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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 4
| Issue : 1 | Page : 39-44 |
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Melasma: Its impact on quality of life
Manjaree Morgaonkar1, Savera Gupta2, Anita Vijay2, Suresh K Jain2, Manoj Sharma2, Shail Agarwal2
1 Department of Dermatology, Venereology and Leprology, Pad. Dr. Vithalrao Vikhe Patil Medical College and Hospital, Ahmednagar, Maharashtra, India
2 Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, Rajasthan, India
| Date of Web Publication | 19-Jun-2017 |
Correspondence Address:
Suresh K Jain
Head of Department, Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-5847.208298
Background: Melasma is the most common cause of facial melanoses in Indian population. It is mostly seen in females of reproductive age group. Since any kind of alteration in skin colour is considered to be abominable and melasma being a difficult-to-treat condition, it is understandable that it adversely affects the psychological and emotional well-being of the patients.
Aim: To study the quality of life (QoL) in patients with melasma and its correlation with disease severity.
Materials and Methods: A total of 104 melasma patients were enrolled. Severity of melasma was scored on the basis of Modified Melasma Area and Severity Index. QoL was assessed by Dermatology Life Quality Index (DLQI) questionnaire.
Results: The overall mean DLQI was 9.92 ± 7.01 with relatively higher value in females than males. Those between the age group 16 and 35 years had higher DLQI compared to the older age group. The DLQI significantly increased with the socio-economic status of the patients. Unmarried females had a significantly poorer QoL (13.64 ± 8.2) compared to married females (9.16 ± 7). The DLQI score increased with the severity of melasma, though the results were not statistically significant. Those with shorter duration of disease (<1 year) had greater impact on QoL when compared to those with longer duration.
Conclusion: The results show that an asymptomatic, totally benign disease such as melasma has a moderate effect on the QoL of the patients. Moreover, the clinical severity cannot be considered as the sole criteria to decide the impact of melasma on patient’s QoL. Other factors such as socio-economic status and marital status additionally play a significant role. Assessment and treatment of psychological consequences must be considered as an indispensable part of management of melasma patients.
Keywords: Melasma, M-MASI, quality of life, severity
How to cite this article:
Morgaonkar M, Gupta S, Vijay A, Jain SK, Sharma M, Agarwal S. Melasma: Its impact on quality of life. Pigment Int 2017;4:39-44 |
| Introduction | |  |
Melasma, derived from a Greek word melas (black), is characterised by symmetrical hyperpigmented macules on the sun-exposed areas of the skin.[1],[2] It is more common pigmentary disorder in Asians. It is most prevalent in women than in men (9:1) and is seen predominantly in women of reproductive age group. Though several factors including sun exposure, hormonal factors[3],[4] and genetic factors are implicated in its aetiology, the exact underlying pathomechanism is yet unknown. The disease is difficult-to-treat, particularly in constitutionally darker skin types.
Nevertheless, any alteration in the homogeneity of skin colour is regarded as unaesthetic and hence melasma poses a significant impact on the emotional and psychological health of those affected.[5],[6] Considering the paucity of data on how melasma affects quality of life (QoL) in the Indian population, we conducted a questionnaire-based study to identify Dermatology Life Quality Index (DLQI) in the affected patients and its correlation with clinical severity of melasma.
| Materials And Methods | | |
It was a hospital-based cross-sectional study conducted during a period of 6 months from March 2016 to August 2016 after approval by the Institutional Ethical Committee. A total of 104 melasma patients who were older than 16 years of age and could read and write in local language (Hindi) and could complete the DLQI questionnaire by themselves were included after obtaining a verbal consent to participate in the study. Diagnosis of melasma was made clinically by two senior dermatologists, and severity was assessed by Modified Melasma Area Severity Index (M-MASI) score.[7] M-MASI score is obtained by applying the equation
where A = area, D = darkness, f = forehead, rm = right malar, lm = left malar and c = chin. The darkness was scored as 0 = absent, 1 = slight, 2 = mild, 3 = marked and 4 = severe. Scoring of the area of involvement was as follows: 0 (absent), 1 (<10%), 2 (10–29%), 3 (30–49%), 4 (50–69%), 5 (70–89%) and 6 (90–100%). The total score ranges from 0 to 24. It can be further categorised into mild (0–8), moderate (8–16) and severe (16–24). Cases of facial melanoses other than melasma such as ashy dermatoses, lichen pigmentosus, lichen planus actinicus, fixed drug eruption, nevus spilus, nevus of Ota, post-inflammatory hyperpigmentation and photocontact dermatitis were excluded from the study. Also, those having systemic causes of pigmentation, on history or on examination, such as systemic lupus erythematosus, Addison’s disease, hemochromatosis, and patients who had been taking drugs that cause pigmentation, for example, minocycline, chlorpromazine, amiodarone, antimalarials, etc. were not enrolled. Demographic profile of the study population was recorded and socio-economic status was assessed by the updated BG Prasad classification.[8] It is based on per capita monthly income and is widely used to determine socio-economic status of the study population in health studies. It has an advantage of being applicable to both urban and rural areas. All the patients were requested to fill the validated Hindi version[9] of DLQI questionnaire originally devised by Finlay and Khan.[10],[11] DLQI is a set of 10 questions that cover six different domains which are symptoms and feelings (Q1, 2), daily activities (Q3, 4), leisure activities (Q5, 6), work and schooling (Q7), personal relationships (Q8, 9) and treatment of the disease (Q10). The patients were asked to score on a scale from 0 to 3, for each of 10 questions, how they felt their lives have been affected by the disease over the preceding week. The response for each question could be 0 = not at all, 1 = a little, 2 = a lot and 3 = very much. The total score ranged from 0 to 30. The higher the score, the poorer was the QoL.
