Melasma and pregnancy in southern Brazil

Melasma and assessment of the quality of life in Brazilian women

BACKGROUND

Melasma is a chronic, acquired hyperpigmentation disease on sun-exposed areas of the skin, which affects patients' quality of life.

OBJECTIVE

To assess the impact on the quality of life of women living in Florianópolis, Brazil, through questionnaire (MelasQol), and investigate the clinical aspects and risk factors for melasma, correlating them with the MelasQol scores.

METHODS

This study was performed on 51 melasma patients cared for at the University Hospital of the Universidade Federal de Santa Catarina. The variables included were: age, gender, age of onset of melasma, Fitzpatrick phototype (I-VI), duration and family history of melasma, onset of melasma during pregnancy, use of hormonal contraceptive, thyroid disorder and distribution of melasma. The MelasQoL questionnaire, validated for Brazilian Portuguese (MelasQoL-BP), was applied.

RESULTS

The mean age was 38.43±6.75 years. All patients were women. The most common Fitzpatrick skin phototypes were III (49.02%) and IV (33.33%). Melasma had a mean age of onset of 29.18±7.05 years and a mean duration of 9.25±6.18 years. The majority of patients did not have familial history of melasma (50.98%). Melasma onset was associated with pregnancy (45.10%). The MelasQoL-BP analysis revealed significant emotional impact on patients, such as feeling bothered (94.11%), frustrated and embarrassed (64.71%), and depressed (52.94%) about their skin appearance, as well as unattractive (78.43%). No social impact was observed (P>0.05).

CONCLUSION

Melasma has a strong emotional impact on quality of life, resulting especially from feelings about skin appearance.

Melasma: a clinical and epidemiological review

Melasma is a chronic acquired hypermelanosis of the skin, characterized by irregular brown macules symmetrically distributed on sun-exposed areas of the body, particularly on the face. It is a common cause of demand for dermatological care that affects mainly women (especially during the menacme), and more pigmented phenotypes (Fitzpatrick skin types III-V). Due to its frequent facial involvement, the disease has an impact on the quality of life of patients. Its pathogeny is not yet completely understood, although there are some known triggering factors such as sun exposure, pregnancy, sexual hormones, inflammatory processes of the skin, use of cosmetics, steroids, and photosensitizing drugs. There is also a clear genetic predisposition, since over 40% of patients reported having relatives affected with the disease. In this manuscript, the authors discuss the main clinical and epidemiological aspects of melasma.

Evidence-based treatment for melasma: expert opinion and a review

Introduction

Melasma is one of the most common pigmentary disorders seen by dermatologists and often occurs among women with darker complexion (Fitzpatrick skin type IV–VI). Even though melasma is a widely recognized cause of significant cosmetic disfigurement worldwide and in India, there is a lack of systematic and clinically usable treatment algorithms and guidelines for melasma management. The present article outlines the epidemiology of melasma, reviews the various treatment options along with their mode of action, underscores the diagnostic dilemmas and quantification of illness, and weighs the evidence of currently available therapies.

Methods

A panel of eminent dermatologists was created and their expert opinion was sought to address lacunae in information to arrive at a working algorithm for optimizing outcome in Indian patients. A thorough literature search from recognized medical databases preceded the panel discussions. The discussions and consensus from the panel discussions were drafted and refined as evidence-based treatment for melasma. The deployment of this algorithm is expected to act as a basis for guiding and refining therapy in the future.

Results

It is recommended that photoprotection and modified Kligman’s formula can be used as a first-line therapy for up to 12 weeks. In most patients, maintenance therapy will be necessary with non-hydroquinone (HQ) products or fixed triple combination intermittently, twice a week or less often. Concomitant camouflage should be offered to the patient at any stage during therapy. Monthly follow-ups are recommended to assess the compliance, tolerance, and efficacy of therapy.

Conclusion

The key therapy recommended is fluorinated steroid containing 2–4% HQ-based triple combination for first line, with additional selective peels if required in second line. Lasers are a last resort.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0064-z) contains supplementary material, which is available to authorized users.

Histological classification of melasma with reflectance confocal microscopy: a pilot study in Chinese patients

OBJECTIVE

To investigate the histological classification of melasma with reflectance confocal microscopy (RCM) in vivo.

METHODS

Two hundred and ten cases with facial melasma lesions were enrolled. After informed consent, the target melasma lesion of 10 patients were imaged with RCM and then biopsied as well. Under the RCM scanning, the distribution of the melanin determined the histological types, and then, the results of RCM images were compared with those of the histopathology. The other 200 cases were tested only with RCM.

RESULTS

For the 10 cases imaged and biopsied, compared with that of the perilesional normal skin, the amount of melanin was significantly increased in the epidermis in all lesions under RCM, while three cases also found melanin in the dermis. Thus, seven of the 10 patients were categorized as the epidermal type while the other three as mixed ones, and the results were well correlated with those of the histopathology. Of the other 200 patients, 143 cases 71.5%) were categorized as the epidermal type while the other 57 (28.5%) cases as mixed ones.

LIMITATIONS

If more melasma cases are biopsied, the data will be more convincing.

CONCLUSION

RCM in vivo analysis shows complete coherence with histopathology results, which could be an alternative for the classification of melasma, and based on the results of RCM imaging, melasma is classified into two major types: the epidermal type and mixed type.

What should be considered in treatment of melasma

Melasma is a common acquired hyperpigmentary skin disorder characterized by light to dark brown macules and patches occurring in the sun-exposed areas of the face. Melasma lesional skin is characterized by epidermal hyperpigmentation through increased melanogenesis in epidermal melanocytes. Some patients have dermal melanin but its amount is not significant and its distribution is very heterogeneous in the whole melasma lesional skin. Melasma is not homogeneous disease and there are personal characteristics of patients with melasma. The pathogenesis of melasma is not fully understood, but several hypotheses have been suggested. Increased vascularity in melasma lesions has suggested the role of increased number of enlarged vessels in the development of melasma. Endogeneous and exogeneous stimuli such as sex hormones and ultraviolet irradiation respectively may stimulate the microenvironment leading to the release of various mediators that cause activation of melanocytes and/or these stimuli may directly activate the melanocytes. Melasma patients may have specialized melanocytes with an intrinsic sensitivity to these stimuli.