Quality of life in Nepalese Patients with Melasma: An Observational Cross-Sectional Study at a Tertiary Center.

BACKGROUND: Melasma is an acquired pigmentation disorder of the sun exposed parts of the body, particularly face. It is a significant cosmetic concern for the young adults, which is the most frequently affected age-group. Finding the level of impairment in quality of life in melasma patients and correlating with the severity. METHODS: All consenting patients with melasma visiting our out-patient from December 2020 to June 2021 were enrolled. Clinical evaluation was done by the same single reviewer in all cases using modified Melasma Area and Severity Index. Dermatology Life Quality Index (Nepali version) was asked to complete to the patient. Data were collected and analyzed. Frequency and mean were calculated for all variables, comparison of means by Mann-Whitney U test and correlation analyses by Spearman's correlation test were performed. RESULTS: Females were 82.5%(99) of total cases. Among these 70.8%(85) were married, 68.3%(82) had family history of melasma and 65%(78) had centro-facial phenotype. Mean Dermatology Life Quality Index score was 10.25±0.54. Mean score of females was higher than that of males. The daily activities sub-domain was the worst affected with 50.67% of impairment. Females suffered significantly more than males in symptom and feeling sub-domain. Modified Melasma Area and Severity Index was significantly higher in males (7.12±.56 Vs. 5.66±.28). The severity and duration of melasma did not correlate to the quality of life. CONCLUSIONS: Melasma had a moderately negative impact in the quality of life of the patients. Females suffered more due to melasma. The clinical severity of melasma did not correlate with the quality of life impairment. Thus, psychological assessment to all the melasma patients seem to be an important aspect of management.

Comparison of generic and specific instruments to assess the quality of life in patients with melasma.

OBJECTIVE: To compare the psychometric performance of a generic and specific instruments in assessing melasma-related quality of life. METHODS: A cross-sectional study was conducted with 150 patients with melasma attending an outpatient dermatology clinic of a public hospital in São Paulo state, Brazil. Data were collected using a questionnaire containing sociodemographic and clinical data as well as the generic WHOQOL-BREF, and the dermatological-specific Skindex-16 and HRQ-Melasma. RESULTS: The overall internal consistency of the domains of the three instruments was ≥ 0.7. A strong positive correlation was identified between the Skindex-16 and HRQ-Melasma domains (0.68-0.78). Item-response theory showed that most Skindex-16 and HRQ-Melasma domains were more informative than WHOQOL-BREF. CONCLUSION: The three instruments for assessing QOL tested presented good psychometric performance, with satisfactory internal consistency values. Only the two dermatological instruments, however, demonstrated a strong correlation between the domains that assess social, emotional, and functional aspects of QOL, indicating that both were able to identify impairments in other QOL dimensions in addition to the physical domain.

Evaluating the quality of life among melasma patients using the MELASQoL scale: A systematic review and meta-analysis.

BACKGROUND: According to the literature, pigmentary disorders have a significantly negative impact on a person's health-related quality of life. Moreover, among pigmentary disorders, incidence of melasma ranks high. The Melasma Area and Severity Index (MASI) is the scale that is generally used to evaluate a melasma-affected area and its severity. However, the relationship between the MASI and Melasma Quality of Life (MELASQoL) scores, as well as the impact of melasma on patients' quality of life, remain unclear. OBJECTIVES: To explore the influence of melasma on patients' lives, analyze the relationship between the MASI and MELASQoL scores, and identify the factors that may be influencing the quality of life of patients with melasma. METHODS: Two reviewers independently searched four databases (PubMed, Embase, the Cochrane Library, and Web of Science) for literature on quality of life of patients with melasma. In addition to an epidemiological study, a cross-sectional study, and validation studies, gray literature was also included. StataSE version 16 software was used for the meta-analysis. The score of each item on the MELASQoL scale was determined using a random-effects model. RESULTS: Fourteen studies with a total of 1398 melasma patients were included in the systematic review, four of which were eligible for meta-analysis. The relationship between the MELASQoL and MASI scores was found to be mixed. Five studies concluded that the MASI and MELASQoL scores were statistically correlated, while seven studies found no statistical correlation between the two. It is obvious that melasma causes emotional distress and has a negative impact on patients' social lives. Patients were most bothered by the appearance of their skin condition. However, the MELASQoL score had no definite correlation with patient characteristics such as age, education levels, and history. CONCLUSION: Melasma has a significant negative impact on patients' quality of life. Thus, evaluating the quality of life of patients with melasma should not be ignored. Additionally, utilization of the MELASQoL scale should be considered in the care plan. Further studies with larger sample sizes are needed to confirm the relationship between melasma and quality of life.

