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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 35-38

Clinical patterns and epidemiological characteristics of melasma in a tertiary care hospital of Nepal


1 Department of Dermatology and Venereology, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
2 Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal

Date of Web Publication19-Jun-2017

Correspondence Address:
Sabina Bhattarai
Department of Dermatology and Venereology, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5847.208296

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  Abstract 


Background: Melasma is an acquired chronic hypermelanosis of sun-exposed areas which significantly impacts quality of life. There are few epidemiological studies in medical literature concerning the disease, even less in the Nepalese population.
Aims: The present study aimed to investigate the epidemiology of melasma in Nepalese patients and to focus on the clinical manifestations and factors that precipitate this condition.
Materials and Methods: A semi-structured questionnaire was administered to melasma patients treated at a dermatology clinic between 2015 and 2016. Melasma was classified on Wood’s light examination, and the patients were thoroughly examined. Various precipitating and etiological factors for melasma were also documented.
Results: We assessed 138 patients, of whom 25 (18.1%) were males and 113 (81.9%) were females. Most of the patients 63 (45.7%) reported their melasma of less than 1-year duration. The most commonly reported trigger factors were prolonged, intense sun exposure 113 (83.3%), stress 48 (34.8%), pregnancy 42 (30.4%), contraceptive pills 8 (5.8%) and over the counter steroids use in 6 (4.3%) patients. Housewives and the unemployed constituted 63 (45.7%) of patients followed by service holders and business associated in 22 (15.9%) of patients. Family history was seen in 47 (34.1%), and a history of previous treatment sought was seen in 62 (44.9%) patients. The maximum number of respondents 91 (65.9%) had Fitzpatrick type III followed by type IV in 42 (30.4%) patients, and 5 (3.6%) had type V skin photo type. Preferred facial topographies were malar 125 (90.6%), central facial 46 (33.3%), forehead 40 (29.0%), and mandibular 19 (13.8%). The pigmentation on woods lamp showed epidermal in 90 (65.2%) followed by dermal in 29 (21.0%) and mixed in 19 (13.8%) patients.
Conclusions: Melasma is more common in females with a strong history of intense sunlight exposure, pregnancy, and stress being the most common provoking factors. A multifactorial etiology has to be sought for in depth for all patients presenting with melasma.

Keywords: Clinical patterns, melasma, nepal, provocation factors


How to cite this article:
Bhattarai S, Pradhan K, Sharma S, Rajouria EA. Clinical patterns and epidemiological characteristics of melasma in a tertiary care hospital of Nepal. Pigment Int 2017;4:35-8

How to cite this URL:
Bhattarai S, Pradhan K, Sharma S, Rajouria EA. Clinical patterns and epidemiological characteristics of melasma in a tertiary care hospital of Nepal. Pigment Int [serial online] 2017 [cited 2020 Oct 30];4:35-8. Available from: https://www.pigmentinternational.com/text.asp?2017/4/1/35/208296




  Introduction Top


Melasma is a chronic acquired hypermelanosis of the sun exposed areas of the skin particularly the face, characterized by irregular brown macules which are usually symmetrically distributed.[1],[2],[3] It is more prevalent in the darker skin types and accounts for one of the most frequent dermatological visits in our sub continent. Because of its esthetic value and face being the most common site involved, it visibly impairs the quality of life in most patients. There are few epidemiological studies in medical literature concerning the disease, even less in the Nepalese population. This study has tried to focus on the epidemiology of the disease, clinical manifestations and factors affecting the disease.


  Materials And Methods Top


The study was conducted on outpatient department (OPD) patients at a tertiary care center over a period of one year (March 2015–February 2016). The study protocol and all the amendments were reviewed and approved by the institutional review board of the medical college. Informed and written consent were obtained from all patients for being included in the study.

The sample size was calculated at 138, taking prevalence of 10% in the Nepalese population with confidence interval of 95 and margin of error of 0.05.

The demographic data regarding age, gender, occupation, and duration of the disease were noted. The data of different precipitating factors including sun exposure, stress, pregnancy, oral contraceptives, anti-epilepsy drugs, cosmetics, topical steroids, systemic steroids were taken, and associated systemic factors such as epilepsy, pregnancy, endocrine dysfunction, hepatic dysfunction, and nutritional deficiency were also accounted for. Data regarding seasonal variation (summer, winter, rainy) along with family history and previous treatment were taken. Improvement to previous medication was based on subjective assessment of the patients and categorized accordingly as mild, moderate or good.

