|Year : 2022 | Volume
| Issue : 2 | Page : 115-121
Clinico-dermatoscopic study of facial melanosis at a tertiary care hospital
Dhruv R Patel, Jinal J Tandel, Rutoo V Polra, Jaishree Ganjiwale, Pragya A Nair
Derpartment of Dermatology, Venereology & Leprosy, Jayshree Ganjewale - Department of Community Medicine & Central Research Services, Pramukhswami Medical College, Shree Krishna Hospital, Karamsad, Gujrat, India
|Date of Submission||27-Jan-2021|
|Date of Decision||01-Apr-2021|
|Date of Acceptance||10-Apr-2021|
|Date of Web Publication||12-Aug-2022|
Dr. Pragya A Nair
Professor & Head, Department of Dermatology, Venereology & Leprosy, Shree Krishna Hospital, Pramukhswami Medical College, Karamsad 388325, Gujrat
Source of Support: None, Conflict of Interest: None
Introduction: Facial pigmentary disorders are a group of heterogeneous disorders with clinical features of hyper- or hypopigmentation. They cause a great degree of psychosocial impact on patients’ quality of life due to their easy visibility. Aims and objectives: To find out different clinical and dermatoscopic patterns in facial melanosis. Materials and methods: Patients with hyperpigmentation or hypopigmentation over the face attending the skin OPD were recruited after taking their written consent in vernacular language. A detailed history was taken to collect demographic data. Clinical examination and dermatoscopy were done in all patients. Relevant investigations and biopsy were carried out as and when required. The descriptive statistics has been used to describe the quantitative data. Qualitative data were presented as frequency and percentage for clinical and dermatoscopic patterns. Results: The study included 180 patients having 20 different facial melanoses. Maximum number of patients (99; 55%) belonged to the age group of 19 to 40 years with female:male ratio of 1.72:1. The most common precipitating factor was sunlight in 66 (36.7%) patients followed by seasonal variation in 27 (15%) cases. Cheek was the most common site involved in 101 (56.1%) cases. Melasma was reported as the most common dermatosis including epidermal melasma 40 (22.2%), dermal melasma 26 (14.4%), and mixed melasma 4 (2.2%) cases followed by postinflammatory pigmentation (18; 10%), acanthosis nigricans (13; 7.2%), and vitiligo (11; 6.1%). In dermatoscopy, the most common pattern seen was reticuloglobular pattern in 68 (37.3%) cases, followed by black-brown globules in 47 (25.6%) cases. Conclusions: Melasma was reported as the most common cause of facial melanosis. The most common dermatoscopic pattern was the reticuloglobular pattern. The study is useful in understanding the different clinical and dermatoscopic patterns of facial melanosis, thereby help the physician to effectively manage the conditions and reduce the need of biopsy. Limitation: Histopathological correlation was not done.
Keywords: Dermatoscopy, facial melanosis, melasma, vitiligo
|How to cite this article:|
Patel DR, Tandel JJ, Polra RV, Ganjiwale J, Nair PA. Clinico-dermatoscopic study of facial melanosis at a tertiary care hospital. Pigment Int 2022;9:115-21
| Introduction|| |
Facial pigmentary disorders are a group of heterogeneous disorders with clinical features of altered pigmentation causing visible cosmetic disfigurement. Pigmentary disorders of the skin can either be hyper- or hypomelanotic. Hyperpigmentary disorders include melasma, exogenous ochronosis, freckles, seborrheic melanosis, erythema dyschromicum perstans (EDP), postinflammatory hyperpigmentation, and acanthosis nigricans. Acquired dermal macular hyperpigmentation (ADMH) is an umbrella term that includes Riehl melanosis (RM)/pigmented contact dermatitis, lichen planus pigmentosus (LPP), ashy dermatosis, and idiopathic macular eruptive pigmentation. Hypopigmentary disorders include vitiligo, pityriasis alba, postinflammatory hypopigmentation, and tinea versicolor. Dermatoscopy has become an essential tool to assess various patterns and depth of pigmentation and to differentiate different facial melanosis without taking biopsy. There are studies in the literature about clinico-epidemiological study on facial pigmentary disorders,,,, but we could not find any study after an extensive search to see the clinical and dermatoscopic pattern of facial melanosis. The objective of the present study was to find out different clinical and dermoscopic patterns of various facial melanosis.