Psychosocial burden of lichen planus pigmentosus is similar to vitiligo, but greater than melasma: A cross-sectional study from a tertiary-care center in north India.

BACKGROUND: Lichen planus pigmentosus can have a negative impact on the quality of life; however, this has not been studied in detail. OBJECTIVES: To study the quality of life in patients with lichen planus pigmentosus and compare it with patients with vitiligo and melasma. METHODS: This was a cross-sectional study conducted in a tertiary-care center in north India from January 2018 to May 2019. Patients ≥ 18 years of age with lichen planus pigmentosus (n = 125), vitiligo (n = 113) and melasma (n = 121) completed the Dermatology Life Quality Index (DLQI) questionnaire and answered a global question on the effect of disease on their lives. In addition, patients with vitiligo completed the Vitiligo Impact Scale (VIS)-22 questionnaire, while those with lichen planus pigmentosus and melasma filled a modified version of VIS-22. RESULTS: The mean DLQI scores in patients with lichen planus pigmentosus, vitiligo and melasma were 10.9 ± 5.95, 9.73 ± 6.51 and 8.39 ± 5.92, respectively, the difference being statistically significant only between lichen planus pigmentosus and melasma (P < 0.001). The corresponding mean modified VIS-22/VIS-22 scores were 26.82 ± 11.89, 25.82 ± 14.03 and 18.87 ± 11.84, respectively. This difference was statistically significant between lichen planus pigmentosus and melasma, and between vitiligo and melasma (P < 0.001 for both). As compared to vitiligo, patients with lichen planus pigmentosus had a significantly greater impact on "symptoms and feelings" domain (P < 0.001) on DLQI, and on "social interactions" (P = 0.02) and "depression" (P = 0.04) domains on VIS-22. As compared to melasma, patients with lichen planus pigmentosus had significantly higher scores for "symptoms and feelings," "daily activities," "leisure" and "work and school" domains of DLQI, and all domains of VIS-22. Female gender was more associated with impairment in quality of life in patients with lichen planus pigmentosus, while lower education, marriage, younger age and increasing disease duration showed a directional trend. LIMITATIONS: Use of DLQI and modified version of VIS-22 scales in the absence of a pigmentary disease-specific quality-of-life instrument. CONCLUSION: Patients with lichen planus pigmentosus have a significantly impaired quality of life. The psychosocial burden of lichen planus pigmentosus is quantitatively similar to that of vitiligo, but significantly greater than melasma.

Randomized, Double-Blinded, Split-Face Study Comparing the Efficacy and Tolerability of Two Topical Products for Melasma.

BACKGROUND: Melasma is a common disorder of hyperpigmentation that disproportionately affects individuals with skin of color. There is a paucity of studies evaluating non-hydroquinone (HQ) topical therapies for the treatment of melasma in darker skin types. OBJECTIVE: To compare the safety, efficacy, and tolerability of a HQ-free, retinol-free cosmetic topical brightener (CTB) and HQ 4% in the treatment of moderate symmetric facial melasma in patients with Fitzpatrick skin types (FST) III–VI. Methods & Materials: This was a randomized, double-blinded, split-face clinical trial. Eighteen adult patients with facial melasma were treated with CTB and HQ 4%, each to a different side of the face, twice daily for 12 weeks. Clinical assessments included half-face Melasma Area Severity Index (MASI), Overall Hyperpigmentation scale, and Melasma Severity Rating Scale (MSRS). Patients completed a Melasma Quality of Life (MelasQoL) questionnaire and clinical photographs were taken at each visit. RESULTS: CTB and HQ 4% demonstrated statistically significant improvements in half-face MASI, Overall Hyperpigmentation, MSRS and MelasQol compared to baseline. HQ 4% showed statistically significant improvements in MSRS at week 12 compared to CTB, but was non-superior for all other clinical endpoints. CONCLUSION: HQ-free, retinol-free CTB and HQ 4% both are effective and well-tolerated in the treatment of moderate facial melasma in FST III–VI. J Drugs Dermatol. 2020;19(9):822-827. doi:10.36849/JDD.2020.5353.

