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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 91-95

Correlation of clinicodermatoscopic and Wood’s lamp findings in patients having melasma


1 Department of Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College & AVBR Hospital, Wardha, Maharashtra, India
2 , India

Date of Web Publication14-Dec-2018

Correspondence Address:
Dr. Rupali Dharni
Department of Dermatology, Venereology and Leprosy, OPD-19, Jawaharlal Nehru Medical College & AVBR Hospital, Sawangi Meghe, Wardha 442001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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  Abstract 


Introduction: Melasma is a commonly acquired pigmentary disorder that manifests as symmetric hyperpigmented macules and patches on the face. Aim: To correlate Wood’s lamp and dermatoscopic findings in patients having melasma. Materials and Methods: A total of 80 patients who were clinically diagnosed with melasma were examined under a Wood’s lamp and dermatoscope, and all the findings were recorded and analyzed. Result: The degree of agreement between the Wood’s lamp findings and dermatoscopic findings was found to be substantial as analyzed by kappa statistics with K = 0.813 and P = 0.0001 (significant). Conclusion: Dermatoscopy is advocated globally as a screening and diagnostic procedure for melasma and other pigmentary disorders, especially for earlier therapeutic intervention targeting different stages and mechanisms involved in pathogenesis.

Keywords: Correlation, dermoscopy, melasma, Wood’s lamp


How to cite this article:
Dharni R, Madke B, Singh AL. Correlation of clinicodermatoscopic and Wood’s lamp findings in patients having melasma. Pigment Int 2018;5:91-5

How to cite this URL:
Dharni R, Madke B, Singh AL. Correlation of clinicodermatoscopic and Wood’s lamp findings in patients having melasma. Pigment Int [serial online] 2018 [cited 2019 Mar 23];5:91-5. Available from: http://www.pigmentinternational.com/text.asp?2018/5/2/91/247508




  Introduction Top


Melasma is a commonly acquired pigmentary disorder. Hypermelanosis manifests as symmetric brown-colored macules and patches on the face. Knowing the depth of pigmentation helps in the proper framing of the treatment plan. Dermatoscopy is a good objective tool for assessing the level of pigmentation. However, there is a scarcity of evidence in dermatology literature demonstrating the correlation between dermatoscopic and Wood’s lamp findings with regard to melasma. Our study was conducted with the purpose of establishing a correlation between dermatoscopic and Wood’s lamp findings in the case of melasma. A polarized dermatoscope allows the observation of the vascular components, which may be relevant in terms of future prospects for pathogenesis and therapeutic consideration.


  Materials and methods Top


A cross-sectional observational study was conducted at the outpatient section of the Department of Dermatology of a tertiary care rural hospital attached to a teaching institute in central India. The study was conducted after the approval of the Institutional Ethics Committee. The study was conducted according to good clinical practice (GCP) guidelines. A total of 80 patients were enrolled for a duration of 1 year (from September 2016 to August 2017). Written informed consent was obtained from all the patients for voluntary participation and photographs. Patients diagnosed to have melasma on clinical grounds were enrolled after considering various inclusion and exclusion criteria. After enrolment, a detailed demographic profile and clinical history was obtained from each of the study participants. A well-trained expert performed a thorough cutaneous examination. Melasma was classified clinically on the basis of the pattern of distribution. Clinical photographs were obtained using a Nikon® digital single lens reflex camera. The severity of melasma was assessed with the help of validated scoring system—Melasma Area Severity Index. All study participants were examined by an expert using an artificial Wood’s lamp (made by Derma India, Chennai, India) to assess the depth of pigmentation. The patients were classified to have epidermal, dermal, and mixed type of melasma. A dermatoscopic examination of melasma was performed using Denolite® AD 4113 dermoscope (under 90× magnification and no contact fluid) with an image capturing software. All clinical, Wood’s lamp, and dermatoscopic images were saved in jpeg (Joint Photograph Expert Group) format. The dermatoscopic classification of melasma was done on the basis of definitive pigmentary pattern.[1] According to dermatoscopy, melasma presents in the following patterns: epidermal melasma presents as regular pigment network with a brownish homogenous pigmentation, dermal melasma presents as grayish brown or grayish black pigmentation with irregular pigment network, and mixed type shows the features of both epidermal and dermal types. A P-value of <0.05 was considered to be statistically significant. Wood’s lamp and dermatoscopic findings were analyzed using kappa statistics, and correlation was established.


