|Year : 2018 | Volume
| Issue : 1 | Page : 19-23
Clinico-epidemiological study of melasma in men
Keerthi Charupalli1, TS Rajasekhar1, Madhusudan Mukkara2
1 Department of Dermatology and Venereology, Sri Devaraj URS Medical College, Kolar, Karnataka, India
2 Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Web Publication||8-Jan-2019|
T S Rajasekhar
Professor and Head, Department of Dermatology and Venereology, Sri Devaraj URS Medical College, Tamaka, Kolar, Karnata
Source of Support: None, Conflict of Interest: None
Background: Melasma is one of the most common and distressing pigmentary disorders presenting to dermatology clinics. There is paucity of data regarding the aetiological factors and clinical presentation of melasma in men. The present study was taken up to fill this lacuna and to understand the unique aspects of melasma in this group.
Methods: Study was conducted in the Department of Dermatology at University teaching hospital from January 2015 to July 2016. A total of 72 male patients with melasma were studied. A detailed history including occupation, onset, duration and evolution of melasma, predisposing factors like sun exposure and genetic factors, were taken followed by general physical examination, cutaneous examination and Woods lamp examination and recorded in a proforma. Laboratory investigations like complete haemogram, hormonal profile, liver function tests were done whenever necessary depending on the presenting condition.
Results: The mean age of onset was 31.5 years. The duration of melasma varied from 3 months to 6.5 years. The aetiological factors identified were, sun exposure in 42 patients (58.3%) and family history in 29 (40.3%). Laboratory investigations revealed hepatic disorders in 5 patients(6.9%), increased luteinizing hormone (LH) and low testosterone in 2 (2.8%) and hypothyroidism in 4 patients (5.6%). According to clinical patterns, malar pattern was seen in 65.3% of patients, centro-facial in 31.9% and mandibular in 2.8% of patients. The most common skin type found to be type IV.
Conclusion: Melasma was evident in men in their fourth decade of life; malar pattern, type IV skin type were most commonly seen.
Keywords: Clinical pattern, epidemiology, melasma, men
|How to cite this article:|
Charupalli K, Rajasekhar T S, Mukkara M. Clinico-epidemiological study of melasma in men. J Clin Sci Res 2018;7:19-23
| Introduction|| |
Melasma is an acquired, increased pigmentation of the skin characterised by symmetrical and confluent grey-brown patches mostly on the areas of the face exposed to the sun, such as the cheeks, forehead and chin. It rarely affects other areas such as the neck and forearms., Melasma is a very common cutaneous disorder, accounting for 0.25–4% of the patients seen in the dermatology clinics in Southeast Asia and is the most common pigment disorder among Indians., The disease affects all races, but there is a particular prominence among Hispanics and Asians. Although women are predominantly affected, men are not excluded from melasma, representing approximately 10% of the cases. It can be a source of embarrassment in men because of its unsightly appearance and the social stigma of being categorised as a disease in pregnant women.
The exact underlying aetiology for melasma remains unknown while several well-known risk factors exist. There are six Fitzpatrick's skin types, in which melasma is most common in darker skin types, particularly Fitzpatrick's skin types III and IV. According to their clinical distribution, facial melasma lesions can be categorised into three types such as (i) centrofacial pattern; (ii) malar pattern; and (iii) mandibular pattern. Under Wood's light examination, melasma is classified into four major histological types depending on the depth of pigment deposition: (i) epidermal type; (ii) dermal type; (iii) mixed type; and (iv) intermediate type.,
Most of the previous studies were done on clinico-epidemiological profile of melasma in general population.,,, Except for few studies,,, there is a paucity of data available in the literature on male patients with melasma. The present study was undertaken to find out the clinico-epidemiological profile of melasma in male population of southern part of the Karnataka, India.
| Material and Methods|| |
The present descriptive study was undertaken in all male patients having melasma who attended the Dermatology, Venereology and Leprosy Department, Sri Devaraj URS Medical College, a tertiary care teaching hospital in South India, during the period from January 2015 to July 2016. Men having melasma aged between 20 and 50 years and attending the Dermatology, Venereology and Leprosy Department were included in the study. Patients aged <20 years and older than 50 years, female patients with melasma, men with other dermatological conditions but were not seeking treatment for coexisting melasma and patients who were unwilling to participate in the study were excluded. The study was approved by the institutional ethics committee. Written informed consent was obtained from all participants.
In all patients, complete history and clinical examination which includes name, age, occupation of the patient, onset and duration of melasma and aggravating factors such as sun exposure, family history and chronic illness (such as thyroid disorders, hepatic disorders, bowel disorders and any other hormonal imbalance) were taken from each patient and were documented. A history related to the treatment taken by patients pertaining to the presenting condition was taken. General physical examinations including signs of endocrinological disturbances were performed. The detailed cutaneous examination was performed, which includes Fitzpatrick's skin type, the pattern of melasma and colour of melasma macule, and the details of the examination findings were documented. The Melasma Area and Severity Index (MASI) score was calculated and documented. Wood's lamp examination was performed in all patients to find the type of melasma. Laboratory investigations such as complete blood count, liver function tests, hormonal assay (T3, T4, thyroid-stimulating hormone [TSH], luteinising hormone [LH] and testosterone) and stool examination were done wherever necessary based on the patient's history and clinical examination. Specific treatment for melasma was given as per the standard of care for management.
