|Year : 2019 | Volume
| Issue : 2 | Page : 96-101
A clinico-epidemiological study of facial melanosis at a tertiary care center in Gujarat
Pooja Agarwal, Krishna Gajjar, Amit Mistry
Department of Skin & VD, Smt SCL General Hospital, Ahmedabad, Gujarat, India
|Date of Web Publication||19-Dec-2019|
Assistant Professor Pooja Agarwal
Department of Dermatology, Smt Shardaben General Hospital, Saraspur, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Background: A group of heterogenous entities having the common clinical feature of altered facial pigmentation have been informally called as facial melanoses. Since, the cosmetic disfigurement is easily visible, it has a lot of impact on the psychological well being of the person. Aim: To assess the patients of facial hyper pigmentary disorders for demographic , etiological and clinical profile. Methods: A prospective clinical study was conducted in a tertiary care center in Gujarat over period of 6 months. 107 patients with facial hyper pigmentary disorders were assessed by detailed history and clinical examination. Results: In our study, most common age group which sought treatment was 30-50 years. Female were predominantly affected (2.5: 1). Six different facial melanosis were observed which included melasma, postinflammatory hyperpigmentation , nevus of ota, exogenous ochronosis, Addison’s disease, and Riehl’s melanosis. Melasma was the most common disorder reported by 94 patients out of 107. Limitations: Dermoscopy could not be done to resource constraint. Conclusion: Increase in awareness and concern with appearance has led to an increase in reported incidence of facial melanosis in both sexes. Prior application of over the counter products poses difficulty in correct evaluation and treatment. Psychological evaluation forms an integral part of the treatment of these patients.
Keywords: Facial melanosis, melasma, prevalence
|How to cite this article:|
Agarwal P, Gajjar K, Mistry A. A clinico-epidemiological study of facial melanosis at a tertiary care center in Gujarat. Pigment Int 2019;6:96-101
| Introduction|| |
Facial melanoses (FM) are a group of heterogeneous entities that share a common clinical feature of increased pigmentation of face. They are commoner in Fitzpatrick skin types III and IV and form a major portion of patients visiting a dermatologist. Though the pathogenesis is not clearly understood in many cases, both light and photosensitizing chemicals seem to play an important role.
Unlike most internal illnesses, skin diseases, especially those on face, are often immediately visible to others and therefore lead to significant psychological consequences.,,
Common causes of FM include melasma, Riehl melanosis, erythema dyschromicum perstans (EDP), lichen planus pigmentosus, nevus of Ota, postinflammatory pigmentation, and miscellaneous causes including erythromelanosis peribuccale pigmentaire of Brocq. This study was done to assess the clinical and epidemiological features of facial melanosis in patients visiting our tertiary care hospital. We did not include any hypopigmented lesions in our study and remained confined to hyperpigmented lesions only.
| Materials and Methods|| |
This was an observational study conducted over a period of 6 months from July 2017 to December 2017 in the dermatology department in Smt Shardaben General Hospital in Ahmedabad, Gujarat. All the patients visiting the outpatient department for facial pigmentation disorders were enrolled in the study on their first visit. Informed consent was taken for enrollment in the study as well as for photographic documentation. Detailed clinical history including age of onset, sex, duration of disease, any predisposing factors and any prior treatment taken was noted. Clinical examination was done to note the distribution of lesions, color of pigment, and any associated findings. Other body areas were examined when indicated. Hematological investigations like thyroid profile were done when needed. Clinical photographs were taken in all cases. Patients with pigmentation restricted to periorbital area and not willing to be photographed were not included in the study.
| Results|| |
The study comprised of 107 patients of increased facial pigmentation. Maximum number of patients were between 30 and 50 years of age. The youngest patient was 19 years old and the oldest was 65 years old. The mean age of presentation was 35.3 years. Female predominance was seen, with 76 patients being females and 31 males (F:M ratio = 2.5:1). The distribution of pigmentation was categorized as centrofacial, malar, mandibular, perioral, and periorbital, in which centrofacial was the most common pattern (75.5%) and was most commonly seen in melasma. Though the distribution pattern of the pigmentation varied between patients, a regular expected pattern of the disease was maintained. Almost all cases reported a gradually progressive darkening of the pigmentation. In our study, we found six different causes of facial hyper melanoses. These were melasma ([Figure 1]), Riehl melanosis ([Figure 2]), nevus of Ota ([Figure 3]), postinflammatory hyperpigmentation ([Figure 4]), Addison disease ([Figure 5]), and exogenous ochronosis ([TABLE 1]). In our study, melasmic pigmentation was the most common (87.8%), followed by postinflammatory hyperpigmentation (5.6%), nevus of Ota (2.8%), and exogenous ochronosis (1.87%). One patient each of Addison disease and Riehl melanosis were seen.
|Figure 2 Riehl melanosis: typical hyperpigmented lesions over the area of application of balm.|
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In melasma, according to distribution of lesions, two clinical patterns were observed. The centrofacial type was the most common, seen in 71 (75.5%) cases, and malar type of pigmentation was seen in 23 (24.4%) cases. Postinflammatory pigmentation did not have any specific pattern and varied according to the previous disease. The most common cause of postinflammatory hyperpigmentation was acne (5.6%), followed by postinfectious etiology like chicken pox and herpes zoster, followed by postprocedural pigmentation.
In patients with Addison diseases, there was diffuse hyperpigmentation involving face, neck, and abdomen. Pressure sites over both elbows, knees, and knuckles were hyperpigmented. Palms, soles, and oral mucosa also showed hyperpigmentation.
