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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 4
| Issue : 2 | Page : 92-97 |
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Impact of melasma on quality of life in Indian patients
Pooja Arora1, Neha Meena1, PK Sharma1, Mohd Raihan2
1 Dr Ram Manohar Lohia Hospital PGIMER, New Delhi, India
2 Rama Medical College, Ghaziabad, Uttar Pradesh, India
| Date of Web Publication | 1-Dec-2017 |
Correspondence Address:
Pooja Arora
9547, Sector C, Pocket 9, Vasant Kunj, New Delhi - 110 070
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-5847.219683
Introduction: Melasma is a chronic acquired disorder of facial melanosis characterized by brown-black macules on sun exposed areas of face. Melasma has a severe impact on the quality of life (QOL) of the patients, causing emotional, psychological, and social stress.
Aims and objectives: (1) To evaluate the impact of melasma on QOL using the Hindi adaptation of Melasma QOL (Hi-MELASQOL). (2) To study the relation between Melasma Area and Severity Index (MASI) score and Hi-MELASQOL.
Materials and Methods: A total of 156 patients of melasma attending the dermatology outpatient department of our institute were included. Patients were subjected to assessment of MASI score and Hi-MELASQOL questionnaire consisting of 10 objective questions using a Likert-scale of 1 to 7.
Results: Hi-MELASQOL did not correlate statistically with MASI score, age of onset of melasma or with its duration. No statistical significant difference was found among the Hi-MELASQOL scores of patients with different occupation, education levels, or marital status. In Hi-MELASQOL questionnaire, 36.54% cases were bothered due to the appearance of their skin due to melasma, 41.03% felt frustrated, 46.03% felt embarrassed, and 48.72% felt depressed.
Conclusion: Impact of melasma as measured by Hi-MELASQOL revealed that patients with melasma felt frustrated, embarrassed, and depressed. Melasma has effect on interpersonal interactions in Indian patients. However, Hi-MELASQOL is independent of MASI score. Hence, QOL should be assessed in every patient of melasma and treatment plan should be devised taking into account the psychosocial and emotional stress.
Keywords: Melasma, MASI, Hi-MELASQOL
How to cite this article:
Arora P, Meena N, Sharma P K, Raihan M. Impact of melasma on quality of life in Indian patients. Pigment Int 2017;4:92-7 |
| Introduction | |  |
Melasma is an acquired disorder of hyperpigmentation characterized by blotchy, light-to-dark brown macules distributed symmetrically on the sun-exposed parts of the body.[1],[2] Multiple factors implicated in the pathogenesis of melasma includes genetic predisposition, pregnancy, ultraviolet radiation, thyroid dysfunction, drugs, for example, oral contraceptive pills (OCPs), and hormonal therapy.[2],[3] However, the exact etiopathogenesis of melasma is still unclear. The disorder has a severe impact on the quality of life (QOL), causing deep psychological and social stress.[4],[5] Previous studies from Western countries revealed that the QOL of patients with melasma does not correlate well with the Melasma Area and Severity Index (MASI) score.[5],[6],[7],[8],[9],[10],[11] The proposed study aims to evaluate the impact of melasma on QOL in Indian patients using the recently developed Hindi adaptation of Melasma QOL scale (Hi-MELASQOL).
| Materials and methods | | |
In this cross-sectional study, a total of 156 patients of age more than 18 years and less than 60 years, attending the dermatology outpatient department of our institute from January 2016 to March 2016 with the clinical diagnosis of melasma, were included after taking bilingual written consent. The Institutional Ethical Committee approved this study.
The demographic data were recorded in a preset proforma designed for the study. History was taken with regard to age of onset of melasma, duration of melasma, family history, medical history (e.g., thyroid disorder), and exacerbating factors (e.g., sun exposure, OCPs, and pregnancy). All patients were subjected to anthropometric measurements to calculate body mass index (BMI) according to Quetelet Index. Melasma severity was assessed by using the MASI developed by Kimbrough-Green et al.[12] The effect of melasma on QOL was assessed by using a validated Hi-MELASQOL Questionnaire consisting of 10 objective questions using a Likert-scale of 1 to 7; in which 1 signified not bothered at all and 7 signified bothered all the time. Hi-MELASQOL score ranges from 10 to 70, with a higher score signifying worse Hi-MELASQOL.[5],[6]
Analysis of data was performed using SPSS version 22 (Statistical Packages for the Social Sciences, Chicago, Illinois, USA). Quantitative data were presented as mean ± standard deviation or median as appropriate. Groups were compared using one-way analysis of variance (ANOVA), Kruskal–Wallis or Mann–Whitney test, whichever was applicable. Chi-square test or Fisher’s exact test, whichever was appropriate, was applied for categorical data. Spearman correlation coefficient was applied to see relationship between different variables. P value of <0.05 was considered to indicate statistical significance.
