|Year : 2017 | Volume
| Issue : 2 | Page : 98-103
A clinico dermoscopic study of melasma in a tertiary care center
Bisalvadi L Nanjundaswamy, Joice M Joseph, Kalasapura R Raghavendra
Department of Skin and VD, MMCRI, Mysuru, Karnataka, India
|Date of Web Publication||1-Dec-2017|
Joice M Joseph
Department of Skin and VD, MMCRI, Mysuru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Melasma is a known, acquired, pigmentary disorder among females. It is very difficult to treat because of its variable response to treatment and rapid recurrence. Dermoscopy is an essential tool, by which, we can classify melasma based on its colour pattern and other findings.
Aims and Objectives: To classify melasma by dermoscopic examination and correlate dermoscopic findings with the clinical diagnosis.
Materials and Methods: A total of 100 patients attending the out patient department of skin department were included in the study. After obtaining the consent, the patients were examined in detail. The dermoscopic examination was performed, and findings were noted.
Results: Out of 100 patients, who enrolled in this study, 80 patients were females, and 20 patients were males. On dermoscopy, 46 patients showed epidermal pattern, out of which 13 were males and 34 were females. Eighteen patients showed dermal pattern and 36 patients showed mixed pattern on dermoscopy. Between dermoscopic analysis and colour, a significant association was observed (Cramer’s V value = 0.534; P value = 0.000). We found that epidermal pattern was more associated with a light brown colour, whereas, the dermal pattern and mixed pattern were associated with ash grey colour and dark brown colour, respectively. Statistical analysis was performed by using percentage and bar diagrams. Both descriptive and inferential statistics were employed. Cramer’s V test was applied to find out the association using the Statistical Package for the Social Sciences software (SPSS Inc., Chicago, IL, USA).
Conclusion: Dermoscopy can be used to assess the type of melasma by analysing colour pattern, as well as depth of pigmentation and to differentiate between melasma and exogenous ochronosis. From our observations, we conclude that dermoscopy can be used as a tool in the management of melasma and other dermatological disorders.
Keywords: centrofacial type, dermoscopy, epidermal pattern type, malar type, melasma
|How to cite this article:|
Nanjundaswamy BL, Joseph JM, Raghavendra KR. A clinico dermoscopic study of melasma in a tertiary care center. Pigment Int 2017;4:98-103
| Introduction|| |
Melasma is a common, acquired, hyperpigmentary condition of the face characterised by symmetrical and asymptomatic brownish or brownish black macules and patches involving sun-exposed areas. The average age of onset of melasma among Indians was found to be 33.45 years in a study conducted by Achar and Rathi. with 19.87% involvement of men. Till now, various etiological factors have been postulated in the etiopathogenesis of melasma. The major etiological factors include genetic predisposition, ultraviolet (UV) radiation, thyroid disorders, pregnancy, oral contraceptives usage and drugs such as phenytoin. Melasma can be classified based on the depth of melanin pigment accumulation into epidermal, dermal and mixed types. On the basis of the distribution of melasma on face, clinically three patterns are described, that is, centrofacial, malar and mandibular., Nowadays, to assess the level and the pattern of pigmentation in melasma, we are using dermoscope in our practice. Dermoscopy is a non-invasive and in-vivo diagnostic tool, which visualises subtle clinical patterns of skin structures not visible to the unaided eyes. Dermatoscopy term was introduced in 1920 by German dermatologist Johann Saphier, but Goldman was the first person to use it for pigmentary lesions. The colour intensity of melanin and the regularity of the pigment network reveal the density and location of melanin. Melanin pigment appears as a dark brown colour with a well-defined network when located in stratum corneum. Whereas, it shows shades of light brown with an irregular network when located in lower layers of the epidermis and blue or bluish grey colour when located in the dermis. Dermoscopy can be used to determine the depth of melasma, to differentiate it from other conditions causing facial hyperpigmentation, to monitor treatment efficacy and to pick up early complications such as atrophy, telengiectasia and development exogenous ochronosis. In our study, we classified the melasma clinically and correlated with the dermoscopic findings.