| Methods|| |
This cross-sectional study was carried out from August 2019 to July 2020 in the Department of Dermatology, Venerology, and Leprosy after approval from the institutional ethic committee. All the patients more than 3 years of age with facial hyperpigmentation or hypopigmentation attending skin OPD were included in the study after taking written informed consent in vernacular language. Patients with active infection (fungal, bacterial, viral) over the face were excluded from the study. Thorough history regarding complaints, aggravating factors, age of onset, duration, past, and family history were recorded. Cutaneous examination was done and clinical diagnosis was made. Relevant investigations such as hemoglobin, vitamin B12, TSH, and biopsy were carried out as and when required. Dermatoscopy was done in all patients from the representative lesion with handheld polarized LED ILLUCO dermoscope IDS-1100 having 10× magnification. The criteria used while doing dermatoscopy were the morphology/arrangement of vascular structures, pigment depth, and arrangement and specific clues. Diagnosis was done on the basis of dermatoscopic findings correlated with other parameters such as history of previous dermatosis, duration of disease, symptoms, personal/family history, morphology, and distribution of lesions. The descriptive statistics has been used to describe the quantitative data. Qualitative data were presented as frequency and percentage for clinical and dermatoscopic patterns.
| Results|| |
Among 180 cases, 153 (85%) patients had hypermelanotic conditions and 27 (15%) had hypomelanotic conditions. Maximum (99; 55%) belonged to the age group of 19 to 40 years followed by 55 (30.6%) in the age group 41 to 60 years. Female preponderance was observed with female:male ratio of 1.72:1. Total 149 (82.8%) patients complained about pigmentation followed by itching and burning in 30 (16.7%) and 23 (12.8%) patients, respectively. Sunlight was the most common precipitating factor in 66 (36.7%) patients followed by seasonal variation and iron deficiency in 27 (15%) and 25 (13.9%) patients, respectively. Most lesions (84; 46.6%) were brown in color followed by black colored lesions in 40 (22.22%) patients. Cheek was the most common site involved in 101 (56.1%) patients, followed by forehead in 68 (37.8%) patients.
Among hypermelanotic conditions, melasma was the most common with 70 (39%) cases [TABLE 1]. In the present study, several patterns were observed under dermoscope of which the most common pattern was reticuloglobular in 68 (37.3%) cases, followed by black-brown globules and reticular pigment network in 47 (25.6%) and 39 (21.6%) cases, respectively [TABLE 2].
Among 70 cases of melasma, 40 (22.2%) had epidermal melasma, 26 (14.4%) dermal melasma, and 4 (2.2%) had mixed melasma. Cheeks were the most common site in 59 (84.29%) cases [Figure 1]a. Reticuloglobular pattern was the most common dermoscopic pattern in epidermal and dermal melasma with 39 (97.5%) and 22 (84.6%) cases, respectively [Figure 1]b. Reticuloglobular pattern 3 (75%) and arcuate pattern 3 (75%) were the most common dermoscopic patterns seen in mixed melasma [TABLE 1].
|Figure 1 (a) Dermal melasma over bilateral cheeks and nose. (b) Dermatoscopy shows accentuated pseudo reticular pattern. (c) Postinflammatory hyperpigmentation over right zygomatic area. (d) Dermatoscopy shows reticuloglobular pattern (red arrow) with erythema present in background.|
Click here to view
Second common hypermelanotic condition was postinflammatory hyperpigmentation (PIH) with 18 cases. The most common site was forehead (59; 44.4%) followed by cheeks (6; 33.3%) [Figure 1]c. Reticuloglobular pattern 14 (77.7%) [Figure 1]d was the most common dermatoscopic pattern. A total of 13 cases of AN were studied on forehead [Figure 2]a. On dermatoscopy, linear crista and sulcus cutis [Figure 2]b were seen in all cases [TABLE 1].