  Results Top


In our study of 80 patients, 70 (87.50%) patients were females and 10 (12.50 %) patients were males. The mean age of the study population was 34 years. Of the 80 patients, 38 (47.5%) patients had centrofacial pattern, 31 (38.75%) had malar pattern, and the rest 11 (13.75%) had mandibular pattern.

As per Wood’s lamp examination, out of the 80 patients, 39 (48.75%) patients had epidermal melasma, 36 (45%) patients had dermal melasma, and 5 (6.25%) patients had the mixed type of melasma.

Dermatoscopic evaluation of the melasma showed that 46 (57.5%) were of epidermal type with regular pigment network with light brown homogenous pigmentation, 29 (36.25%) were dermal type with grayish brown or grayish black pigmentation with irregular pigment network, and 5 (6.25%) were of mixed type showing the mixed features of both dermal and epidermal types with a diffuse reticular pigmentation of brownish or grayish black patch.

Correlation analysis between Wood’s lamp findings and dermatoscopy findings was performed in 56.25% of the patients [Figure 1],[Figure 2],[Figure 3], and the degree of agreement between the Wood’s lamp findings and dermatoscopic findings was found to be substantial as analyzed by kappa statistics [Table 1].
Figure 1: Correlation between clinical, Wood’s lamp (accentuation of pigment), and dermatoscopic findings (regular pigment network with a brownish homogenous pigmentation) in a patient with clinical epidermal melasma

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Figure 2: Correlation between clinical, Wood’s lamp (no accentuation of pigment), and dermatoscopic findings (grayish brown or grayish black pigmentation with irregular pigment network) in a patient with clinical dermal melasma

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Figure 3: Correlation between clinical, Wood’s lamp (Wood’s light enhances the color contrast in some areas), and dermatoscopic findings (diffuse reticular pigmentation of brownish or grayish black irregular patches; mixed features of both epidermal and dermal patterns) in a patient with clinical mixed melasma

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Table 1: Correlation between Wood’s lamp findings and dermatoscopic findings

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  Discussion Top


Melasma is a commonly acquired pigmentary disorder that manifests as symmetric brownish macules and patches on the face. It occurs on the sun-exposed areas of the body (usually the face, neck, and arms). It has a considerable impact on the quality of life of the affected patients. Etiological factors to melasma include exposure to ultraviolet (UV) light, genetic predisposition,[2] pregnancy,[3] the use of oral contraceptives,[4] and endocrine dysfunction or hormone treatments.[5],[6] Cosmetics and drugs containing phototoxic agents (e.g., anticonvulsant medications) have also been linked to melasma.[7] The release of melanocyte-stimulating hormone, which can be influenced by stress, suggests that melasma can be stressed induced in some cases.

Exposure to UV light is the most common etiologic factor. In our study, sun exposure was a strong aggravating factor in patients, that is, 100% of the patients reported a history of sun exposure. Similarly, Pathak[8] had also reported sun exposure as a trigger factor in all patients in his study.

The prevalence of melasma varied between 1.5 and 33.3% depending on the population. Worldwide, its prevalence during pregnancy was reported to be around 50–70%.[9] The incidence of melasma in pregnant women with white skin is reported to be more than 50%. However, in Indian studies, it was found to be nearly 10%.[10]

Melasma is more common in women as compared to men.[10] Similarly, in our study of 80 patients distributed according to their gender, it was observed that 70 (87.50%) patients were females while 10 (12.50 %) patients were males. The mean age was 34 years in this study, which was higher than the mean age observed in a study by Khunger et al.[11]

On the basis of the clinical presentation of lesion, melasma is of the following types: centrofacial, malar, mandibular, and mixed. Clinically, centrofacial melasma is the most common worldwide, but in India, the malar pattern of melasma is the most common (73%).[12] However, in our study, it was observed that out of the 80 patients, 38 (47.5%) patients had centrofacial pattern, 31 (38.75%) patients had malar pattern, and 11 (13.75%) patients had mandibular pattern.

