who attended the Dermatology outpatient department during the study period. After enrolling the participants in our study, a detailed history with emphasis on sun exposure, intake of any systemic drug and presence of any underlying systemic disease was taken. Following this, the diabetic profile and thyroid profile of all patients were assessed. This was succeeded by clinical examination and Wood’s lamp (WL) examination. The extent of melasma was then evaluated using MASI scoring, and the study was concluded by asking all the participants to fill up a questionnaire in order to assess the DLQI, for which scores were given based on the patients response to the questions in the questionnaire [Figure 1],[Figure 2],[Figure 3]. As all variables assessed were qualitative, they were expressed as percentage values.
Figure 1: The DLQI questionnaire used in our study

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Figure 2: Scoring system of the DLQI questionnaire

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Figure 3: Scoring system evaluation of the DLQI questionnaire

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  Results Top


Out of the 175 females with melasma who were enrolled in our study, 44% were in the age group between 31 and 40 years, 26.9% in the age group between 41 and 50 years, 16.6% in the age group between 21 and 30 years, and 9.7% in the age group between 51 and 60 years.

The duration of melasma in most of the cases was less than 1 year; details of which have been summarized in [Table 1].
Table 1: Duration of melasma of the participants in our study

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The major precipitating factors identified in our participants were UV radiation (44.5%), followed by cosmetics (22.2%), idiopathic condition (21.14%), drugs (5.1%) and pregnancy (2.8%). Out of the cosmeceuticals used, the most common agents identified were fairness creams (48.72%), turmeric (43.59%), hair dye (5.13%) and sandalwood paste (2.55%). The drug implicated in all our patients with drug-induced melasma was oral contraceptive pills.

In 54.3% of our participants no irregularities in menses were witnessed. Amongst 10.9% of our participants, menstrual abnormalities such as menorrhagia and polymennorhoea were identified. 25.1% of our study patients were menopausal with 6.9% having had a hysterectomy and 2.9% of our study subjects being pregnant.

Associated hypothyroidism was noted in 46 participants, followed by diabetes mellitus in 32 candidates, hypertension in 15 and hyperlipidemia in 11 patients. The remaining 89 had no underlying systemic disorder.

A positive family history was obtainable from 54.85% of the participants in our study.

The commonest phenotype observed was the malar variant seen in 61.14% of the cases, followed by centrofacial type in 37.71%, and mandibular type in the remaining 1.14% cases.

WL examination [Figure 4] revealed that the dermal variant constituted 61.14% of our patient load, with the epidermal and mixed variants depicting values of 36% and 2.85%, respectively.
Figure 4: A comparative picture revealing how clinically melasma appears with the findings observed under Wood’s lamp demonstrating pigment accentuation in epidermal type of melasma

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The mean MASI score in our study was 5.3. DLQI did not demonstrate any significant impact in the day-to-day life of 73.71% of our patients, with a mild effect being identified in 23.42% of our patients and a moderate effect in the remaining 2.85%.


  Discussion Top


Melasma constitutes a major disorder of pigmentation in most of the Dermatology clinics, notorious for its recalcitrant nature. It may pose to hinder normal social life in few individuals leading to a reduced sense of well being.

In the present study of 175 cases of melasma, the age of patients ranged from 19 to 63 years, with the mean average age being 38.43 years. This was very similar compared to other studies done in this regard both in India and abroad[5],[6],[7],[8],[9] and has been summarized in [Table 2].
Table 2: Various comparative melasma parameters of our study with respect to other previous studies

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The fact that melasma is a disorder of the middle-aged population is very clear in most of the studies except for the study by Achar and Rathi,[6] wherein the disorder was noted in a slightly younger age group.

The mean duration of melasma in our study was 3.64 years, which was comparable to the studies done by Kulandaisamy et al.[5] with a mean duration of 4.14 years and Achar and Rathi,[6] who demonstrated a mean duration of 3.59 years.

The major precipitating factor for melasma in our study was exposure to solar radiation. This was at par with most of the other studies[6],[7],[8],[9] in this regard, details of which have been summarized in [Table 2].

An association of hypothyroidism was witnessed in 26.27% of our participants, which was much higher when compared to the study done by Dogra et al.,[10] who demonstrated an association of 14.28%, Yazdanfer and Hashemi,[11] who demonstrated an association of 11.1%, KrupaShankar et al.,[7] who depicted hypothyroidism to be present in 11% of their melasma patients and Achar and Rathi,[6] who identified an association of only 6.41%. Our findings here, thereby, make us speculate that the relationship with melasma and hypothyroidism could actually be much higher than what was previously thought of.

A decipherable genetic link of 54.85% was observed in our study. This was almost similar to the study conducted in Thailand.[9] However, on comparing this to other Indian studies[5],[6],[7] and the data given by Goh and Dlova,[8] our finding was significantly higher and has been summarized in [Table 2].

The clinical morphology that pre-dominated our study was the malar variety (61.14%) followed by the centrofacial variant (38.86%). Similarly Kulandaisamy et al.[5] and Sardesai et al.[12] also demonstrated malar melasma in 51.9% and 65% of their patients, respectively. However, according to Achar and Rathi[6] and KrupaShankar et al.,[7] malar melasma constituted 43.26% and 39% of the study population, respectively, with the centrofacial type showing a greater number.

