Journal of Pakistan Association of Dermatologists. 2016;26 (3):188-192.

Original Article
Association of epidermal melasma with skin phenotypes
and other contributing factors
Numera Amin, Asher Ahmed Mashhood, Afsheen Bilal

Dermatology Department, Combined Military Hospital, Multan

Abstract Objective The objective of this study was to determine the extent to which various factors
contribute in the development of epidermal types of melasma.

Methods This single-center, cross-sectional study was carried out in the Department of
Dermatology, Combined Military Hospital Multan, from July 2014 to December 2014. The study
population was married females of reproductive ages, who reported in skin outpatient for treatment.
A proforma was designed to get information regarding various factors that are assumed to
predispose to the development of epidermal melasma. Type of our data was categorical. SPSS
version 19 was used to analyze the data.

Results 88 patients were included in the study. Their ages ranged between 20-45 years (mean age
30±5.5 years). Eighty-two patients were housewives and 6 teachers. The main skin phenotype seen
in our patients was type IV (60.2%). 56.8% of patients developed melasma while they were
pregnant and 27.3% developed it after excessive sun exposure.

Conclusion Among various suspected causes; skin type IV, pregnancy and excessive sun exposure
were the major contributory factors in causation of epidermal-type melasma.

Key words
Epidermal melasma, skin phenotypes, hemoglobin.

Introduction melasma and the contributing factors in this

regard are; pregnancy, use of oral
Melasma, the most common acquired contraceptives, sun exposure and iron
hypermelanosis in females, is characterized by deficiency.3 Melasma is seen in women mostly
brownish and grey black, bilaterally symmetrical in their reproductive years. It is rare in pre-
macules and patches on face. It predominantly pubertal and postmenopausal women4; strongly
affects areas above the upper lips, nose, cheeks, suggesting a hormonal etiology. There has not
forehead and chin.1 There are three distinct types been any study regarding the prevalence of
of melasma; epidermal, dermal and mixed type, melasma in Pakistan. The disease worsens
epidermal being the most common type.2 It during summer season and fades relatively
affects women more than men. There are many during winters5. It being the cosmetic concern,
studies that have been conducted to investigate puts the patients under psychological stress and
the factors that contribute to the development of social disruptions.

Address for correspondence Methods

Brig. Asher Ahmed Mashhood
Classified Skin Specialist This was a single-center, cross-sectional study,
CMH, Peshawar
E mail: [email protected] carried out in the Department of Dermatology,

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Combined Military Hospital Multan, a tertiary are all known to contribute to melasma. Diseases
care hospital from July 2014 to December 2014 excluded in the study were Addison’s disease,
over a period of six months. Cushing’s syndrome, hypo- and
hyperthyroidism. The contributing factors were
The study population was married females of assessed by detailed history, examination and
reproductive ages, who reported in skin OPD for interview of the patient. Hemoglobin status was
treatment. The patients in the study group were checked through rapid method. Skin phenotype
not the permanent residents of Multan city, but was assessed according to Fitzpatrick’s skin type
were there due to their husband’s posting; hence scale which classifies skin into six phenotypes, I
presenting as a mixed ethnic group. to VI. Type of melasma was assessed using
Wood’s lamp.
We selected one hundred female patients of
reproductive age group. Out of 100, 88 patients Type of our data was categorical. SPSS version
were having epidermal type and 12 having 19 was used to analyze the data and the
dermal type melasma. As the main focus of our relationship among various variables was
study was epidermal type so we selected only 88 established by using cross tabulation. Each
patients with epidermal-type melasma for the factor was discussed in detail as an individual
study. variable. Statistical significance was assessed by
using chi-square (X2) goodness of fit test. At
Inclusion criteria of the study were: voluntary 95% confidence interval the level of significance
consent for participation in the study, only (α) was 0.05.
female patients of melasma, females in the
reproductive age group and patients having Results
epidermal type melasma only. Females below 15
and above 55 years of age were excluded. Total 88 female patients with epidermal-type
melasma were selected for the study. The ages
A proforma was designed to get information of these patients ranged between 20-45 years
regarding various factors that predisposed to the (mean age 30±5.5 years). Regarding occupation,
development of epidermal melasma and to find 82 patients were housewives and 6 were doing
out the relationship of epidermal melasma with some teaching jobs.
skin phenotypes. Each patient was informed
about the purpose of study in detail and In our study group, intermediate skin phenotypes
informed consent was sought from the patients (III, IV, and V) were predominantly seen. Out of
to fill up the proforma. The proforma included 88, 7 (8.0%) patients had type III, 53 (60.2%)
patient’s biodata i.e. name, age, occupation, patients had type IV and 28 (31.8%) had type V
social status, residence; types of skin (I to VI); phenotype. The results showed that skin type IV
and types of melasma (epidermal, dermal and was most vulnerable to develop epidermal
mixed). It also included 14 questions relating to melasma as compared to phenotypes III and V.
contributing factors (viz. pregnancy, level of sun This relationship of epidermal melasma with
exposure, use of oral contraceptives, endocrine skin phenotype IV was statistically significant
and other disease associations, drug intake other too. Figure 1 shows relationships of various
than contraceptives and iron deficiency). Drugs skin phenotypes with epidermal melasma.
taken into consideration for study were
chlorpromazine, ACTH, and antimalarial as they

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As regards other contributing factors, 50 out of 88 patients had pregnancy (56.8%), 24 had

Figure 1 Frequency of melasma in different skin types.