Post-Inflammatory Hyperpigmentation: A Review of Treatment Strategies.

Post-inflammatory hyperpigmentation (PIH) is a reactive process resulting from increased melanin or abnormal distribution of melanin secondary to inflammatory skin conditions, dermatologic therapies, and external stimuli. Because PIH is a common condition that has a substantial effect on the quality of life, an understanding of its treatment modalities is essential. Though there are many therapeutic strategies for hyperpigmentary conditions such as melasma that are described in the literature, fewer studies focus on PIH. This article aims to provide a comprehensive literature review of therapies specifically used to treat PIH, such as topical combinations, chemical peels, and lasers. J Drugs Dermatol. 2020;19(8): doi:10.36849/JDD.2020.4887.

The Therapeutic Use of Antioxidants for Melasma.

Melasma is a chronic dermatologic condition with an incompletely understood pathogenesis and well-demonstrated impact on patient quality of life. Melasma is a common cause for seeking dermatologic care, and with no universally efficacious therapy or cure, com-bination treatment is the best approach for many cases. Numerous studies have demonstrated the role of oxidative stress in patients with melasma, prompting investigation into several antioxidants for melasma therapy. In this review, we discuss the well-defined role of oxidative stress in melasma and the therapeutic efficacy of various antioxidants for patients suffering from melasma. We focus our discussion on studies investigating the role of vitamin C, azelaic acid, cysteamine, glutathione, carotenoids, and numerous other antioxidants in disorders of hyperpigmentation. There is promising evidence for the use of these antioxidants, as topical, oral, and intra-venous preparations, both in isolation and in conjunction with other melasma therapies. J Drugs Dermatol. 2020;19(8):788-792. doi:10.36849/JDD.2020.5079.

Melasma's Impact on Quality of Life

Melasma is a commonly acquired condition that mostly affects women with Fitzpatrick skin types III-VI with prominent brown pigmentation with or without an underlying erythema. Despite multiple treatment options, melasma can be challenging given its chronic and relapsing nature. The objective of this article is to review the quality of life impact of melasma and offer suggestions for enhancing the melasma specific quality of life scale. J Drugs Dermatol. 2020;19(2)184-187. doi:10.36849/JDD.2020.4663

Assessment and Comparison of Quality of Life in Patients with Melasma and Vitiligo.

Background Melasma is an acquired hyperpigmentary condition that is characterized by development of irregular brown to black macules occurring predominantly on the face. Vitiligo is an acquired depigmenting skin disease characterized by progressive loss of inherited skin colour, which leads to appearance of white patches. Both the conditions occur more frequently in people with racially pigmented skin resulting in psychological morbidities and impacting the quality of life. Objective To evaluate and compare the quality of life in patients suffering from melasma or vitiligo, which represent two opposite ends of pigmentary disorders using the Dermatology Life Quality Index (DLQI). Method This was a hospital based cross sectional study that was conducted at the Department of Dermatology and Venereology, Tribhuwan University Teaching Hospital from September 2016 to August 2017. The study population included adult patients of either sex with melasma or vitiligo, who consented to participate in the study. Result There were a total of 100 patients each in both melasma and vitiligo groups. While females outnumbered their male counterparts by a ratio of 9:1 in melasma, the gender distribution was more equal in vitiligo. Melasma had a mean DLQI score of 5.64 ± 5.41 and a median score of 4 while vitiligo had a mean DLQI score of 4.13 ± 3.74 and a median score of 3. Conclusion Melasma patients had a higher impairment in quality of life compared to vitiligo patients. The quality of life in both the conditions varied based on age, gender, duration and distribution.

Assessing skin disease and associated health-related quality of life in a rural Lao community.

