An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology
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57 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2018 • Volume 11 • Number 2 R E V I E W suprabasal layers, whereas dendritic melanocytes and melanophages are present in the dermal type. In an Indian study, HPE was done in 48.8 percent (20/41) of the male patients, and the findings revealed that epidermal melasma was the most common pattern (50%), followed by mixed melasma (45%). Dermal melasma was the least common (5%) (Table 3). Other features included solar elastosis in 17 subjects (85%), flattening of rete ridges in nine (45%) and chronic inflammatory infiltrate in six (30%) male patients with no evidence of basal layer degeneration. 5 In concordance with this study, two other studies also reported epidermal melasma as the predominant histopathological type seen in men (Table 3). 16,17 The study by Jang et al 43 also found epidermal melasma and increased elastotic material in the lesional dermis compared to the nonlesional dermis was more common among male patients, however, the difference was not statistically significant. 43 Further, it has been demonstrated that stem cell factor (SCF) and its receptor c-kit have an important role in the pathogenesis of melasma. Recently, in a study of 60 Korean women with melasma, researchers observed increased expression of SCF around the dermal fibroblast and c-kit in the basal layer of the lesional skin compared to normal skin. 44 In order to study these factors in men, Jang et al 43 compared the HPE characteristics of eight men to 10 women with melasma and found a significant increase in SCF and c-kit expression in the lesional skin of the men. Further, the lesional to nonlesional ratio of SCF in the epidermis was increased in the men compared to the women. This suggests that chronic UV radiation might be associated with signaling of paracrine cytokines, which could play an important role in the mechanism of melasma in male patients. Additionally, the investigators found that vascularity in male patients with melasma was higher than that in female patients, suggesting that chronic UV exposure could play a large role in the development melasma in men. 43 MELASMA AND QUALITY OF LIFE Melasma is a can have a significant impact on the psychosocial well-being of the patient. Patients with melasma commonly report feelings of shame, low self-esteem, sadness, dissatisfaction, and decreased motivation to go out. 45 In the study by Pichardo et al, 6 there was a statistically significant difference in the Dermatology Life Quality Index (DLQI) in men with melasma compared to those without melasma (7.5 vs. 2.8) in a group of poultry workers, indicating a moderately poor QoL (Table 4). However, the men the other two groups (men in cross-sectional farm worker study and men in the longitudinal farm worker study) did not report such a difference. 6 Further studies need to be done to better quantify the impact of the melasma on the QOL of male patients. Studies on women with melasma have shown that the QOL score has a poor correlation with the clinical severity of the disease, suggesting that a patient's subjective perception of the disfiguration goes beyond the clinical dimension of the dyschromia. 45,46 DIAGNOSIS While the diagnosis of melasma is usually a straightforward process, certain facial melanosis can closely mimic melasma and must be ruled out before a definitive diagnosis of melasma can be made. The differential diagnosis of melasma in men includes post-inflammatory hyperpigmentation, pigmented contact TABLE 4. Dermatology Life Quality Index in men with melasma 6 STUDY GROUPS MEAN TOTAL DLQI IN MEN WITH MELASMA MEAN TOTAL DLQI IN MEN WITHOUT MELASMA SIGNIFICANCE Poultry worker study (n=25) 7.5 2.8 0.02* Cross-sectional farm worker study (n=54) 3.5 4 0.82* Longitudinal farm worker study (n=300) 1.12 1.09 0.92* DLQI: Dermatology Life Quality Index FIGURE 1. A 31-year-old man with malar melasma FIGURE 2A, B. A 35-year-old man with centrofacial melasma