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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 9
| Issue : 3 | Page : 176-181 |
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A study of dermoscopy in patients of melasma in a tertiary care centre in North India
Neerja Puri, Sukhpreet Kaur Gill, Sumir Kumar, B.K. Brar, Anahita Chahal
Department of Dermatology, GGS Medical College, Faridkot and Dayanand Medical College and Hospital, Ludhiana, India
| Date of Submission | 06-Dec-2020 |
| Date of Decision | 04-Apr-2021 |
| Date of Acceptance | 15-Apr-2021 |
| Date of Web Publication | 30-Nov-2022 |
Correspondence Address:
Dr. Neerja Puri
Assistant Professor, Department of Dermatology, G G S Medical College, Faridkot, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/pigmentinternational.pigmentinternational_
Aims and Objectives: The aim of the study is to determine dermoscopic findings of melasma after evaluating them based upon clinical examination and to correlate each clinical picture with dermoscopic findings. Materials and methods: Various patients of melasma from December 2019 to December 2020 were enrolled from outpatient department. Detailed history was taken. The dermoscopic examination and photographic documentation of clinical as well as dermoscopic picture was done and findings were noted. Results: We enrolled 50 patients in study including 80% females and 20% males. Mean age of melasma in our study was 31.28 years. Mostly the patients were farmers and housewives with the most common precipitating factor being sun exposure.Twenty patients on clinical examination along with Wood’s lamp showed epidermal pattern, 18 patients showed mixed pattern, and 12 patients had dermal pattern. On dermoscopy, melasma showed perifollicular sparing in all patients (100%), but in 36 patients, along with perifollicular sparing, it also showed perifollicular pigmentation in some areas, granular pattern in 38 patients, globular pattern in 42 patients, blotches in 36 patients, telangiectasias in 30 patients, arcuate pattern in 32 patients, and annular in 12 patients.The frequency of findings was nearly similar in all three three types except for the arcuate pattern. In the dermal pattern, nearly 83% patients (P = 0.1) showed arcuate pattern as compared to 40% (P = 0.004) in epidermal pattern. Limitations: A larger sample size is required. Also, since a few of the patients were already on topical corticosteroids, it may have affected the dermoscopic findings. Conclusion: Dermoscopy is a noninvasive tool that can be used to diagnose and differentiate it from other disorders of hyperpigmentation, but it cannot be used to classify melasma into epidermal, dermal, or mixed pattern.
Keywords: Centrofacial, dermoscopy, melasma, perifollicular
How to cite this article:
Puri N, Gill SK, Kumar S, Brar B, Chahal A. A study of dermoscopy in patients of melasma in a tertiary care centre in North India. Pigment Int 2022;9:176-81 |
| Introduction | |  |
Melasma is a common disorder of pigmentation characterized by irregular and symmetric patches of hyperpigmentation with color varying from light brown to dark brown.[1] Clinical patterns include centrofacial, malar, and mandibular. Centrofacial pattern is the most common in which pigmentation is present over forehead, cheeks, nose, and upper lip. Hormonal influences, sun exposure, and genetic factors have been thought to play a significant role in causation of melasma.[2] Melasma is more prevalent in women (especially in their thirties and forties) and in darker skin type. Hyperpigmentation significantly affects quality of life owing to its cosmetic concerns.[3],[4] Depressive disorders are also common in melasma leading to function disability.[5]
Melasma is also considered a photoaging disorder by some owing to its histopathological features, for example, solar elastosis, increased vascularity, and mast cell count.[6] Histologically, melasma can be epidermal, dermal, or mixed depending on the depth of pigment.[7]
Dermoscopy is a noninvasive skin imaging technique that helps in visualization of structures that are not normally visible to naked eye.[8] On dermoscopy, the commonly observed pattern is light to dark brown background with granules, globules, and perifollicular sparing.[9] Dermoscopic pattern is clinically correlated as this enhances the diagnostic accuracy. Dermoscopy in melasma can be used to determine the depth of melasma, to differentiate it from other causes of facial melanosis, and to assess the prognosis of melasma.[10].
| Aims and Objectives | | |
The aim of the study is to determine dermoscopic findings of melasma after evaluating them based upon clinical examination and to correlate each clinical picture with dermoscopic findings.
| Materials and Methods | | |
Patients of melasma from December 2019 to December 2020 were enrolled from outpatient department. Detailed history was taken. Clinical and dermoscopic images were taken and findings were noted.