|Figure 2 (a) Acanthosis nigricans over forehead. (b) Dermoscopy shows linear crista (blue arrow) and Sulcus cutis (red arrow). (c) Periorbital pigmentation. (d) Reticular pigment network (red arrow), blotches (blue arrow).|
Click here to view
A total of 10 cases of periorbital pigmentation [Figure 2]c were studied. The most common dermatoscopic patterns were reticuloglobular pigment network in six (60%) cases [Figure 2]d followed by speckled patterns in four (40%) and blotches in three (30%) cases. A total of six cases of LPP were studied, with forehead as the most common site in four (67%) cases [Figure 3]a. Dermatoscopy showed hem-like pattern [Figure 3]b in five (83.3%) cases. Five cases of Riehl melanosis were studied with forehead affected in four (80%) cases [Figure 3]c. The most common dermoscopic pattern was black-brown globules [Figure 3]d seen in three (60%) cases [TABLE 1].
|Figure 3 (a) Lichen planus pigmentosus over bilateral forehead, and cheek. (b) Hem-like pattern (red arrow) and perifollicular hypopigmentation (blue arrow). (c) Riehl melanosis over forehead and cheeks. (d) Dermoscopy shows black-brown globules (blue arrow).|
Click here to view
|Figure 4 (a) Clofazimine-induced pigmentation over forehead and cheeks. (b) Dermoscopy shows yellow white globules (blue arrow), honeycomb-like pattern (red arrow). (c) Ashy dermatosis over Forehead and right zygomatic area. (d) Dermoscopy shows pinkish to brownish background (red arrow) and black-brown globules (blue arrow).|
Click here to view
|Figure 5 (a) Becker’s nevus over right mandible and neck. (b) Dermoscopy shows focal hypopigmentation (red arrow), reticular pigment network (brown arrow), and perifollicular hypopigmentation (blue arrow). (c) Chikungunya induced pigmentation over nose. (d) Dermoscopy shows pinkish background (blue arrow), perifollicular scaling (green arrow), and black-brown globules (red arrow).|
Click here to view
|Figure 6 (a) Exogenous ochronosis bilateral cheeks and zygomatic area. (b) Dermoscopy shows worm-like pattern (red arrow) and white dots (green arrow). (c) Vitiligo over bilateral upper eyelid and left cheek. (d) Dermoscopy shows white glow in ameboid pattern (red arrow).|
Click here to view
|Figure 7 (a) Halo nevus over left lower eyelid. (b) Dermoscopy shows white glow (red arrow). (c) Tinea versicolor over right cheek and neck. (d) Dermoscopy shows reduced pigmentary network (red arrow), scaling (green arrow), and satellite lesion (yellow arrow).|
Click here to view
Other hypermelanotic conditions seen in the minority include clofazimine-induced pigmentation, ashy dermatosis seborrheic melanosis [TABLE 1].
Of hypomelanotic conditions, vitiligo was common with total 11 cases. Lower eyelids were most commonly involved site in nine (81.8%) cases. White glow and white yellow structureless areas were seen in dermatoscopy in all cases. A total of 10 cases of P. alba were studied where dermatoscopy showed pinkish patch with irregular scale in all cases [TABLE 1].
| Discussion|| |
Facial melanosis is a group of heterogeneous entities, sharing a common clinical feature of altered pigmentation of the face and thus easily visible cosmetic disfigurement and significant psychosocial consequences. Due to increased patient awareness, greater use of cosmetics, and over-the-counter drugs, their incidence and importance are growing rapidly. It is a common presentation in Indian patients, with complex diagnostic and therapeutic problems consisting of well-defined clinical entities, of which some have overlapping features. A noninvasive, diagnostic tool like a “Dermatoscope” provides better magnification and reduces the number of unnecessary biopsies in day-to-day practice.
In our study, the most common age group affected was 19 to 40 years in 55% cases, similar to Hassan et al. and Rao et al. study in which the most common age group was 21 to 40 years (56.73%). Female predominance seen in our study was 63.3% comparable with study by Hassan et al. This was seen probably due to hormonal influence and females being more conscious about their appearance in comparison to males.