BACKGROUND: Skin diseases are common and often have an impact on an individual's health-related quality of life. In rural communities where access to healthcare may be limited and individuals rely on farming for food and income, the impact of skin diseases may be greater. The objectives for this study were to perform an assessment of skin disease prevalence in a rural village in Laos and assess the associated impact of any skin disease found using the Dermatology Life Quality Index (DLQI). METHODS: A rural village was purposively selected and 340 participants examined by dermatologists over a four day period. Brief questionnaires were performed, followed by full body skin examinations and DLQI questionnaires completed were relevant. The data were analysed using chi square and Wilcoxon signed rank tests. RESULTS: One hundred and eighty-one participants were found to have a skin disease (53%). The six most common skin diseases were: eczema (22%), dermatophyte infections (19%), acne (10%), scabies infestation (9%), melasma (8%) and pityriasis versicolor (4%). Just over half of those with skin disease (51%) completed the DLQI, with scores ranging from 0 to 24. Those with skin problems on examination were significantly more likely to be farmers, have had a previous skin problem, be older or live in a smaller family. Conclusions This study represents the first formal documentation of skin disease prevalence in Laos and establishes the high rate of skin disease in the rural community and the associated impact these diseases have on health-related quality of life.

Development and validation of a multidimensional questionnaire for evaluating quality of life in melasma (HRQ-melasma).

BACKGROUND: Melasma has a major impact on quality of life. MELASQoL is the only validated specific psychometric instrument to evaluate melasma QoL. OBJECTIVE: To develop and validate a multidimensional questionnaire for evaluating quality of life related to facial melasma. METHODS: Cross-sectional study performed in 2 institutions (public and private) from Brazil. Two focus groups were carried out: 5 board-certified dermatologists and 10 melasma patients, indicating the dimensions and significant units of melasma QoL. The preliminary questionnaire with 49 itens was applied to 154 facial melasma patients. Item reduction was performed by Rasch analysis. Parallel evaluations of clinical (MASI), demographic, and QoL aspects (MELASQoL, DLQI) were performed. The dimensional structure was assessed by confirmatory factor analysis. Temporal stability was tested in a subgroup of 42 individuals within 7-14 days. RESULTS: The mean (SD) age of the 154 interviewed subjects was 39±8 years, and 87% were females. The median (p25-p75) DLQI and MELASQoL were: 2 (1-6) and 30 (17-44). HRQ-Melasma consisted of 19 items distributed in 4 dimensions: Physical/Appearance, Social/Professional, Psychological, and Treatment. Cronbach's alpha for HRQ-Melasma was 0.96, and >0.74 for each dimension. There was high correlation between HRQ-Melasma and DLQI and MELASQoL (rho=0.80 and 0.83), but modest with MASI (rho=0.35). Dimensional structure of HRQ-Melasma was stated by confirmatory factor analysis coefficients. Test-retest analysis disclosed an intraclass correlation coefficient of 0.91 (p<0.01). STUDY LIMITATIONS: Single-center study. CONCLUSIONS: A specific instrument to evaluate QoL in melasma with multidimensional characteristics was developed and validated, with appropriate psychometric performance.

Development and validation of a multidimensional questionnaire for evaluating quality of life in melasma (HRQ-melasma)

Abstract: BACKGROUND: Melasma has a major impact on quality of life. MELASQoL is the only validated specific psychometric instrument to evaluate melasma QoL. OBJECTIVE: To develop and validate a multidimensional questionnaire for evaluating quality of life related to facial melasma. METHODS: Cross-sectional study performed in 2 institutions (public and private) from Brazil. Two focus groups were carried out: 5 board-certified dermatologists and 10 melasma patients, indicating the dimensions and significant units of melasma QoL. The preliminary questionnaire with 49 itens was applied to 154 facial melasma patients. Item reduction was performed by Rasch analysis. Parallel evaluations of clinical (MASI), demographic, and QoL aspects (MELASQoL, DLQI) were performed. The dimensional structure was assessed by confirmatory factor analysis. Temporal stability was tested in a subgroup of 42 individuals within 7-14 days. RESULTS: The mean (SD) age of the 154 interviewed subjects was 39±8 years, and 87% were females. The median (p25-p75) DLQI and MELASQoL were: 2 (1-6) and 30 (17-44). HRQ-Melasma consisted of 19 items distributed in 4 dimensions: Physical/Appearance, Social/Professional, Psychological, and Treatment. Cronbach's alpha for HRQ-Melasma was 0.96, and >0.74 for each dimension. There was high correlation between HRQ-Melasma and DLQI and MELASQoL (rho=0.80 and 0.83), but modest with MASI (rho=0.35). Dimensional structure of HRQ-Melasma was stated by confirmatory factor analysis coefficients. Test-retest analysis disclosed an intraclass correlation coefficient of 0.91 (p<0.01). STUDY LIMITATIONS: Single-center study. CONCLUSIONS: A specific instrument to evaluate QoL in melasma with multidimensional characteristics was developed and validated, with appropriate psychometric performance.