Dots are small, round structures less than 0.1 mm in diameter that may be black, brown, gray, or blue-gray. Black dots are caused by pigment accumulation in the stratum corneum and in the upper part of the epidermis. Brown dots represent focal melanin accumulations at the dermoepidermal junction. Gray-blue granules (peppering) are caused by tiny melanin structures in the papillary dermis. Gray-blue or blue granules are due to loose melanin, fine melanin particles, or melanin “dust” in melanophages or free in the deep papillary or reticular dermis. Globules are symmetrical, round to oval, well-demarcated structures that may be brown, black, or red. These have a diameter that is usually larger than 0.1 mm and correspond to nests of pigmented benign or malignant melanocytes, clumps of melanin, and melanophages situated usually in the lower epidermis, at the dermoepidermal junction, or in the papillary dermis. Arcuate pattern is arc-like pattern of pigmentation. Annular pattern is ring-like pattern of pigmentation.
| Results | | |
We enrolled 50 patients in the study. Out of them, 40 were females (80%) and 10 were males (20%). Mean age of melasma was 31.28 years with males having relatively younger mean age of presentation [Table 1]. Sixteen patients (32%) had excessive exposure to sun owing to their profession. These included mostly farmers and housewives. Twelve patients (24%) were using topicals from local practitioners. It mostly included use of topical potent steroids and triple combinations. Six patients (12%) had pregnancy as their inciting factor in melasma that only progressed later and two were on oral contraceptives. For 14 patients (28%), melasma could not be related to any specific precipitating conditions. Clinical examination revealed 30 patients (60%) with centrofacial type of melasma and 20 patients (40%) with malar type of melasma and no patient with mandibular type.
Twenty patients on clinical examination along with Wood’s lamp showed epidermal pattern, 18 patients showed mixed pattern, and 12 patients had dermal pattern. On dermoscopy, melasma showed perifollicular sparing in all patients (100%) with concomitant perifollicular pigmentation around some follicles in 36 patients, granular pattern in 38 patients, globular pattern in 42 patients, blotches in 36 patients, telangiectasias in 30 patients, arcuate pattern in 32 patients, and annular in 12 patients [Figure 1],[Figure 2],[Figure 3],[Figure 4]. | Figure 1 On the right shows clinical picture of epidermal type of melasma and on left shows dermoscopic picture showing reticuloglobular pattern, perifollicular sparing (light green arrow), granules(brown arrow), globules (blue arrow) and telangiectasias (dark green arrow)
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 | Figure 2 On the right shows clinical picture of dermal type of melasma and on the left shows dermoscopic picture showing accentuation of pseudoreticular pattern, perifollicular sparing (green arrow) as well as Perifollicular pigmentation (brown arrow), annular pattern (purple arrow), arcuate pattern (blue arrow)
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 | Figure 3 Shows mixed type of melasma showing reticuloglobular pattern, perifollicular sparing (dark green arrow), perifollicular pigmentation (blue arrow), and blotches (light green arrow)
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 | Figure 4 Shows dermoscopic findings in epidermal, dermal as well as mixed Melasma
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The frequency of findings was nearly similar in all three types (epidermal, dermal, and mixed) except for the arcuate pattern. In the dermal pattern, nearly 83% patients (P = 0.1) showed arcuate pattern as compared to 40% (P = 0.004) in the epidermal pattern.
| Discussion | | |
Melasma is a common hyperpigmentation disorder most commonly affecting women in their middle age. It is most common in skin Fitzpatrick types III and IV.[11]In our study, 80% were females and 20% % were males, which is in concordance with the study done by Nanjundaswamy et al. in which female versus male ratio was 4:1. Similar findings were reported by Achar et al. and KrupaShankar et al. in their studies.[10],[12] However, studies outside India reported even up to 97% of female prevalence.[11] This difference can be due to different environmental conditions.