WL examination revealed 61.14% of our participants to have the dermal variant of melasma, the remaining being epidermal with no mixed type being identified in our study. Even Achar and Rathi[6] and Kulandaisamy et al.[5] demonstrated the finding of dermal melasma being the most common type identified with a value of 54.48% and 91.3% respectively. The findings of Kulandaisamy et al.,[5] were much higher when compared to our study and the study done by Achar and Rathi.[6]

The mean MASI score in our study was 5.3, almost comparable to the findings obtained by Kulandaisamy et al.[5] of 5.2. However, Leeyaphan et al.[9] from Thailand obtained a mean MASI score of 14.8, which was much higher compared to our study. Whether this was related to demographic characteristics needs further elaboration.

The mean DLQI score in our study was 1.46 in comparison to 7.3 from a study from Thailand.[9] The difference in scores could have been due to the predominance of malar melasma in our study, difference in lifestyle of both study groups, freshly diagnosed cases in our study with majority of patients having the disease for less than one year and most of our participants having a lower socio-economic status.

On analyzing our study population, there were a few questions that needed contemplation. Though there were many patients utilizing fairness creams and turmeric, yet the results obtained demonstrated that they were minimally bothered by their disease. This could be explained by the fact that, in Tamil Nadu, India, it is an age-old trend in majority of females to apply turmeric and fairness creams on their faces as a part and parcel of their daily activity, little realizing that this eventually could prove to be a precipitating factor for melasma. In our study, the highest MASI score obtained was 10.9 and the lowest was 0.6, with the mean DLQI being 1.46. However, in most of the patients, the MASI score and the DLQI did not correlate. Even patients with a higher MASI score presented with low DLQI values, depicting that the disease did not have much of an effect on patient’s quality of life. The authors feel that this could have been due to the Fitzpatrick skin types 5 and 6 in nearly all patients of the study sample, wherein the contrast between melasma and normal skin was not so clearly discernable when compared to fairer skin types. Further, as most patients in our study belonged to the lower socioeconomic strata that again could have been a factor for these contrasting results.


  Conclusion Top


To conclude, melasma appears to be a common dermatologic disorder notorious for its resistant quality to treatment. It is a disorder mainly affecting middle-aged females with a definite genetic link and exacerbated with exposure to solar radiation. Certain systemic disorders could predispose to melasma development like hypothyroidism, and the association of which was very high in our study, when compared to other studies done in the past. Examination using WL is essential to classify the type of melasma, which could also serve as a prognostic indicator of the disease and at the same time help in planning further line of management. Evaluating the severity of melasma using the MASI score further enables the clinician to tailor his/her treatment individually for each patient. Assessing the DLQI for melasma patients, further equips the clinician in managing patients with melasma, as it takes into consideration the emotional stability of the patient. Though in our study DLQI assessment was not significant, yet the importance of DLQI assessment cannot be underestimated owing to its holistic approach in managing melasma patients. It stresses on the necessity for good psychological support along with medical management to improve the quality of life in these patients, which should not be neglected by clinicians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sheth VM, Pandya AG. Melasma: A comprehensive update: Part I. J Am Acad Dermatol 2011;65:689-97.  Back to cited text no. 1
    
2.
Pasricha JS, Khaitan BK, Dash S. Pigmentary disorders in India. Dermatol Clin 2007;25:343-522.  Back to cited text no. 2
    
3.
Sivayathorn A. Melasma in Orientals. Clin Drug Investig 1995;10(Suppl 2):24-40.  Back to cited text no. 3
    
4.
Grimes PE. Melasma. Etiologic and therapeutic considerations. Arch Dermatol 1995;131:1453-7.  Back to cited text no. 4
    
5.
Kulandaisamy S, Thappa DM, Gupta D. Exogenous ochronosis in melasma: A study from south India. Pigment Int 2014;1:17-22.  Back to cited text no. 5
  Medknow Journal  
6.
Achar A, Rathi SK. Melasma: A clinico-epidemiological study of 312 cases. Indian J Dermatol 2011;56:380-2.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Krupa Shankar DS, Somani VK, Kohli M, Sharad J, Ganjoo A, Kandhari S et al. A cross-sectional, multicentric clinico-epidemiological study of melasma in India. Dermatol Ther (Heidelb) 2014;4:71-81.  Back to cited text no. 7
    
8.
Goh CL, Dlova CN. A retrospective study on the clinical presentation and treatment outcome of melasma in a tertiary dermatological referral centre in Singapore. Singapore Med J 1999;40:455-8.  Back to cited text no. 8
    
9.
Leeyaphan C, Wanitphakdeedecha R, Manuskiatti W, Kulthanan K. Measuring melasma patients’ quality of life using willingness to pay and time trade-off methods in Thai population. BMC Dermatol 2011;11:16.  Back to cited text no. 9
    
10.
Dogra A, Dua A, Singh P. Thyroid and skin. Indian J Dermatol 2006;51:96-9.  Back to cited text no. 10
  Medknow Journal  
11.
Yazdanfer A, Hashemi B. Association of melasma with thyroid autoimmunity: A case control study. Iran J Dermatol 2010;13:51-3.  Back to cited text no. 11
    
12.
Sardesai VR, Kolte JN, Srinivas BN. A clinical study of melasma and a comparison of the therapeutic effect of certain currently available topical modalities for its treatment. Indian J Dermatol 2013;58:239.  Back to cited text no. 12
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]


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