Evaluation Instruments for Quality of Life Related to Melasma: An Integrative Review.

The aim of this study was to analyze scientific production concerning the validation and cultural adaptation of quality of life evaluation instruments for patients with melasma and to offer a critical reflection on these methods. A literature review was performed based on a search of the Web of Science, Bireme, PubMed, Elsevier Scopus, and Google Scholar databases. All published articles from indexed periodicals in these electronic databases up to December 2015 were included. Eight articles were identified, of which only one (12.5%) referred to the development and validation of a specific instrument for evaluation of the quality of life of melasma patients. An additional six articles (75%) referred to transcultural adjustment and validation of the same instrument in other languages, and another (12.5%) article reported the development of a generic instrument for evaluation of quality of life in patients with pigment disorders. This review revealed only one specific instrument developed and validated in different cultures. Despite being widely used, this instrument did not follow the classic construction steps for psychometric instruments, which paves the way for future studies to develop novel instruments.

Evaluation instruments for quality of life related to melasma: an integrative review

The aim of this study was to analyze scientific production concerning the validation and cultural adaptation of quality of life evaluation instruments for patients with melasma and to offer a critical reflection on these methods. A literature review was performed based on a search of the Web of Science, Bireme, PubMed, Elsevier Scopus, and Google Scholar databases. All published articles from indexed periodicals in these electronic databases up to December 2015 were included. Eight articles were identified, of which only one (12.5%) referred to the development and validation of a specific instrument for evaluation of the quality of life of melasma patients. An additional six articles (75%) referred to transcultural adjustment and validation of the same instrument in other languages, and another (12.5%) article reported the development of a generic instrument for evaluation of quality of life in patients with pigment disorders. This review revealed only one specific instrument developed and validated in different cultures. Despite being widely used, this instrument did not follow the classic construction steps for psychometric instruments, which paves the way for future studies to develop novel instruments.

Sun-protective behaviors in patients with cutaneous hyperpigmentation: A cross-sectional study.

BACKGROUND: Disorders of hyperpigmentation are seen commonly in clinical practice. Despite numerous studies investigating sun-protective habits among healthy persons, little is known about these behaviors within patient populations with hyperpigmentation disorders. OBJECTIVE: We sought to examine photo-protective behaviors and their associations in individuals with disorders of hyperpigmentation. METHODS: This cross-sectional study was conducted with 404 adults who complained of cutaneous hyperpigmentation. RESULTS: About 67.5% reported using a product containing sunscreen, and 91% endorsed using one with a sun protection factor of 21 or higher. Among the participants, 48.5% were not sure if their sunscreen provided broad-spectrum protection, and only 7.6% reapplied every 2 hours. The odds of a patient with melasma using sunscreen were 6.7 times the odds of a patient with postinflammatory hyperpigmentation using sunscreen (P < .001). Additional predictors for sunscreen use were female sex (OR = 3.8, P = .0004) and disease duration of ≥1 year (OR = 2.1, P = .003). In a multivariate analysis, the odds ratio of sunscreen use among African Americans compared to whites was 0.31 (P = .008). LIMITATIONS: Limitations included recall bias, question misinterpretation, and reporter bias. CONCLUSION: Patients diagnosed with postinflammatory hyperpigmentation, men, and those with disease duration <1 year reported lower sunscreen usage. These groups might benefit from increased counseling on sun-protective behaviors.

Psychometrican analysis and dimensional structure of the Brazilian version of melasma quality of life scale (MELASQoL-BP).