The statistical analysis was done using the Statistical Package for the Social Sciences version 16 (SPSS Inc., Chicago, IL, USA) for Windows and P value of <0.05 was considered to be statistically significant.
| Results | | |
Out of total 104 patients, 82 (78.84%) were females and 22 (21.15%) were males, with F:M ratio of 3.7:1. Mean age of the patients was 31.45 ± 8.19 years (range 16–50 years), and majority (51, 49%) were in the age group of 26–35 years. A total of 74 (71.15%) cases were married and 30 (28.84%) were unmarried. Almost all the patients resided in urban areas (95, 91%), and only 9 (9%) patients were from rural areas. A total of 91 (88%) patients were employed, and the rest 13 (12%) were unemployed.
On analysing the socio-economic status of the study group, the majority were from upper (26, 25%) and middle (25, 24%) socio-economic class. Family history was positive in 24 (23%) cases. A total of 20 female patients gave history of past or present use of oral contraceptive pills. Excessive sun exposure was found to be the contributory factor in 35 (34%) cases.
Forty three patients (41.34%) had a disease duration of less than 1 year, 47 (45.19%) between 1 and 5 years, and only 14 (13.46%) had a duration of >5 years. On classifying the patients according to severity of melasma using M-MASI score, there were 78 (75%) patients with mild disease, 23 (22.11%) patients with moderate disease and only 3 (2.88%) patients had severe disease.
The mean DLQI score of total sample size was 9.92 ± 7.01. No significant difference was found on comparing the mean DLQI scores between different age groups (P value 0.37). Comparison of the mean DLQI scores based on gender revealed that females had a higher score, that is, 10.09 ± 7.4 than males who had a score of 9.27 ± 5.9, but the results were not statistically significant (P value 0.63). Though the urban population had a higher score (10.28 ± 7.5) compared to rural population (6.11 ± 5.25), but it was not statistically significant (P value 0.1). Similarly, the employed individuals had higher scores (10.6 ± 6.8) as compared to the unemployed individuals (8.2 ± 5.1), but the results were statistically insignificant (P value 0.22). The comparison of mean DLQI scores of various socio-economic status showed that those with higher status had significantly higher scores (P value <0.001). Cases of upper class had a mean 13.57 ± 7.9, while value for upper middle class, middle class, lower middle class and lower class were 12.36 ± 6.9, 9.12 ± 5.5, 7.33 ± 7 and 4.76 ± 3.39, respectively. Moreover, unmarried females had a significantly higher mean DLQI score (13.64 ± 8.2) as compared to married females (9.16 ± 7) (P value 0.02). However, no such difference was found in male patients [Table 1]. | Table 1: Descriptive characteristics of cases and their correlation with DLQI
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Regarding the mean DLQI scores of patients with respect to severity of melasma, patients with mild disease had a mean DLQI score of 9.34 ± 7, while the respective values for moderate and severe disease were 11.17 ± 7.5 and 15.33 ± 6.8. This showed that the mean DLQI score increased with an increase in severity of melasma, though the results were not statistically significant (P value 0.23) [Table 2].
The mean DLQI score was higher in patients suffering from melasma ≤1 year (11 ± 7.2), while higher durations had lower value for mean DLQI. The results were, however, not statistically significant (P value 0.30) [Table 3].
Mean DLQI scores for each of the 10 questions showed that the highest score was given for question no. 2 (1.75), followed by question no. 10 (1.17) [Figure 1]. The seventh question was given the least score by the patients. Accordingly, the most affected domain of DLQI was symptoms and feelings, followed by treatment. The domain affecting work and school was least affected [Figure 2]. | Figure 1: Bar graph depicting average scores of each of the questions of DLQI questionnaire
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A total of eight patients responded when asked whether they felt the questions were difficult. Three patients found question no. 5 to be difficult, for another three patients question no. 9 was difficult and for two patients question no. 10 was difficult.
| Discussion | | |
Facial melanoses cause cosmetic disfigurement with considerable psychological impact in those affected. Melasma, the most common facial melanosis in Indian patients, adversely affects the QoL as one’s appearance plays a profound role in self-perception as well as social interactions.[12] QoL is a broad ranging concept that assesses the complex way by which a particular medical condition affects psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment. We evaluated the effect of melasma on patients’ QoL by calculating the scores of DLQI questionnaire, which is the first and most frequently used dermatology-specific QoL assessment tool. It is validated for use in over 90 languages, including Hindi. We found that the overall mean DLQI of the study population was 9.92. On the basis of the interpretation of the DLQI scores,[13] that is, score 0–1 = no effect at all on patient’s life, 2–5 = small effect on life, 6–10 = moderate effect, 11–20 = very large effect, 21–30 = extremely large effect on patient’s life, it could be derived that melasma had a moderate impact on QoL of our patients.