Clinical evaluation was done, and the distribution of the lesions was recorded as centrofacial, malar, mandibular, and/or forehead, and skin types were recorded as per the Fitzpatrick scale.

Wood’s light examination was used to classify melasma clinically (epidermal, dermal or mixed), and the Melasma Area Severity Index (MASI) was also recorded in all patients.

Data were compiled, and appropriate statistical tools were used to find out the significance of variables.


  Results Top


We assessed 138 patients, of which 25 (18.1%) were males, and 113 (81.9%) were females with a male female ratio of 4.5:1. The age of the patient ranged from 20 to 56 years with a mean of 30.83 ± 7.45 years. The duration of the disease ranged from less than 1 month to 30 years with a mean of 3.26 ± 4.58 years. Sixty-three (45.7%) patients reported that their melasma was less than 1 year duration [Table 1].
Table 1: Duration of melasma

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Housewives and the unemployed constituted 63 (45.7%) of patients followed by service holders and business associated in 22 (15.9%) of patients. A positive family history of melasma was observed in 47 (34.1%) patients. Seasonal variation to melasma was reported in 93 (67.3%) patients. Sixty-six (47.8%) of the patient gave a history of summer exacerbation while winter exacerbation was reported in 27 (19.6%) patients.

Out of the total number of patients, 62 (44.9%) gave history of previous treatment done for melasma, and 41/138 (29.7%) had applied steroids for the same with only mild improvement [Figure 1].
Figure 1: Previous treatment taken by the patients for melasma

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The precipitating factors causing melasma were studied, out of which, sun exposure was the most common cause reported in 115 (83.3%) patients while stress was reported in 48 (34.8%) patients. Pregnancy was reported as a provoking factor in 42 (30.4%) which persisted even after the termination [Table 2]. Prolonged sun exposure, stress, and pregnancy were found to be statistically significant.
Table 2: Precipitating factors associated with melasma in patients

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Malar distribution of melasma was the most common factor seen in 125 patients (90.6%) followed by forehead in 40 (29.0%) patients, centrofacial in 46 (33.3%), and mandibular in 19 (13.8%). Majority of the patients, 91 (65.9%) had Fitzpatrick type III skin while type IV was seen in 42 (30.4%), and type V in 5 (3.6%) patients.

Woods lamp examination showed an epidermal preponderance in 90 (65.2%) patients while dermal was seen in 29 (21.0%) and mixed pattern in 19 (13.8%) patients [Table 3]. On assessing the MASI in all patients, less than 30 were reported in 65 (47.1%) while more than 30 were reported in only 1 (0.7%) patient [Figure 2]. However, when the MASI was correlated with the most common precipitating factors such as chronic sun exposure, stress, and pregnancy, it was not found to be statistically significant.
Table 3: Showing pigmentation on woods lamp examination

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Figure 2: Melasma Area Severity Index in patients

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  Discussion Top


Melasma is a chronic acquired hyperpigmentary condition of the skin, mostly, the centrofacial area. The reported prevalence of Melasma ranges from 4 to 10% of all new cases in dermatology OPD.[1],[2] There are also reports, however, which state melasma to be found in 8.8% of Latin American females[3] and up to 40% population in south East Asia.[4]

It occurs mostly in middle-aged adults. The age of the patients in the present study ranged from 20 to 56 years with a mean of 30.83 ± 7.45 years. This is comparable to the other studies which showed similar findings.[5],[6],[7]

Melasma in our study showed a female preponderance with 81.9% females as compared to 18.1% in males with a male female ratio of 4.5:1. The percentage of female prevalence ranged from 67.9 to 80.13%[5],[6],[7],[8],[9] which is comparable to other studies reported in the literature. This could be explained from the fact due to more esthetic care seeking behavior in females with frequent dermatological consultations as the face was the most commonly involved site.

