Introductory Chapter: Quality of Life in the Patients with Melasma

1. Introduction

When we were thinking about the title for the introductory chapter, naturally, the most common pigmentation diseases were the priority [1]. In other chapters of the book, vitiligo was discussed from both psychological and clinical aspects. On the other hand, the clinical course of melasma and post-inflammatory hyperpigmentation was present in other chapters, but there was no room for a psychological discussion of melasma patients and its effects on the patient’s quality of life.

Melasma is a characteristic pattern of marginated facial hyperpigmentation, occurring primarily on the face. The cause of melasma is not completely known, but pregnancy, estrogen therapy, exposure to sunlight and ultraviolet light, and positive family history in Caucasian patients are well known [2]. Melasma is more common in women and non-Caucasian people, although it has been seen in men of all races [2, 3].

Melasma can have significant emotional and psychological impacts on patients. The 10-item the Melasma Quality of Life (MELASQOL) scale was devised from the comprehensive Health-Related Quality of Life (HRQoL) assessment set [4, 5]. HRQoL is a scale used to define the social, physical, and psychological well-being of an individual and to evaluate the distress of disease on daily living [6, 7].

In this chapter, we will concisely review the clinical aspects, treatments, and the impact of melasma on the quality of life (QoL) of the patients.

2. Clinical manifestations

Melasma is an acquired hyperpigmentation ailment in which some light to dark brown and irregular macules and patches are distributed on the sunlight-exposed body areas. Lesions are usually on the skin of the forehead, temples, upper lip, and cheeks [8].

It is often disseminated in one of four clinical patterns, that is, centrofacial, malar, mandibular, and extrafacial; the last pattern is variable but is predominantly located on the upper extremities, often on sun-exposed sites. It is known that the centrofacial pattern is the most common type. Melasma is sometimes classified as epidermal, dermal, or mixed types based on the level of melanin deposition in the epidermis and/or the dermis [2, 9].

The disorder is common in women, especially during reproductive ages, although it is possible in the teenage years, in older women who take special medicines, and sometimes in men [10]. Although the main cause of melasma is still unknown, it seems to be the result of genetic and environmental factors that play a role in causing it [4].

Among the many factors that are associated with melasma, contact with sunlight is the most related [8]. Among other factors, pregnancy, some hormones, birth control pills, some endocrine disorders, especially thyroid gland disorders, family history, using some cosmetic products, anti-epileptics, and phototoxic drugs are seen [11, 12].

Wood’s lamp is a simple diagnostic device that can be used to see the depth of skin pigmentation. When exposed to UV light in a dark environment, the pigmented skin is clearly visible, and the dark border becomes fluorescent [13]. Moreover, with Wood’s lamp, superficial or epidermal melasma is usually seen more clearly under light, whereas deep or dermal melasma shows no particular changes [14].

When examined with a dermoscope, in superficial or epidermal melasma, a network of brown reticulated islands with dark and small seeds can be seen scattered [14]. Reflectance confocal microscopy can be used in cellular evaluation in patients with melasma. Sometimes a skin biopsy is used to confirm the diagnosis of melasma and of course often to rule out other differential diagnoses.

3. Treatments

The most common therapeutic agents used are those that inhibit the production of melanin by decreasing melanogenesis and melanocyte proliferation. Using 2–5% hydroquinone cream at night for 2 to 4 months has a significant improvement in melasma. Kojic acid, azelaic acid, and tranexamic acid can be mentioned as topical treatments. In the treatment of melasma, before using chemical peeling or laser therapy, it is better to use only topical treatments first [15]. Kligman’s formula, which is a mixture of hydroquinone, tretinoin, and dexamethasone in a cream base, is currently the best treatment for melasma and leads to recovery in 60–80% of patients, which is why it is called the gold standard treatment [9, 16, 17]. The use of hats and broad-spectrum sunblock creams is very important for the success of melasma treatment and the prevention of the recurrence of the disease.

Oral tranexamic acid has become popular because of its low price and availability. A meta-analysis study of randomized controlled trials shows that this drug has significant efficacy and safety [18]. But before prescribing it, the physician should consult with the patient about the dosage and its side effects. It should be noted that topical use of tranexamic acid has no significant effect.