| Results | | |
The demographic profile of the 156 patients included in the study is depicted in [Table 1]. Various predisposing factors of melasma in the study population are summarized in [Table 2]. MASI score and Hi-MELASQOL were calculated in all patients. Mean MASI score was 4.9 ± 3.02 and mean Hi-MELASQOL score was 37.73 ± 15.00. Hi-MELASQOL questionnaire and responses of all questions (Q1–Q10) on Likert-scale (1–7) are shown in [Table 3], [Table 4], and Graph 1 
. Variation in mean MASI score and mean Hi-MELASQOL with educational qualification, occupation, and marital status are depicted in [Table 5]. | Table 3: MELASQOL questionnaire[5],[6] and responses of all questions (Q1–Q10) on Likert-scale (1–7)
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 | Table 5: Mean MASI score and Mean MELASQOL score in relation to educational qualification, occupation, and marital status of the melasma patients in the study
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Hi-MELASQOL was not statistically correlated with MASI score (P = 0.131, Spearman’s rho R = −0.121). There was no statistical significance difference between the Hi-MELASQOL scores of females and males (P = 0.986). Hi-MELASQOL does not correlate with the age of onset of melasma (P = 0.351, R = −0.075) or its duration (P = 0.292, R = 0.085). Hi-MELASQOL was also not statistically correlated with BMI (P = 0.311, Spearman’s rho R = −0.083). No statistical significant difference was found among the Hi-MELASQOL scores of patients with different occupation (P = 0.952). Similarly, there was no statistically significant difference between the Hi-MELASQOL of patient with different education levels (P = 0.444). We also observed that there was no statistical significant difference of Hi-MELASQOL and marital status of the patients (P = 0.671).
In Hi-MELASQOL questionnaire, out of total 156 melasma patients, 66 (42.31%) were either not bothered at all or not bothered sometimes (Likert-scale 1–3) due to the appearance of their skin due to melasma, 33 (21.15 %) gave neutral response (Likert-scale 4), whereas 57 (36.54%) were bothered sometimes or all the times (Likert-scale 5–7). In this study, 64 (41.03%) cases felt frustrated about their skin condition all the times or sometimes, 73 (46.03%) felt embarrassment, and 76 (48.72%) felt depressed. When the study population was asked about the effects of melasma on their interactions with other people (e.g., interactions with family, friends, close relationship, etc.), 81 (51.93%) patients of melasma felt that their melasma bothered them (Likert-scale 5–7), while 53 (33.97%) cases felt that it did not bother them (Likert-scale 1–3). In 79 (50.64%) cases, melasma also had effect on their desire to with other people; however, 52 (33.34%) cases felt otherwise. In 62 (39.74%) cases, melasma made it hard to show affection, whereas 67 (42.94%) cases did not feel this way. We found that 62 (39.75%) cases felt that melasma made them unattractive to others; interestingly, almost equal number of cases that is, 58 (37.17%) were not bothered about this. Most importantly, only one-fourth of the study population felt that melasma made them less vital/productive, and that it affected their sense of freedom (36 [23.08%] and 42 [26.93%]).
| Discussion | | |
Melasma is a common disorder of acquired hyperpigmentation characterized by tan or brown macules and patches localized to photo-exposed areas of the face, particularly the malar areas, forehead, and chin.[1],[2] Melasma accounts for 0.25 to 4% of the patients seen in dermatology clinics in South East Asia and is the most common pigment disorder among Indians.[1],[3],[13] It is more prevalent in women, with men comprising about 10% of all cases as in our study.[1],[2],[14] The common age group affected is 21 to 40 years as in the present study.[14] Melasma affects all races but is especially prevalent in those with darker skin types (Fitzpatrick skin types IV to VI) and has been highly reported in patients of Hispanic, African American, Arab, Southeast Asian, and East Asian descent.[2],[13]
The exact etiopathogenesis of melasma is still unclear. Studies suggest that both melanocytosis as well as increased melanogenesis are responsible for the hyperpigmentation in melasma.[2] Also, Kim et al. found that vascular endothelial growth factor was increased in lesional skin in melasma signifying increased vascularization.[15] Various factors implicated in occurrence of melasma includes genetic predisposition, ultraviolet light exposure, pregnancy, oral contraceptives, hormone replacement therapy, thyroid disease, cosmetics, and medications.[1],[2],[4] The lesions are usually asymptomatic but often have considerable emotional and psychological effects.[1],[2],[4] In a recent study conducted by Achar et al. in 312 Indian patients, the mean age of patients with melasma was 33.45 years, ranging from 14 to 54 years.[1] There was a female preponderance with a female-to-male ratio of approximately 4:1. The mean age of onset was 29.99 years, with the youngest and oldest being 11 and 49 years, respectively.[1]
The concept of QOL is becoming increasingly important in medicine, particularly in dermatology where many cutaneous diseases have the potential to affect the quality rather than the length of life.[4],[5],[16] As such, there has been increasing interest in devising methodology to accurately measure the impact of disease on QOL for use in clinical practice, research studies, and economic analyses. There are several instruments used to capture the impact of disease on QOL, which can be categorized into two principal categories: preference-based measures and health status QOL assessments. Preference-based measures are derived from decision-making theory and determine patient preferences for a specific health state by inviting patients to hypothetically give up something of value, such as money, years of life, and so forth. In contrast, health status QOL measures capture the impact of disease on various dimensions of QOL, such as the cognitive, social, and emotional aspects, as well as physical discomfort and limitations.[16]
Assessing QOL is important in determining a treatment plan and its efficacy, particularly because health status may not correlate with severity of disease. MASI is developed by Kimbrough-Green et al. for the assessment of melasma.[12] The MASI score is used to reliably measure the clinical severity of melasma and monitor changes after therapy. However, the QOL of patients with melasma does not correlate well with the MASI score.[5],[6],[7],[8],[9],[10],[11] Hence, the psychological impact of melasma, with its disfiguring facial discoloration and chronic nature, has profound negative effects on patients’ QOL, which is not captured by the MASI.