Data were recorded on a predesigned pro forma and were analysed using Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, USA). The statistical software IBM SPSS Statistics Version 20 was used for all mathematical computations and statistical calculations. All the data were presented as frequency, percentage or number of patients. P < 0.05 was considered statistically significant.
| Results|| |
Seventy two male patients with melasma were analysed in the present study. The common age distribution of melasma [Table 1] in this study was between 31 and 35 years (n = 27, 37.5%) and 26 and 30 years (n = 14, 19.4%), followed by 36–40 years (n = 13), 20–25 years (n = 8), 41–45 years (n = 7) and 46–50 years (n = 3). The age of onset of melasma was found to be between 31 and 35 years (n = 28, 38.9%), followed by 26–30 years (n = 22, 30.6%), 36–40 years (n = 8), 21–25 years (n = 7), 41–45 years (n = 5) and one patient each in age group of <20 years and >45 years. In the present study, most of the patients (n = 30, 41.7%) had 1–2 years' duration of melasma, followed by 2–5 years (n = 21, 29.2%), <1 year (n = 14) and >5 years (n = 7). A positive family history of melasma in the relatives was noted only in 29 (40.3%) patients. Forty-two (58.3%) patients had a history of sun exposure as a precipitating factor in the present study because majority of our patients were outdoor workers and the remaining 30 (41.7%) patients had no history of sun exposure.
In our study, four patients showed thyroid abnormality (hypothyroidism) with raised TSH levels and low T3 and T4 levels. Two patients showed low levels of testosterone with elevated levels of LHs and five patients showed hepatic dysfunction with raised aminotransferases.
Four (5.6%) patients had history of past treatment; of these three patients used triple combination (hydroquinone, steroid and retinoid) and the other patient had undergone two sessions of 35% glycolic acid peel. The remaining 68 (94.4%) patients had not taken any treatment related to melasma in the past.
The most common skin type (Fitzpatrick's skin type) in the present study [Table 2] was found to be type IV (brown colour) (n = 46, 63.9%), followed by type III (light brown) (n = 22, 30.6%) and type V (dark brown) (n = 4, 5.5%). The colour of the melasma macule was light brown (n = 38, 52.8%) [Figure 1]a, bluish grey (n = 19, 26.4%) [Figure 1]b and dark brown or black (n = 15, 20.8%) [Figure 1]c. The most common pattern of melasma observed was malar pattern (n = 47, 65.3%), followed by centrofacial pattern (n = 23, 31.9%) and mandibular pattern (n = 2, 2.8%). Wood's lamp examination of melasma lesions revealed epidermal type (n = 35, 48.6%) [Figure 2]a and [Figure 2]b, dermal type (n = 24, 33.3%) and mixed type (n = 13, 18.1%) [Figure 3]a and [Figure 3]b. Majority of patients had a MASI score of 11–15 (n = 24, 33.3%), followed by 6–10 (n = 18, 25%), <5 (n = 13, 18.1%), 16–20 (n = 12, 16.7%) and >20 (n = 5, 6.9%).
|Figure 1: (a) Light brown colour of melasma macule, (b) bluish grey colour of melasma lesion, (c) black colour of melasma lesion|
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|Figure 2: (a) Centrofacial pattern of melasma, (b) Wood's lamp examination showing accentuation of lesion (epidermal type)|
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|Figure 3: (a) Centrofacial pattern of melasma, (b) Wood's lamp examination showing mixed type of both accentuation and no accentuation lesion|
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| Discussion|| |
Melasma is an acquired hyperpigmentary disorder of the skin. It is the most common pigmentary disorder in the Indian population. Although women are predominantly affected, men are not excluded from melasma, representing approximately 10% of the cases. The exact causes of melasma are unknown, but multiple factors seem to be contributing to its aetiopathogenesis, mainly sunlight, genetic predisposition and the role of female hormonal activity. Other factors include oral contraceptives, pregnancy, oestrogen–progesterone therapies, thyroid dysfunction, certain cosmetics and phototoxic and anti-seizure drugs. Melasma in men has not been adequately studied.
The youngest patient with melasma in our study was 22 years and the eldest was 50 years old. In the two different studies, the age of melasma in men was 33.5 years and 34.5 years, respectively, which is similar to our study. The most common age-distribution in our study was in the age - group of 31-40 years (55.5%) which is similar to the observation reported by Sarkar et al(51.2%). However, in two other studies,, 33.3% - 42% of patients belonged to the age - group 31-40 years.