Wood’s lamp examination was performed in all the participants, and their melasma was classified into epidermal (accentuation of light present), dermal (no accentuation of light), and mixed type (patchy enhancement of light). In our study, according to Wood’s lamp examination, out of the 80 patients, 39 (48.75%) patients had epidermal melasma, 36 (45%) patients had dermal melasma, and 5 (6.25%) patients had the mixed type of melasma. On the basis of an observational study conducted by Manjunath et al. using Wood’s lamp, out of 50 patients, 19 (38%) patients showed complete enhancement and hence their lesion was classified as epidermal, 27 (54%) patients had no enhancement and hence their lesion was classified as dermal, and 4 (8%) patients showed few areas of enhancement and hence their lesion was classified as mixed melasma.[1]

In earlier times, Wood’s lamp examination was thought to be accurate for predicting epidermal versus dermal pigment deposition. However, recent studies have suggested that dermal melanin deposition might be under-recognized by Wood’s lamp.[13] Some studies suggest that Wood’s lamp examination is less specific and might not be an accurate method to determine the depth of melanin pigment deposition.[14],[15] Additionally, collagen and vascular changes, the use of sunscreens, and topical drugs may affect the test, resulting in variable results.[16]Dermatoscopic examination played an important role in our study for accurately identifying the type of melasma based on the location of pigment. The important advantages of dermatoscopy over Wood’s lamp are that its observation and result are not affected by patients’ skin type (color of the skin). In addition, with a dermatoscope, the visualization of collagen and vascular changes is possible.

Epidermal melasma presents as a regular pigment network with a brownish homogenous pigmentation while sparing the follicles and sweat gland openings, which produces exaggerated pseudonetwork pattern with concave borders called the “jelly sign.” With the help of a dermoscope, it is possible to visualize the vascular component, which is present in a large number of patients.[1]

Dermal melasma shows grayish brown or grayish black pigmentation with irregular pigment network. It is less responsive to conventional therapies. Mixed melasma shows the features of both epidermal and dermal types. On dermatoscopy, it shows a diffuse reticular pigmentation of brownish or grayish black irregular patches (mixed features of both epidermal and dermal patterns).

As discussed previously, in our study, out of the 80 patients, 46 (57.5%) had melasma of epidermal type with regular pigment network with light brown homogenous pigmentation, 29 (36.25%) has melasma of dermal type with grayish brown or grayish black pigmentation with irregular pigment network, and 5 (6.25%) had melasma of mixed type showing the mixed features of both dermal and epidermal types with a diffuse reticular pigmentation of brownish or grayish black patches.

In our study, correlation between Wood’s lamp findings and dermoscopy findings existed in 56.25% of the patients, and the degree of agreement between the Wood’s lamp findings and dermatoscopic findings was found to be substantial as analyzed by kappa statistics and presented in [Table 1] (K = 0.813, P = 0.0001). Similarly, in a study conducted by Manjunath et al. with 50 patients enrolled in study, the degree of agreement between Wood’s lamp and dermatoscopy was found to be substantial using kappa statistics with K = 0.833 and P < 0.001.

In our study, there was a minor discordance in diagnostic comparison by Wood’s lamp examination and by dermatoscopy. We observed that 13 (16.25%) patients were having melasma of epidermal type according to Wood’s lamp, which turned out to be dermal on dermatoscopy. In addition, 20 (25%) patients were having melasma of dermal type according to Wood’s lamp, which turned out to be epidermal by Wood’s lamp examination.