Melasma occurs in middle-aged adults and is more commonly seen in females. Males constituted 21% of our cases. This is comparable to other studies from India where men represented 20.5–25.83% of the cases.[14],[15],[16] This could be attributed to the fact that melasma is more common among women because hormonal activity is considered one of the important causative factors. In our study, the female patients showed a greater impairment of QoL than the male patients, similar findings were noted by Arellano et al.[17] and Ali et al.[18] These results indicate that women are likely to be more conscious and apprehensive about their appearance than men. The mean age of patients in our study was 31.45 ± 8.19 years with maximum number of patients in the age group of 26–35 years. Various studies revealed the mean age between 36 and 40 years.[19],[20],[21] This could be attributed to social and ethnic variations in different parts of world. Since 20–30 years is peak age for getting married in our country, this might compel people to report and seek advice earlier about their disease. Though there was no statistical difference between the DLQI of different age groups, it was noticed in our study that the QoL was less affected by melasma in patients of age group 46–55 years, this was similar with the result of Farag et al.[19] and Balkrishnan et al.,[21] where patients of this age also showed less QoL impairment as compared to other age groups. In our study, the mean DLQI was higher in urban population than rural population. Those who were employed had higher scores than the unemployed. Moreover, the socio-economic class to which one belongs has proved to play a notable role in QoL of the patients. In our survey, patients with upper socio-economic class showed a significant worse QoL (very large effect) when compared with lower socio-economic class (small effect). These results are in contrast to those found be Dominguez et al.[22] and Freitag et al.[23] In both these studies, it was observed that there was a significant worse QoL in an inferior educational status class, which in our opinion could not be fully rationalised. Agreeably, the higher income group of our society leads a professional life and tends to socialise more. In this context, a difficult-to-treat hyperpigmentation on the face could be a cause of excessive self-consciousness, embarrassment and anxiety.
Our study showed that among the female patients, unmarried female patients had a significantly greater impairment (very large effect) of QoL than the married ones (moderate effect). Similar findings were noted in the study by Ali et al.[18] A study by Dominguez et al.,[22] however, noted no such difference. This is understandable owing to the undue importance given to ‘fair’ skin by some individuals in our country. This is so because lighter skin tone has been considered a superior trait in most races, especially in women of Asian or African descent who have Fitzpatrick skin types IV–VI.The present study revealed that patients suffering from more severe disease had a higher mean DLQI score, although no significant correlation was seen. Our findings are consistent with those of Freitag et al.[23] On the contrary, a significant correlation was seen by Ali et al.[18] study. A moderate correlation was observed in studies performed by Farag et al.[19] and Balkrishnan et al.[21] Results of present study indicate that clinical severity is not the sole criterion used by patients to assess the impairment caused by their skin condition. Thus the physician may erroneously consider a patient as having mild form of disease, whereas in fact he/she may be extremely upset, anxious and may feel that his/her lesions cause a significant impact of his/her life. This emphasises that therapeutic decisions cannot be solely based on clinical aspects but should also consider the psychological aspect. Thus QoL in melasma has emerged as an important outcome of clinical investigation and should be assessed as far as possible.[24]
In the present study, the patients with melasma for a shorter duration of time had a poorer QoL. This finding is in contrast with previous studies conducted by Dominguez et al.[22] and Ali et al.,[18] which demonstrated that QoL is more impaired in cases with long standing disease. Our results could be explained as a more recent change in skin colour may be more distressing to the patient. On the other hand, those with longer duration may accommodate themselves with the disease, and melasma being an asymptomatic condition may not pose a profound impact on daily lives of this subgroup of patients.
The most adversely affected domain of DLQI in our study was the symptom and feelings followed by treatment, implying that the hyperpigmentation over face led to the feeling of unattractiveness and worthlessness in our patients. Believing that others are focusing on their skin resulted in avoidance of social gatherings, thereby hampering the QoL. As melasma is a difficult-to-treat condition and is associated with frequent relapses after treatment discontinuation, this particular aspect caused distress to the patients, both in terms of time and money.
Despite melasma being the most common cause of hyperpigmentation on face, the studies evaluating its impact on QoL are scarce. This study highlights the fact that since the clinical severity of melasma does not proportionately match with its impact on QoL, it is imperative to manage the patient as a whole considering both the clinical as well as emotional aspects. In addition to medical or aesthetic modalities of treatment, a due regard to assessment and treatment of psychological consequences must be given. This would not only result in better overall patient satisfaction, but also help build a doctor–patient rapport.
Nevertheless, there are a few limitations to the present study. Firstly, it represents data from a particular region of the country, and regional and cultural variations altering the DLQI score are expected. Moreover, a larger sample size and inclusion of the age- and gender-matched control group would have added more value to the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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