| Materials and methods|| |
The study was conducted at the Department of Dermatology, Venereology and Leprology from February 2016 to March 2016 for a period of 2 months. The study was approved by the ethics and research committee of our institution. A total of 100 clinically suspected melasma patients were selected for the study. The patients who have not given consent, along with some have already taken treatment in the last 3 months and patients with the suspicious diagnosis of other facial hypermelanosis were excluded from the study. The complete clinical history was taken from all the patients. Clinical examination of the affected part of the face was performed with a hand lens and the readings were classified according to the distribution and level of depth. Dermoscopic examination was performed using dermlite DL3 dermoscope (3Gen, Dana Point, CA, USA). The features were noted, and the photographs were taken after obtaining consent from patients. Statistical analysis was performed by using percentage and bar diagrams. Both descriptive and inferential statistics were employed. Cramer’s V test was applied to find out the association using the Statistical Package for the Social Sciences software (SPSS Inc., Chicago, IL, USA).
| Results|| |
Out of 100 patients who enrolled in the study, the numbers of male and female patients were 80 and 20, respectively. The patients were in 21–62 years age group. Mean age of onset of melasma was 36.64 with a standard deviation of 9.37. Cramer’s V revealed a significant association between gender and age, where we found that melasma occurred at younger age among males and at middle age among females. Main aggravating factor was sun exposure (64%) followed by cosmetic usage (36%), out of which 22 patients were using daily cream, and 14 patients gave their history of usage of topical steroids. Twelve patients had the history of oral contraceptive usage. Positive family history was present in 35% patients. After clinical examination, 53 patients were of malar type of melasma. Thirteen males and fourty females belonged to malar type [Figure 1] and 47 patients (7 males and 40 females) belonged to centrofacial type [Figure 2]. On dermoscopy, 46 patients showed epidermal pattern [[Figure 3]–scattered islands of brown reticular network with dark fine granules scattered on surface], out of which 13 were males and 34 were females. A total of 18 patients showed dermal pattern [[Figure 4]–uniform skin involvement and no areas of sparing with dark brown to grey hyperpigmented lesions], and 36 patients showed mixed pattern on dermoscopy [Figure 5]. Reticuloglobular pattern was seen in 35 patients, exaggerated pseudo network with granular pigmentation was observed in 18 patients and archiform structures in 21 patients. Exogenous ochronosis, atrophy, and telengiectasias were present in 7, 20 and 35 patients, respectively. Exogenous ochronosis was characterised by brown amorphous areas obliterating the follicular structures rather than just surrounding them [[Figure 6]a]. Other findings observed in exogenous ochronosis were multiple arc like patterns [[Figure 6]b], worm like structures [[Figure 6]c] and wave like pattern [[Figure 6]d]. Between dermoscopic analysis and colour, a significant association was observed (Cramer’s V value = 0.534; P value = 0.000), where we found that epidermal pattern was more associated with light brown colour, dermal pattern was more associated with ash grey colour, and mixed pattern was most associated with dark brown colour [Table 1]. Between dermoscopic analysis and gender, no significant association was found (Cramer’s V value = 0.182; P value = 0.190) [Table 2]. As revealed by chi-square test, no significant association was found between malar and centrofacial patterns. Between dermoscopic analysis and age, a significant association was observed, where we found that the younger age groups showed epidermal pattern, and the middle age group showed mixed pattern (Cramer’s V value = 0.281, P value = 0.015) [Table 2].