The use of chemical peels and lasers should be approached with caution, as they may exacerbate or cause a relapse of melasma [9]. These interventions should be undertaken by an expert with an understanding of skin color. A series of 3–6 sessions of chemical peels with active ingredients, such as alpha hydroxy acids (AHA), for example, 6–12% glycolic acid cream or lotion, and beta hydroxy acids (BHA), for example, salicylic acid, has also been shown to be useful in the treatment of melasma as they can remove surface skin and decrease the physiological activity of tyrosinase [19].

Intense pulsed light (IPL) devices have a range of different wavelengths that are used to treat superficial and deep melasma [20]. This treatment is better used together at the same time with topical medications. IPL treatment only gives a moderate improvement if it is not combined with topical treatments, and the recurrence rate will also be moderate. Q-switched lasers, ablation lasers, and picosecond lasers can also be used to treat melasma but may cause deeper hyperpigmentation after treatment [9, 20].

In general, laser therapy, compared to topical treatments, has a higher probability of recurrence and disease resistance to treatment [9]. Some treatments may be associated with post-inflammatory hyperpigmentation or hypopigmentation, which should be considered before treatment. Cosmetic camouflage creams can be an important auxiliary treatment for these complications in patients [17].

Finally, it is important to mention that the treatment of melasma should often be done with a multifaceted approach, and its goal is to reduce pigment production and achieve balance in the patient’s skin [16]. Because of the high chance of recurrence, maintenance treatments are often required, along with protection from strong sunlight with broad-spectrum sunscreens.

4. Quality of life

Despite the existence of various drugs and methods in the treatment of melasma, there is little information about their effect on the daily lives of patients. Health-related quality of life (HRQoL) is a measure to describe a person’s physical, social, and mental health and assess the disease burden in daily life [6, 7]. When a patient has extensive melasma on the face, a person’s overall emotional health can be significantly affected, also leading to reduced social functioning, efficiency at work or school, and decreased self-confidence [6, 7, 21].

As melasma has a much impact on the psychological aspects of a patient’s life than on the physical, a new instrument was needed to more accurately determine the HRQoL in these patients [4].

Some studies have shown that the three life domains most affected by melasma are social life, recreation and leisure, and emotional well-being. The sensitivity to change of the MELASQOL was examined in 72.8% of the patients with melasma. These patients were reassessed 6–8 months following topical treatment and demonstrated highly significant improvement in the MELASQOL total score. The largest effect size was obtained in the social life domain. These results indicate that MELASQOL is able to capture changes in patients’ improvement that are not reflected in clinical rating scales of melasma severity. In addition, the present studies provide evidence for the excellent responsiveness of MELASQOL to treatment-induced changes [4, 5].

As mentioned before, melasma occurs in exposed areas of the body, especially in the face, and clearly affects the appearance of sufferers, so the patient is affected by the mental aspects and social illness, and almost always it affects the generality of the patients and has an effect on the quality of life of the sufferers that results in the influence of a person’s self-concept and the patient’s self-confidence [22]. Melasma is also due to people’s complaints about their appearance and beauty, which causes many problems. It creates an obvious psychological problem in patients [12, 23].

Measuring the quality of life in skin diseases is very important because these diseases are not mostly life-threatening [12], but through different ways, such as causing symptoms (itching and pain), mental pressure (deficiency of self-confidence and nervousness), influence on social relations and family, and treatment problems (financial burden and waste of time), they can affect the patient’s life [24, 25].

Melasma is no exception to this rule; the results of the studies carried out indicate that melasma is very destructive to the quality of life of the sufferers and has the most negative effect in the areas of social life, entertainment, and mental health of patients’ lives [23, 26].

5. Conclusions

Melasma has a significant negative impact on the patient’s quality of life. Thus, evaluating the quality of life of patients with melasma during treatment should not be ignored. Additionally, utilization of the DLQI and especially the MELASQoL scale should be considered in the care plan.

Competing interest

None declared.