Mean age of melasma in our study was 31 years with 24% patients giving history of the application of topicals and 12% reporting pregnancy as their inciting factor. Similar findings were reported in a study done by Achar et al. in which the mean age of melasma was 29 years and 23.39% patients used cosmetics on regular basis. In their study, 22.4% patients reported melasma precipitation during pregnancy.[13]
Telangiectasias were seen in 30 patients but were more pronounced in patients having history of use of triple combination and topical corticosteroids. The most common triggering factor was sun exposure in our study, which is similar to study done by Yalamanchili et al. Similar findings were also seen in Brazilian study where 44.4% patients reported sun exposure as the most common triggering factor.[14],[11]
Centrofacial pattern [Figure 1]A and B was most common in our study (60%), whereas there was no patient of mandibular pattern . These findings are similar to studies done in India. A study done in Tunisia on 188 patients also showed centrofacial pattern in 77% of patients, malar pattern in 23%, and mandibular in 1% of patients.[15],[13],[16] But some studies show malar type to be most predominant.[11],[17]
Dermoscopy of melasma in our study showed perifollicular sparing in almost all patients together with perifollicular pigmentation in nearly 72% of patients in some blotches, granular patten in nearly 76% of patients, globular in 84% of patients, blotches in 72% of patients, telangiectasias in 60%, arcuate in 64%, and annular in nearly 24% of patients. The color varied from light brown to dark brown. Twenty patients on clinical examination along with Wood’s lamp showed epidermal pattern, 12 patients had dermal pattern [Figure 2]A and B and 18 patients showed mixed pattern [Figure 3]A and B. In the dermal pattern, nearly 83% of patterns showed arcuate pattern as compared to 40% (P = 0.004) in the epidermal pattern [Figure 4]. Other findings were nearly similar in all the three types.
A study done by Sonthalia et al. also reported similar findings, which are diffuse brown pseudoreticular network, brown dots, granules, globules, and arcuate and annular structures with sparing of the perifollicular region.[9] Gupta and Sarkar also reported similar findings, which are reticular pigment network and perifollicular sparing with color varying from light brown to dark brown.[18]
Dermoscopy can be used where facial pigmentation is difficult to differentiate from other conditions (e.g., lichen planus pigmentosus, Reihl’s melanosis, ochronosis) or where melasma is not responding to treatment. It can also be used as a baseline investigation for monitoring response to treatment, but in our study it could not be used to classify melasma.[18]
In ochronosis, various dermoscopic findings described are bluish‐gray amorphous areas obliterating follicular structures rather than surrounding them as seen in melasma blue-gray dots, globules that had a caviar-like appearance, and scattered structureless areas.[19],[20]
In lichen planus pigmentosus, brown background, hem-like pattern of pigmentation, gray to brown dots, globules, and perifollicular pigment deposition are the most common findings reported.[21],[22] In Reihl’s melanosis, pseudo network, gray dots, globules, and telangiectasias are the most common findings, followed by scales, keratotic plugs, and perifollicular whitish halo.[23],[24]
A study done by Nanjundaswamy et al. showed brown reticular network with dark granules scattered on surface in epidermal type of melasma, uniform skin involvement with no areas of sparing and dark brown to grey hyperpigmented lesions and ash grey colour in dermal pattern of melasma and dark brown colour in mixed type of melasma. Other studies reported irregular network with bluish-gray pigmentation and bluish-gray areas with loss of regular network in the dermal type of melasma.[11] But in our study, epidermal, dermal, and mixed melasma showed similar findings with only exception of the arcuate pattern that had statistically significant difference between epidermal and dermal melasma.
Thus, in our study dermoscopy could not help in classifying melasma with the help of these findings. Dermoscopy was not considered a good classification method as shown in a study in which evaluation of melasma classification was done based on response to treatment.[25] It is possible that all patients have some component of each type of melasma and all types of melasma are mixed.
| Conclusion | | |
Melasma is a multifactorial hyperpigmentation disorder mostly present in women. Dermoscopy is a noninvasive tool that can be used to diagnose and differentiate melasma from other disorders of hyperpigmentation, but it cannot be used to classify melasma into epidermal, dermal, or mixed pattern.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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