With regard to the age of onset of melasma in the present study, the mean age of onset was found to be 31.5 years, which is similar to the previous studies., The duration of melasma varied from 3 months to 6.5 years in the present study. The mean duration of melasma was 2.3 years. In the other studies done by Sarkar et al., Achar and Rathi and Vachiramon et al., the mean duration of melasma was found to be 1.4 years, 3.59 years and 7 years, respectively. Comparatively, early reporting of patients for treatment in the present study reflects the concern of our patients regarding their facial appearance.
In the present study, 42 (58.3%) patients had a history of sun exposure as a precipitating factor because majority of our patients were agriculturists, labourers, security guards, auto drivers etc. All these patients had 4–6 h of sun exposure/day. Melasma and other pigmentary conditions are more common in dark-complexioned individuals and in those who have greater exposure to the sun caused by their occupation, as observed in the present group of patients. The various studies,,, conducted in men with melasma suggested that prolonged sun exposure can be a precipitating factor, which is consistent with our study.
A positive family history of melasma in the relatives was noted in 29 (40.3%) patients in this study. In three other studies,, a family history of melasma was reported is 70.4%, 33.3% and 14.28% of men with melasma. In a study, all patients had a family history, while two patients acknowledged of having an affected male relative. In another study, which documented remarkable differences even between populations living in similar environmental conditions, the authors suggested that susceptibility of melasma is polygenic in nature. Downregulation of H19 gene which can be detected by microarray analysis of hyperpigmented skin from melasma patients could help in further genetic research.
Hormonal changes, although different from women, may analogously play a role in the development of melasma in men. In the present study, 2 (2.8%) patients showed low levels of testosterone and elevated levels of LH. A study in 15 Indian male melasma patients found higher level of LH and lower level of testosterone when compared with 11 male controls. A similar finding has been reported in another study from India, although in only 9.7% of patients. This finding indicated that subtle testicular resistance may be involved in the pathogenesis of melasma in men.,
In our study, 4 patients were found to have hypothyroidism. Sarkar et al. conducted similar study in 41 males with melasma and noticed hypothyroidism in 3 patients. Lutfi et al. found that thyroid disorders are four - times more frequent in melasma patients than controls, and significant differences were also reported by another study. However, the issue is still controversial. A study showed no difference in thyroid levels between melasma patients and controls, and similar results were also reported by Sacre et al. Further larger studies are needed to clarify this association.
There is no supporting evidence for other causative factors such as, nutritional disorders, hepatic disorders and parasitic infestations, which suggests that the development of melasma is influenced by many factors and depends on the interaction of environmental and hormonal influences in genetically predisposed individuals.,
The most common skin type of patients (Fitzpatrick's skin type) in the present study was found to be type IV (brown colour) seen in 46 (63.9%) patients, followed by type III (light brown) in 22 (30.6%) patients and type V (dark brown) in 4 (5.5%), which was similar to the observation is a study done in male melasma patients In another study, skin type IV (55.5%) was the most common followed by skin type V (44.4%). In the present study, the colour of the melasma macule was light brown in 38 (52.8%) patients, bluish grey in 19 (26.4%) patients and dark brown/black in 15 (20.8%) patients. Dark brown- or black-coloured melasma macules were seen in 66.66% of patients and 33.33% showed light brown-coloured melasma macule in a study done in Tunisian male population. Malar type of pattern in 47 (65.3%) patients is the most common pattern seen in our study, followed by centrofacial pattern in 23 (31.9%) and mandibular pattern in 2 (2.8%) patients, which is consistent with other studies.,, In a similar study by Sialy et al., conducted in male melasma patients, the authors showed centrofacial pattern in 80% followed by malar pattern in 13.3% and mandibular pattern in 6% of patients, which is in contrast to our study. This variation in results might be due to the regional and environmental differences. In the present study, Wood's lamp examination of melasma showed epidermal type in 48.6% of patients followed by dermal type in 33.3% and mixed type in 18.1% of patients, which is similar to other studies., In our study, majority (33.3%) of the patients had a MASI score ranged between 11 and 15 years, followed by 6–10 in 18 patients (25%) and <5 in 13 (18.1%) patients. In the present study, MASI score ranged from 1.2 to 24, with a mean score of 11.6. Pandya et al. stated that MASI has face validity, as it attempts to measure the size and darkness of the pigmentation associated with melasma, which are the most frequent symptoms of patients with this disorder.
Melasma is a common pigmentary disorder that often motivates the search for dermatological care. It is more frequently observed in Indian men, but is definitely less common than in women even though only male patients with melasma were analysed. Although melasma has multifactorial aetiology, the main aggravating factors are sun exposure and family history. Early reporting of patients for treatment reflects the concern of our patients regarding facial appearance. Although the current study is a source of new relevant data on the aetiopathogenesis and epidemiology of melasma in men, prospective studies would be needed for better understanding of this frequent skin disease.
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]
[Table 1], [Table 2]