  Conclusion Top


A comparative evaluation of Wood’s lamp and dermatoscopy as noninvasive diagnostic tools in diagnosing melasma highlights the utility of dermoscopy and its need for more routine use. Dermoscopy provides comprehensive insight into other pathomechanisms (vascular) involved in the pathogenesis of melasma and is quite fruitful for the objective classification of the subtypes of melasma eliminating the influence of confounding factors. In our study, correlation between Wood’s lamp findings and dermatoscopic findings was present in 56.25% of the patients, and the degree of agreement between the Wood’s lamp findings and dermatoscopic findings was found to be substantial as analyzed by kappa statistics (K = 0.813, P = 0.0001). In addition, in 35 (43.75%) patients, there was no correlation between Wood’s lamp and dermatoscopic findings, leading to minor discordance in both diagnostic techniques. Thus, the widespread application of dermatoscopy is advocated as a screening and diagnostic procedure of melasma and other pigmentary disorders, especially for earlier therapeutic intervention targeting different stages and mechanisms involved in pathogenesis.

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.



 
  References Top

1.
Manjunath KG, Kiran C, Sonakshi S, Agrawal R. Melasma: Through the eye of a dermoscope. Int J Res Dermatol 2016;2:113-7.  Back to cited text no. 1
    
2.
Vazquez M, Maldonado H, Benmaman C, Sanchez JL. Melasma in men: A clinical and histologic study. Int J Dermatol 1988;27:25-7.  Back to cited text no. 2
    
3.
Sodhi VK, Sausker WF. Dermatoses of pregnancy. Am Fam Physician 1988;37:131-8.  Back to cited text no. 3
    
4.
Resnik S. Melasma induced by oral contraceptive drug. JAMA 1967;199:95-9.  Back to cited text no. 4
    
5.
Lufti RJ, Fridmanis M, Misiunas AL, Pafume O, Gonzalez EA, Villemur JA et al. Association of melasma with thyroid autoimmunity and other thyroidal abnormalities and their relationship to the origin of the melasma. J Clin Endocrinol Metab 1985;61:8-31.  Back to cited text no. 5
    
6.
Perez M, Sanchez JL, Aguilo F. Endocrinologic profile of patients with idiopathic melasma. J Invest Dermatol 1983;81:543-5.  Back to cited text no. 6
    
7.
Grimes PE. Melasma: Etiologic and therapeutic considerations. Arch Dermatol 1995;131:1453-7.  Back to cited text no. 7
    
8.
Pathak MA. Clinical and therapeutic aspects of melasma: An overview. In: Fitz Patrick TB, Wick MM, Toda K, editors. Brown Melanoderma. Tokyo: University of Tokyo Press 1986. p. 161-72.  Back to cited text no. 8
    
9.
Sarkar R, Arora P, Garg VK, Sonthalia S, Gokhale N. Melasma update. Indian Dermatol Online J 2014;5:426-35.  Back to cited text no. 9
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10.
Dwari BC, Palaian S, Poudel A, Prabhu S. Clinical profile and management pattern of melasma patients in Western Nepal: A hospital based study. Internet J Dermatol 2009;7:XX.  Back to cited text no. 10
    
11.
Khunger N, Sarkar R, Jain RK. Tretinoin peels versus glycolic acid peels in the treatment of melasma in dark-skinned patients. Dermatol Surg 2004;30:756-60.  Back to cited text no. 11
    
12.
Chatterjee M, Vasudevan B. Recent advances in melasma. Pigment Int 2014;1:70-80.  Back to cited text no. 12
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13.
Katasambas A, Antoniou C. Melasma: Classification and treatment. J Eur Acad Dermatol Venereol 1995;4:217-23.  Back to cited text no. 13
    
14.
Grimes PE, Yamada N, Bhawan J. Light microscopic, immunohistochemical, and ultrastructural alterations in patients with melasma. Am J Dermatopathol 2005;27:96-101.  Back to cited text no. 14
    
15.
Sarvjot V, Sharma S, Mishra S, Singh A. Melasma: A clinicopathological study of 43 cases. Indian J Pathol Microbiol 2009;52:357-9.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Ortonne JP, Passeron T. Melanin pigmentary disorders: Treatment update. Dermatol Clin 2005;23:209-26.  Back to cited text no. 16
    


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