Mean MASI score in our study was 4.7; this is in agreement with study by Yalamanchili et al. who reported mean MASI of 5.7.[14] However, mean MASI score in recent study by Sarkar et al. was 20.0 ± 7.5.[6]
Balkrishnan et al. developed a QOL instrument for patients with melasma that accounted for the unique impact of the facial lesions on the psychological and social wellbeing of the individual while ignoring physical symptoms.[5] They devised the original MELASQOL in English to address the inadequacy of generic and dermatology QOL instruments for evaluating melasma. Balkrishnan et al. reported mean MELASQOL score of 36, and the mean age was 39.7 years. The mean MEALSQOL in our study was 37.5. Women in the 20- to 30-year age group had a significantly higher MELASQOL mean of 50.4 than other age groups.[5]
MELASQOL has now been translated and validated in Spanish, French, Brazilian Portuguese, Persian, Iranian, Turkish, and very recently in Hindi.[5],[6],[7],[8],[9],[10],[11],[16],[17]
In a very recent Indian study of 100 melasma female patients, Sarkar et al. reported the mean Hi-MELASQOL score of 37.19 which is slightly lower than our score.[6] Lower mean MELASQOL score was also reported by Balkrishnan et al., Dogramaci et al., and Misery et al. (36, 29.9, and 20.9, respectively).[5],[7],[8] On the other hand, Dominguez et al. and Aghaei et al. reported higher mean MELASQOL score (42 and 52.85, respectively) score.[10],[11]
In a French study of 28 females with melasma, the mean MELASQOL-F score was 20.9 (range 15.9–25.9). Women over 45 years of age had a higher score than those below 45 years of age (24.6 vs. 18.5). The MELASQOL-F score was 14.8 when time with melasma was less than 5 years, 28.7 from 6 to 10 years, and 23.6 when melasma was present for more than 10 years. However, we did not find such correlation between Hi-MELASQOL and duration of disease. High BMI did not modify MELASQOL-F score similar to our study.[8] These variations in MELASQOL may be due to differences in cultural, social, occupational, sun exposure, skin type, self awareness, and so on. Dogramaci et al. found no statistical difference between MELASQOL-Tr score and education level, age, and variations in other demographic factors similar to our study.[7]
Similar results were seen in previous studies by Balkrishnan et al., Freitag et al., Dominguez et al., and Sarkar et al. that found no statistical significant correlation between MELASQOL and MASI score.[5],[6],[9],[10] This suggests that the impact of melasma is not related with the degree of severity of melasma. Patient with lower MASI score may be more stressed due to melasma as compared to the patient with higher MASI score. Balkrishnan suggests that clinical severity is not the sole criterion used by patients to assess the impairment caused by their skin condition.[5] This implies that the therapeutic decisions should not only be based on the clinical aspects or MASI, but also include the psychological impact of melasma.
| Limitation | | |
Larger sample size may help in further validation of our results.
| Conclusion | | |
Hi-MELASQOL is an important tool for assessment of the impact of melasma on patient’s emotional and psychological wellbeing. Patients with melasma felt frustrated, embarrassed and depressed. Melasma has effect on interpersonal interactions. This impact is independent of the MASI, sex, age of onset, and duration of disease. Hence, QOL should be assessed in every patient of melasma and treatment plan should be devised taking into account the psychosocial and emotional stress.
Acknowledgement
We are thankful to Dr. Rashmi Sarkar (Professor, Department of Dermatology, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India) for giving us the permission to use Hi-MELASQOL in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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