|Figure 1: Malar type showing patches of hyperpigmentation over malar area|
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|Figure 2: Centrofacial type showing patches of hyperpigmentation over cheeks, nose, above eyebrows and upper labium|
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|Figure 3: Scattered islands of brown reticular network with dark fine granules scattered on surface suggesting epidermal type on dermoscopy|
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|Figure 4: Uniform skin involvement and no areas of sparing with dark brown to grey hyperpigmented lesions with reticuloglobular pattern, telengiectasia and archiform structures suggesting dermal type on dermoscopy|
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|Figure 5: Mixed type showing feature of both epidermal and dermal pattern on dermoscopy|
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|Figure 6: Showing exogenous ochronosis on dermoscopy. (a) Exogenous ochronosis showing brown amorphous areas obliterating the follicular structures rather than just surrounding them. (b) Multiple arcs like patterns. (c) Worm like structures. (d) Wave like pattern|
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|Table 2: Dermoscopic pattern among different age groups and sex analysis|
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| Discussion|| |
Melasma is a common, acquired, pigmentary condition which commonly occurs in middle-aged females. In our studies, the mean age of patients was 37.63 with an age distribution from youngest 21 to oldest 62, which was very similar to the observation made by Yalamanchili et al. in the same geographic area. In our studies, we noticed that the females were most commonly affected compared to males. Only about 20% of the reported cases were males. Similar observations were also previously reported by Hassan et al. (15.09%), and Achar and Rathi (19.87%)., Middle-aged females were commonly affected (30%), and Cramer’s V revealed a significant association between gender and age, where we found males are at a younger age, and females are at a middle age., It is statistically proved that among the middle-aged females, incidence of melasma is more, which was attributed to an increased sun exposure, variations in internal oestrogen hormone profile and age related changes in dermis. Sun exposure plays a pivotal role in the development of melasma. It is known that upon prolonged sun exposure, melasma exacerbates, and after strict sun protection, the darkness of melasma fades. Melasma is more prevalent among Asians and Hispanic origin and also in Fitzpatricks skin photoype 4–6, especially those who work under intense ultraviolet light., In our study, 36% of the patients were using cosmetic creams including steroidal cream, 14% used oral contraceptive pills and some of the patients had positive family history. It again proves various etiological factors playing a role in the development of melasma. Malar − clinical type of melasma was more common in our study, but centrofacial − clinical type was also observed in 47%, but no mandibular − clinical pattern was noticed. Yalamanchili et al. reported malar type as the most commonly observed clinical type, who studied melasma in our same geographical region. However, Manjunath et al. observed centrofacial type as more common in their study. Although previously malar type was more common, but nowadays almost equal incidence of centrofacial and malar types are observed. This may be due to the cosmetic over usage and environmental changes.
Upon detailed dermoscopic examination, scattered islands of brown reticular network with dark fine granules on surface were observed in about 46% of the patients, which is characteristic of epidermal type of melasma. Homogeneous reticular network of pigmentation was noticed in majority of the epidermal type of melasma, and woods lamp examination confirmed the diagnosis.,, Dermal type of melasma on dermoscopy showed uniform skin involvement and no areas of sparing with dark brown to grey hyperpigmented lesions observed with 18% of the patients. Several authors reported that the dermal pattern shows irregular network with bluish grey pigmentation,, bluish grey which loses regular network. Mixed pattern of melasma on dermoscopy was observed in 36% of the patients, and the results were in concordance with other studies [Table 3]., Reticuloglobular pattern, exaggerated pseudo network with granular pigmentation, archiform structures, exogenous ochronosis, atrophy and telengiectasias were the other dermoscopic features observed. Charlín et al. reported dermoscopic features of two patients with exogenous ochronosis, where they observed blue-gray amorphous areas obliterating some follicular openings. Gil et al. reported the dermoscopic features as irregular, brown-gray, globular, annular, and arciform structures in exogenous ochronosis. Khunger and Kandhari observed ’worm like pattern’. Our dermoscopic findings were similar to previously reported findings. In addition, we observed a characteristic ’wave-like’ pattern. In our studies using dermoscope, the epidermal type of melasma commonly presented with a light brown colour, dermal type of melasma with an ash grey colour and mixed type with dark brown colour which was proved statistically also. The epidermal type of melasma was observed more at younger age group and mixed pattern with the middle age group, which was proved statistically significant. The above observation may be due to the fact that during the initial development of melasma, the accumulation of pigment will be only in the epidermis because of external factors. However, as the age progresses the hormonal influence, self-medication and multiple treatment regimens lead to the development of mixed type of melasma.
| Conclusion|| |
Melasma is a common, acquired, pigmentary condition that develops among middle-aged females with almost universal occurrence. Cosmetically it is a distressing condition for both females and treating dermatologist because of its variable response to treatment and recurrence. Nowadays dermoscopy has become an essential tool to assess the type of melasma by analyzing colour pattern and depth of pigmentation. By serial dermoscopic examinations, we can also assess the treatment response. We can differentiate melasma from exogenous ochronosis, and it will help in the correct management of melasma. From our observations, we conclude that dermoscopy can be used as a very useful tool in the management of melasma and other dermatological disorders.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]