Majority of patients had brown colored hyperpigmentation, which indicated epidermal pigmentation, followed by mixed type. This was a clinical observation only.
There was a history of use of over-the-counter creams in 39 (36.4%) cases. Majority of the patients gave history of self-initiated unsupervised application of triple combination creams for skin lightening over an extended period of time.
| Discussion|| |
Facial pigmentary disorders are among the most common group of skin disorders. Being easily visible, they are a source of great psychological distress to the patients. Increased patient concern regarding one’s appearance, greater use of cosmetics, and over-the-counter drugs have led to a steady but steep rise in their incidence and importance in dermatology practice. Depending on the depth of the melanin pigment, three clinical patterns have been described in literature ([TABLE 2]).
|TABLE 2 Types of Hypermelanosis Based on the Depth of Melanin Pigment|
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Our clinic-epidemiological study of various facial hyperpigmentary disorders was completed over a period of 6 months and involved 107 patients.
The age of patients varied from 19 to 65 years and the mean age of was 35.3 years, which is comparable to the study by Hassan et al., where they found the mean age to be 27.40 years. In authors’ opinion, predominant reporting of facial hyper melanosis in this age group may be due to increased awareness over the appearance, peer pressure, and the abnormal fairness standards set by various nonpharmaceutical companies.
Females were affected more than males. Female predominance in facial melanosis is mainly linked to hormonal changes. Changes in estradiol levels are well studied, although controversial causes of increased pigmentation are seen in females. Appearance of new lesions or exacerbation of old lesions during oral contraceptive therapy, pregnancy, and lactation support the hormonal therapy.,
We found ∼28% involvement of men in our study compared to 15.06 and 19.87% in other studies., The higher incidence of male patients in our study could be due to the occupational factors. Most patients coming to our hospital are working in outdoor environment for major portion of the day. Any specific drug intake or local application history was not found in male patients unlike the study by Sarkar et al. 
Patients with facial hypermelanosis were categorized into six groups. Melasma was the most common entity and comprised 87.8% of the cases. Though there were no pregnant females in the study, there was a history of aggravation of facial pigmentation of melasma during pregnancy in 5.6% cases. Similar findings have been reported by Hassan et al., in which 16% of female patients have exacerbation during pregnancy.
We found centrofacial distribution to be the most common pattern in our study, which is comparable to studies by Goh et al. and Sanchez et al. but in contrast to other studies that reported malar to be the most common., This can be explained by regional and environmental variations.
Associated thyroid dysfunction was seen in 1.86% of patient, which is quite low as compared to the study by Hassan et al., where they reported association of thyroid dysfunction with melasma in 10.95% of the patients. 
In 36.4% of our patients, there was a history of application of various cosmetic products, compared to 32.73% of patients in the study by Hassan et al. Postinflammatory hyperpigmentation was the second most common cause of increased facial pigmentation. Most common etiology was secondary to acne vulgaris. We found PIH in 5.6% of the patients in our study. Other studies reported 6.7 and 42.2%., Other causes of PIH that are reported in studies include postprocedural and postinfectious (chicken pox, herpes zoster), which we did not observe at our center.
In our study, we came across three patients having unilateral nevus of Ota. Mucosal involvement was not seen in any case. All were classified as type 1 ([TABLE 3]). No similar family history was present in any case and all presented more than 5 to 9 years after onset of lesions. A gradual increase in size for initial years was reported by all.
We found two (1.86%) patients with exogenous ochronosis in our study. Both had a history of unsupervised use of creams containing hydroquinone and steroids for a prolonged period ranging from 7 months to 1.5 year. The patients had history of improvement in lesions initially and recurrence on stopping the creams, which prompted the prolonged self-use. There was diffuse bluish-gray speckled pigmentation over face, more prominent over cheeks.
Riehl melanosis constituted only 0.93% of total cases. The patient was male and had a history of balm application over forehead and perfumed hair oil since 1 year. Lesions were more pronounced on forehead and temporal regions, which were dark brown in color with gradual fading of color over lower face. An increased incidence of Riehl melanosis in females has been noted by Hassan et al. Sensitization by chemicals in cosmetics has also been seen by Rorsman and Hassan et al.
One patient was diagnosed clinically as Addison disease based on the characteristic distribution of the pigmentation. There was progressive, diffuse cutaneous and mucosal pigmentation. Increased pigmentation of palmar creases and friction sites was also present. The patient gave history of lethargy and weight loss also. Past history of tuberculosis was present. Hematological investigations revealed mild anemia and hyponatremia. Abdomen sonogram showed bilaterally atrophic and adrenals with areas of calcification. Serum cortisol and corticotrophin stimulation test could not be performed due to limitations of resources and the patient was referred to endocrinologist for further care.
| Limitations|| |
All the patients were diagnosed on clinical basis only. Dermatoscopy to study the various clinical patterns could not be done due to limited resources. Histopathological evaluation for confirmation of diagnosis could not be done due to patients’ reluctance. Hematological investigations were not done in all patients.
| Conclusion|| |
Facial melanosis, because of its significant psychological impact, is causing an increasing burden of dermatological patients. Unlike past, male patients seeking treatment for various melanoses are slowly increasing. Melasma is still the most common cause followed closely by others like postinflammatory pigmentation. Riehl melanosis and exogenous ochronosis are other common conditions that result from the increased cosmetic use in both males and females.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[TABLE 1], [TABLE 2], [TABLE 3]