An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology
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56 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2018 • Volume 11 • Number 2 R E V I E W association needs to be substantiated by further studies. 5 Further, the association of melasma with thyroid diseases has also been suggested, with higher incidence of thyroid autoimmunity occurring in patients with melasma, but the results have been conflicting. 38,39 CLINICAL FEATURES Melasma typically presents as well-defined, symmetrical, brown-black hyperpigmented patches on sun-exposed areas of the skin. The clinical presentation of melasma in men is similar to the presentation in women, except for a few subtle differences. The age of onset of melasma in male patients is variable, ranging from 18 to 72 years, with the average age of onset being 30.7 years. 6,16,17 In the study by Sarkar et al, 5 there was no difference in the mean age of melasma between men (33.5 years) and women (31.5 years) (Table 1). In a study of Hispanic men, melasma was present across all age groups, but was most prevalent in men over 31 years old (70%). 6 Two other Indian studies reported the mean age of men with melasma as 33.5 years and 34.5 years. Of the 41 men with melasma, 51.2 percent (21/41) were between 31 and 40 years of age, 26.8 percent (11/41) were between 19 and 30 years, and 22 percent (9/41) were aged 41 years or older. 5 In contrast to these findings, Vazquez et al 16 observed a higher average age (38.8 years) of melasma in men (Table 3). The mean duration of melasma reported in the two Indian studies were 1.4 years 17 and 3.55 years in contrast to a longer duration of eight years reported Pichardo and colleagues. 6 A shorter duration of melasma ranging between 2 months to 1.5 years was reported in another study (Table 3). 30 According to the predominant localization of the lesions on the face, three patterns of facial melasma are recognized clinically: malar (Figure 1), centrofacial (Figures 2A and 2B), and mandibular. In the centrofacial pattern, the forehead, cheeks, nose, upper lip, and chin are affected, whereas the malar pattern distributes melasma on the cheeks and nose, and the mandibular pattern covers the mandibular ramus. Among women, the centrofacial pattern is most common. Among men, the malar pattern is most common, representing 44.1 to 61 percent of male patients. The second most common pattern among men is the centrofacial variant. 5,16,17 Clinically, melasma is most commonly seen on the face, but melasma on other sun-exposed areas such as the arms, neck, sternal regions, and back, have been seen in women. Extra- facial melasma affecting the upper body occurs mainly among elderly, menopausal women, and might be associated with hormone replacement therapy. 34,40,41 A few cases of melasma on the neck and forearms have also been reported in men. 34,42 However, no other similarities were documented in these male patients. Similar to women, woods lamp examination of melasma revealed the epidermal pattern (accentuation of pigmentation) to be the most common in men across three studies (48.4– 68.3%). 5,16,17 HISTOPATHOLOGY The diagnosis of melasma is generally made clinically. However, skin biopsy with histopathological examination (HPE) can be done. The histopathology of melasma in men is similar to that in women. 5 In epidermal melasma, increased melanin seen in the basal and TABLE 3. Characteristics of melasma in men CHARACTERISTICS REFERENCE (N=TOTAL NUMBER OF PATIENTS) Sarkar et al 17 (N=31) Sarkar et al 5 (N=41) Vazquez et al 16 (N=27) Sialy et al 30 (N=15) AGGRAVATING FACTORS Sunlight 14 (45.16%) 20(48.8%) 18 (66.6%) - Family history (melasma in at least one family member) 5 (16.13%) 16(39.0%) 19 (70.4%) - Drug (Phenytoin) 2 (6.45%) 3 (7.3%) 0 - Use of mustard oil - 18(43.9%) 0 - Cosmetics (soaps, shaving creams, aftershave, perfumes) - - 25 (92.6%) - Chronic illness (Post typhoid period, thyroid disorder, inflammatory bowel disease) 5 (22.2%) - - - AGE Range of age (years) 19–43 19–53 25–72 20–40 Mean (years) 34.5 33.5 38.8 DURATION Duration of melasma 2 months–4 years 1 month–8 years - 2 months–1.5 years Mean duration of melasma (years) 1.4 3.5 8 - CLINICAL PATTERN OF MELASMA Centrofacial 15 (48.39%) 12(29.3%) 12 (44.1%) 12 (80%) Malar 16 (51.61%) 25 (61%) 12 (44.1%) 2 (13.3%) Mandibular 0 (0%) 4 (9.7%) 3 (11.1%) 1 (6.7%) WOOD LIGHT EXAMINATION Epidermal 15 (48.39%) 28(68.3%) 18 (66.6%) - Mixed 6 (19.35%) 9 (22.0%) 2 (7.4%) - Dermal 10 (32.26%) 4 (9.7%) 7 (25.9%) - HISTOPATHOLOGICAL EXAMINATION Epidermal - 10/20(50%) 4/5 (80%) - Mixed - 9/20 (45%) 1/5 (20%) - Dermal - 1/20 (5%) 0 - Acknowledged from Sarkar R, Garg S. Melasma in men. In: Melasma: A Monograph.1st ed. Sarkar R (ed). New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd; 2015:80–84