Johnston et al.[10] pointed out a fact in his study correlating fluctuation of the depth of distribution of the pigmentation in synchrony with the menstrual cycle; however, Grimes points out female sex hormones might not be an essential casual factor for the development of the disease.[11]

The duration of melasma was less than a year, and a positive family history was reported by 34.1% patients in our study which is similar to the result of Yalamanchili et al.[7] A stronger family history has been reported with 61% as was published by Handel et al.[12]

Majority of patients complained of their melasma being exacerbated during the summer season. Sun exposure was found to be the most common precipitating factor in studies done round the globe. Sarkar et al.[13] found it to be the most important factor for causing melasma in males. Sunlight exacerbates melasma has also been stressed upon by Achar and Rathi[5] and similar studies showing chronic sun exposure has been highlighted.[6],[7] Stress was the second common cause though very less reports suggest stress as one of the common factors. Stress could lead to more common frequent application of over the counter drugs and leading to more hyperpigmentation. The cortisol and other hormones secreted during stress could also be explanatory specially the adrenocorticotropic hormone and the melanocyte stimulating hormone.[14] Pregnancy as the provoking factor has been well studied in the literature. Our study showed 30.4% patients stating that their melasma was correlated with pregnancy which is similar to the other studies.[5],[6],[7]

Malar area followed by the forehead was the most common site involved in melasma in our study which was similar to Yalamanchili et al.[7] The pattern, however, presented with regional variation in the study reported by Achar and Rathi[5] and Thappa.[15]

Epidermal type of pigmentation was the most common type and on assessing the severity index less than 30 was reported in 65 patients. MASI score, as reported by Pandya et al.,[16] has only face validity and helps to attempt to measure the size and darkness of pigmentation associated with melasma.


  Conclusion Top


Melasma is more common in females with a strong history of intense sunlight exposure, pregnancy and stress being the most common provocation factors. This was one of the first attempts to look for epidemiological factors associated with melasma in this part of the world. However, a multifactorial etiology has to be sought for in depth for all patients presenting with melasma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Failmezger C. Incidence of skin disease in Cuzco, Peru. Int J Dermatol 1992;31:560-1.  Back to cited text no. 2
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Sivayathorn A. Melasma in orientals. Clin Drug Invest 1995;10:34-40.  Back to cited text no. 3
    
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Werlinger KD, Guevara IL, González CM, Rincón ET, Caetano R, Haley RW et al. Prevalence of self-diagnosed melasma among premenopausal Latino women in Dallas and Fort Worth, Tex. Arch Dermatol 2007;143:424-5.  Back to cited text no. 4
    
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Achar A, Rathi SK. Melasma: A clinico-epidemiological study of 312 cases. Indian J Dermatol 2011;56:380-2.  Back to cited text no. 5
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KrupaShankar DS, Somani VK, Kohli M, Sharad J, Ganjoo A, Kandhari S et al. Cross-sectional, multicentric clinico-epidemiological study of melasma in India. Dermatol Ther (Heidelb) 2014;4:71-81.  Back to cited text no. 6
    
7.
Yalamanchili R, Shastry V, Betkerur J. Clinico-epidemiological study and quality of life assessment in melasma. Indian J Dermatol 2015;60:519.  Back to cited text no. 7
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Hexsel D, Lacerda DA, Cavalcante AS, Machado Filho CA, Kalil CL, Ayres EL et al. Epidemiology of melasma in Brazilian patients: A multicenter study. Int J Dermatol 2013;53:440-4.  Back to cited text no. 8
    
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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. 9
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Johnston GA, Sviland L, McLelland J. Melasma of the arms associated with hormone replacement therapy. Br J Dermatol 1998;139:932.  Back to cited text no. 10
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Grimes PE. Melasma. Etiologic and therapeutic considerations. Arch Dermatol 1995;131:1453-7.  Back to cited text no. 11
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Handel AC, Lima PB, Tonolli VM, Miot LD, Miot HA. Risk factors for facial melasma in women: A case-control study. Br J Dermatol 2014;171:588-94.  Back to cited text no. 12
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Sarkar R, Jain RK, Puri P. Melasma in Indian males. Dermatol Surg 2003;29:204.  Back to cited text no. 13
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Wolf R, Wolf D, Tamir A, Politi Y. Melasma: A mask of stress. Br J Dermatol 1991;125:192-3.  Back to cited text no. 14
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Thappa DM. Melasma (chloasma): A review with current treatment options. Indian J Dermatol 2004;49:165-76.  Back to cited text no. 15
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16.
Pandya AG, Hynan LS, Bhore R, Riley FC, Guevara IL, Grimes P et al. Reliability assessment and validation of the Melasma Area and Severity Index (MASI) and a new modified MASI scoring method. J Am Acad Dermatol 2011;64:78-83.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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