Melasma was reported as the most common cause of melanosis consisting of 39% cases. This is slightly higher than that reported by Hassan et al. with 35%, whereas Rao et al. study had reported 55% cases of melasma.
Cases of epidermal melasma were 57%, dermal melasma 37%, and mixed melasma were 6% in our study that coincides with the study by Goh and Dlovaet al with 68%, 29%, and 3%, respectively. Assessing pigment level also helps in deciding the prognosis of melasma, as dermal and mixed melasma has a poor response to treatment. Melasma is more prevalent among Asians and Hispanic origin and also in Fitzpatricks skin phototype 4 to 6, especially those who work under intense ultraviolet light. Melasma typically shows reticular pigment network with perifollicular sparing and color varying from light to dark brown. The most common dermoscopic pattern seen in our study was reticuloglobular (91%) followed by brown-black globules (50%). Reticuloglobular pattern was also found to be the most common dermoscopic pattern in Nanjundaswamy et al., Kaur et al., and Yalamanchili et al.
PIH was the second most common cause of facial melanosis (10%) similar to Hassan et al. with 16.34% cases. The most common dermatoscopic pattern was reticuloglobular pattern (78%) followed by dark brown globules (28%) in our study. A case report showed the presence of multiple scattered brown-colored globules and circular to oval-shaped brown rings with perifollicular accentuation.
In the present study, all cases of AN showed a dermoscopic pattern of linear crista and sulcus cutis same as reported by Nirmal in a case, having hyperpigmented dots and streaks.
POP may be either because enough oxygen is not reaching the periorbital tissues or due to facial pallor that makes the periorbital region look comparatively darker. In the present study, the total cases of POP were 5.55% similar to Hassan et al. with 6.7% cases. Patients with anxiety had aggravation of dark circles during periods of stress that causes increased melanocyte-stimulating hormone secretion through hypothalamic–pituitary–adrenal axis leading to hyperpigmentation. In our study, the most common dermoscopic patterns were reticuloglobular pigment network (60%) followed by speckled pattern (40%) and blotches (30%) similar to Jage et al. in which blotches (30%), speckled pattern (25%), and increased pigment network (28%) were seen.
ADMH group of disorders shows (1) dots/globules/blot (black/brown/violet) arrange as predominant pigment structures arrange as dots, Chinese letter, reticulate, or diffuse pattern, (2) telangiectasia, (3) accentuation of the normal pseudo-reticular pigment, and (4) owl’s eye structure. LPP is a rare variant of lichen planus, consisting of 3.33% of cases in our study similar to Hassan et al. with 4.8% cases. In our study, the most common facial site was forehead (66.6%) followed by zygomatic area (50%), whereas in Sharma et al. and Hassan et al. studies, these were the forehead (84%) and temporal region (76%). Pigmentation in different patients varies from slate gray to brownish‑black, but in our study, slate-grey colored pigmentation was reported to be the most common pigmentation that is similar to studies by Hassan et al. and Sharma et al. Dermoscopic finding in our study was hem-like pattern (83.3%) followed by perifollicular hyperpigmentation (50%), whereas in a study by Sharma et al., it was reticular pattern (39.5%) followed by hem-like pattern (20%).
In our study, 2.7% of cases of Riehl melanosis were found that coincide with Hassan et al. study with 5.7% cases. The most common aggravating factor was cosmetics (60%) that coincides with Hassan et al. and Rao et al. In the present study, the most common dermatoscopic feature reported is black-brown globules (60%) followed by reticular pigment network (40%) similar to a case report.
Vitiligo was the most common cause of facial hypopigmentation. Thyroid disorder was seen in 27.27% of cases in our study that was higher than Hassan et al. and Gandhi et al. All cases showed a white glow followed by perifollicular pigmentation (36.4%), reduced pigmentary network (27.3%), and starburst pattern (18.2%). Thatte et al. reported white glow (90%), reduced pigmentary network (40%), absent pigmentary network (30%), and perifollicular pigmentation (6.7%), whereas Gandhi et al. reported white glow (91.87%) and perifollicular pigmentation (46.25%).