Figure 2 Frequency of various factors in melasma.

excessive and significant sun exposure (27.3%), Hb below the standard value, iron deficiency
1 (1.1%) gave history of using oral contraceptive could not be documented as the sole contributing
pills (OCPs), 2 (2.3%) gave history of taking factor because it was seen in association with
antimalarial and 2 (2.3%) had positive history of other major contributing factors like pregnancy.
hyperthyroidism. As regards iron deficiency, 63 In only 7 of 17 patients, iron deficiency was the
(71.6%) patients had hemoglobin (Hb) around only contributing factor. Of all factors,
the standard value while 17 (19.32%) had Hb pregnancy and skin type IV were statistically
below the standard value, remaining 8 patients significant with chi-square value of X2 =1.636
did not turn up for follow-up with their and 3.682, respectively, less than the critical
laboratory reports. Out of 17 patients who had value of 3.84 (calculated).

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Table 1 Comparison of the results of various studies on the role of contributing factors in causation of melasma
Study Pregnancy Oral contraceptive Sun exposure Iron deficiency
pills
Ilaria and Aled [2] Yes Yes - -
Athar Moin et al. [3] 14.5% 11% 9.8% -
Tamega et al. [4] 36% 16% 27% -
Arun and Sanjay [5] 22.4% 18.4% 55.12% -
Ana Carolina et al. [6] 85% - 66% -
Nooshin et al. [7] 10% - 15%
Passeron [8] - - 26% -
Ortonne et al. [10] 42% 25% - -
Present study 56.8% 1.1% 27.3% 19.3%

Figure 2 shows the observed and expected the dermal melasma being the most common
frequencies of various contributing factors under type seen in 54.48% patients; epidermal and
study. mixed types were seen in 21.47% and 24.03% of
the cases respectively while in our study group
Discussion epidermal melasma was the most common type.5

Various studies on melasma focused on Another study by Ana Carolina et al.6 showed
contributing factors of melasma. In our study that 52 out of 61 (85%) patients reported having
skin type IV (60.2%), pregnancy (56.8%) and melasma during pregnancy and 66% contributed
sun exposure (27.3%) were major contributing it to sun exposure.
factors for epidermal melasma.
A study by Bagherani et al.7 revealed the
2
In a study by Muller and Reeds, there was high familial predisposition and genetic component is
prevalence of melasma in pregnancy. Other the most important risk factor for the
contributing factors were use of OCPs and development of melasma, with 10% and 15% of
association with thyroid disorder in one case. patients having pregnancy and UVR,
respectively as other important predisposing
In another study by Athar et al.3 11% of patients factor in the melasma development.
declared that they developed melasma after
using OCP’s, 14.5% developed after pregnancy A study by Passeron8 revealed the following
and 9.8% after excessive sun exposure. contributing factors in his study population;
genetic background, exposure to ultraviolet
In the study by Tamega et al.4 the most common radiation and female sex hormones.
triggering factors were pregnancy 36%, OCPs
16% and intense sun exposure 27%. In a study by Aluka et al.9 the frequency of
epidermal melasma was highest (46.5%) like our
A study by Arun and Sanjay5 showed that about study.
55.12% patients reported their disease to be
exacerbated during sun exposure. Among 250 In a study by Ortonne et al.10, 48% of subjects
female patients, 56 (22.4%) reported pregnancy questioned had a family history of melasma
and 46 (18.4%) reported oral contraceptive as (97% in a first-degree relative). Subjects with
the precipitating factors. The same study showed family history of melasma tended to have darker

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skin (90% types III-VI) compared to those 3. Athar M, Zahra J, Nader F. Prevalence and
without (77% types III-VI). The most common awareness of melasma during pregnancy. Int
J Dermatol. 2006;45:285-8.
time of onset was after pregnancy (42%), 25% 4. Tamega Ade A, Miot LDB, Bonfietti C,
who had used hormonal contraception claimed Gige TC, Marques MEA, Miot HA. Clinical
that melasma appeared for the first time after its patterns and epidemiological characteristics
use. of facial melasma in Brazilian women. J Eur
Acad Dermatol Venereol. 2013;27:151-6.
5. Arun A, Sanjay KR. Melasma: a clinico-
A comparison of results of these studies with our epidemiological study of 312 cases. Indian J
study is presented in Table 1. Dermatol. 2011;56:380-2.
6. Ana CH, Luciane DBM, Hélio AM.
Melasma: a clinical and epidemiological
Conclusion review. An Bras Dermatol. 2014;89:5.
7. Bagherani N, Gianfoldoni S, Smoller B. An
Among the various factors which were studied overview on melasma. J Pigment Disord.
as the cause of epidermal-type melasma, we 2015;2:216. doi: 10.4172/2376-0427.
1000216
could only find pregnancy and sun exposure as 8. Passeron T. Melasma pathogenesis and
statistically significant contributory factors. influencing factors - an overview of the
Among skin phenotypes, type IV showed more latest research. J Eur Acad Dermatol
Venereol. 2013;27 (Suppl 1):5-6.
vulnerability to develop epidermal melasma
9. Aluka JR, Priyank K, Sanker RS, Jain SK.
followed by type V. Endocrinological evaluation of melasma in
females of western Uttar Pradesh region. Int
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