BACKGROUND: Although asymptomatic, melasma inflicts significant impact on quality of life. MELASQoL is the main instrument used to assess quality of life associated with melasma, it has been validated in several languages, but its latent dimensional structure and psychometric properties haven´t been fully explored. OBJECTIVES: To evaluate psychometric characteristics, information and dimensional structure of the Brazilian version of MELASQoL. METHODS: Survey with patients with facial melasma through socio-demographic questionnaire, DLQI-BRA, MASI and MELASQoL-BP, exploratory and confirmatory factor analysis, internal consistency of MELASQoL and latent dimensions (Cronbach's alpha). The informativeness of the model and items were investigated by the Rasch model (ordinal data). RESULTS: We evaluated 154 patients, 134 (87%) were female, mean age (± SD) of 39 (± 8) years, the onset of melasma at 27 (± 8) years, median (p25-p75) of MASI scores , DLQI and MELASQoL 8 (5-15) 2 (1-6) and 30 (17-44). The correlation (rho) of MELASQoL with DLQI and MASI were: 0.70 and 0.36. Exploratory factor analysis identified two latent dimensions: Q1-Q3 and Q4-Q10, which had significantly more adjusted factor structure than the one-dimensional model: Χ2 / gl = 2.03, CFI = 0.95, AGFI = 0.94, RMSEA = 0.08. Cronbach's coefficient for the one-dimensional model and the factors were: 0.95, 0.92 and 0.93. Rasch analysis demonstrated that the use of seven alternatives per item resulted in no increase in the model informativeness. CONCLUSIONS: MELASQoL-BP showed good psychometric performance and a latent structure of two dimensions. We also identified an oversizing of item alternatives to characterize the aggregate information to each dimension.

Psychometrican analysis and dimensional structure of the Brazilian version of melasma quality of life scale (MELASQoL-BP)

Abstract: Background: Although asymptomatic, melasma inflicts significant impact on quality of life. MELASQoL is the main instrument used to assess quality of life associated with melasma, it has been validated in several languages, but its latent dimensional structure and psychometric properties haven´t been fully explored. Objectives: To evaluate psychometric characteristics, information and dimensional structure of the Brazilian version of MELASQoL. Methods: Survey with patients with facial melasma through socio-demographic questionnaire, DLQI-BRA, MASI and MELASQoL-BP, exploratory and confirmatory factor analysis, internal consistency of MELASQoL and latent dimensions (Cronbach's alpha). The informativeness of the model and items were investigated by the Rasch model (ordinal data). Results: We evaluated 154 patients, 134 (87%) were female, mean age (± SD) of 39 (± 8) years, the onset of melasma at 27 (± 8) years, median (p25-p75) of MASI scores , DLQI and MELASQoL 8 (5-15) 2 (1-6) and 30 (17-44). The correlation (rho) of MELASQoL with DLQI and MASI were: 0.70 and 0.36. Exploratory factor analysis identified two latent dimensions: Q1-Q3 and Q4-Q10, which had significantly more adjusted factor structure than the one-dimensional model: Χ2 / gl = 2.03, CFI = 0.95, AGFI = 0.94, RMSEA = 0.08. Cronbach's coefficient for the one-dimensional model and the factors were: 0.95, 0.92 and 0.93. Rasch analysis demonstrated that the use of seven alternatives per item resulted in no increase in the model informativeness. Conclusions: MELASQoL-BP showed good psychometric performance and a latent structure of two dimensions. We also identified an oversizing of item alternatives to characterize the aggregate information to each dimension.

Development and validation of a Hindi language health-related quality of life questionnaire for melasma in Indian patients.

BACKGROUND: Melasma, which is fairly common in Indians, causes significant emotional and psychological impact. A Hindi instrument would be useful to assess the impact of melasma on the quality of life in Indian patients. OBJECTIVE: To create a semantic equivalent of the original MELASQOL questionnaire in Hindi and validate it. METHODS: A Hindi adaptation of the original MELASQOL (Hi-MELASQOL) was prepared using previously established guidelines. After pre-testing, the Hi-MELASQOL questionnaire was administered to 100 women with melasma visiting the out-patient registration counter of Safdarjung Hospital, Delhi. These women were also administered a Hindi equivalent of the Health Related Quality of Life (HRQOL) questionnaire. Melasma area severity index (MASI) of all the participants was calculated. RESULTS: The mean MASI score was 20.0 ± 7.5 and Hi-MELASQOL score was 37.19 ± 18.15; both were highly, positively and significantly correlated. Reliability analysis showed satisfactory results. Physical health, emotional well-being and social life were the most adversely affected life domains. LIMITATIONS: It was a single-center study and the number of patients studied could have been larger. CONCLUSION: Hi-MELASQOL is a reliable and validated tool to measure the quality of life in Indians with melasma.