Pityriasis alba was seen in 37.03% cases among all hypopigmentary conditions as compared to Al-Refu et al. study with 15% cases. All cases showed a pinkish patch with irregular scales similar to Vinod et al. and Ankad et al. where a white structureless area with ill-defined margin and fine scales were noted.
| Conclusion|| |
Among 180 patients, Melasma was reported as the most common cause of facial melanosis. The most common dermoscopic pattern seen was reticuloglobular pattern. The study is useful in understanding the various demographic details with different clinical and dermoscopic patterns of facial melanosis, thus help the physician to effectively manage the conditions and reduce the need of biopsy.
| Limitation|| |
Histopathological correlation was not done.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khanna N, Rasool S. Facial melanoses: Indian perspective. Indian J Dermatol Venereol Leprol 2011;77:552-64.
] [Full text]
Vinay K, Bishnoi A, Parsad D, Saikia U, Kumaran M. Dermoscopic evaluation and histopathological correlation of acquired dermal macular hyperpigmentation. Int J Dermatol 2017;56:1395-9.
Hassan I, Aleem S, Bhat YJ, Anwar P. A clinic epidemiological study of facial melanosis. Pigment Int 2015;2:34-40. [Full text]
Rao C, Paqurissamy O, Govardhan J, Medasani V. Clinico-epidemiological study of facial hyper-melanoses among patients attending dermatology outpatient department at a tertiary care hospital at Pondicherry. Int J Res Dermatol 2020;6:48-56.
Mrinal Gupta, Vikram K. Mahajan. Clinical profile of 300 men with facial hypermelanosis. Dermatol Case Rep 2017;2:20-24.
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.
Nanjundaswamy BL, Joseph JM, Raghavendra KR. A clinico dermoscopic study of melasma in a tertiary care center. Pigment Int 2017;4:98-103. [Full text]
Gupta T, Sarkar R. Dermoscopy in melasma − is it useful? Pigment Int 2017;4:63-4. [Full text]
Kaur S, Kaur J, Sharma S, Sharma M, Mahajan A, Singh A. A clinico-dermatoscopic study of 100 cases of melasma in a tertiary care hospital. Int J Res Dermatol 2018;4:41-45.
Yalamanchili R, Shastry V, Betkerur J. Clinicoepidemiological study and quality of life assessment in melasma. Indian J Dermatol 2015;60:519.
] [Full text]
Nirmal B. Dermatoscopy image characteristics and differences among commonly used standard dermatoscopes. Indian Dermatol Online J 2017;8:233–4.
] [Full text]
Jage M, Mahajan S. Clinical and dermoscopic evaluation of periorbital hyperpigmentation. Indian J Dermatopathol Diagn Dermatol 2018;5:42-47. [Full text]
Sharma VK, Gupta V, Pahadiya P, Vedi KK, Arava S. Dermoscopy and patch testing in patient with lichen planus pigmentosus. Indian J Dermatopathol Diagn Dermatol 2017;6:34-36.
Gupta V, Sharma VK. Ashy dermatosis, lichen planus pigmentosus and pigmented cosmetic dermatitis: Are we splitting the hair?. Indian J Dermatol Venereol Leprol 2018;84:470-4.
] [Full text]
Gandhi S, Shamanur M, Shashikiran AR, Kusagur M, Sugareddy Bhaskar V. A study of clinico-epidemiological and dermoscopic patterns of vitiligo in pediatric age group. Indian J Paediatr Dermatol 2017;18:292-8. [Full text]
Thatte SS, Khopkar US. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo. Indian J Dermatol Venereol Leprol 2014;80:505-8.
] [Full text]
Al-Refu K. Dermoscopy is a new diagnostic tool in diagnosis of common hypopigmented macular disease: a descriptive study. Dermatol Rep 2019;11:791-6.
Vinod S, Singh G, Dash K, Grover S. Clinico epidemiological study of pityriasis alba. Indian J Dermatol Venereol Leprol 2002;68:338-40.
] [Full text]
Ankad BS, Koti VR. Dermoscopic approach to hypopigmentary or depigmentary lesions in skin of color. Clin Dermatol Rev 2020;4:79-83. [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[TABLE 1], [TABLE 2]