Histological features of melasma include epidermal and dermal melanin with varying quantities related to the severity of the hyperpigmentation. There is no increase in melanocytes but there is an increase in the number of melanosomes, size of the cells, and elongation of dendrites.1 It was initially thought that areas that illuminate under a Woods lamp have epidermal involvement while areas that do not light up have dermal involvement. However, more recent research suggests that this may not be completely accurate.4,16 Other histologic features of melasma include an increase in mast cells, solar elastosis, and dermal blood vessels.1
The treatment of melasma requires a multimodal approach with a focus on skin lightening, improving the vascular component and strict broad spectrum photoprotection. High protection factor sunscreen decreases the intensity of melasma and reduces the incidence during pregnancy by over 90%.6,17,18 The gold standard of treatment includes hydroquinone with broad spectrum photoprotection, but a variety of therapies have been used. In efforts to stunt the growth of melanocytes, inhibit the formation of melanosomes and increase their destruction, several therapies have included topical retinoids, azaleic acid, kojic acid, chemical peels, tranexamic acid, mequinol, melatonin, glutathione, cysteamine, flutamide, methimazole, polypodium leucotomos, and a multitude of lasers.1,16,19,20 Tranexamic acid is a fibrinolytic agent that effectively treats melasma with downstream effects that impede melanin synthesis, decrease mast cells, and inhibit angiogenesis.1 Lasers have shown benefit in improving melasma and can be implemented as a treatment option for patients who have not responded to topical or oral therapy. Fractional resurfacing is FDA approved for melasma and patients treated with this have shown improvement.21 Intense pulse light (IPL) therapy has also been beneficial for the hyperpigmentation and vascular component associated with melasma.7 Copper bromide lasers have been useful in treating melasma, especially in patients with increased vascularity.21
Despite the variety of treatment options, treating melasma presents a unique challenge that is often chronic and relapsing.
Quality of Life Scales and Discussion
Although the weight that patients with melasma carry cannot be measured by the same traditional physical endpoints as other chronic diseases such as diabetes or cardiac disease, the psychosocial effects are undeniable. Melasma is a highly visible skin condition that has been shown to negatively impact a patient’s quality of life (QoL), similar to acne.1,2,4 This pigmentation disorder is a chronic condition that occurs in a relatively young population. Patients with melasma report feelings of frustration, embarrassment, and depression stemming from the presence of their melasma.1,22 This chronic pigmenta tion condition is sometimes dismissed as simply a cosmetic concern while other skin conditions such as psoriasis are not. One commentary even suggests that inadequate treatment of psoriasis should be considered a box warning, a spin on a term that the US Food and Drug Administration uses to highlight potentially harmful prescription medications.23 When examining the effects that melasma has on QOL, a similar sensitivity of the psychosocial impact and disease burden should be given, as it typically affects the face which is harder to conceal than other parts of the body.
Several scales have been used to capture the QOL effects on various skin conditions including the Dermatology Life Quality Index (DLQI) and SKINDEX-16. Interestingly, a Singaporean study used the DLQI scale to compare the QOL effects from melasma to that of other skin conditions. The study results showed that the DLQI of melasma was lower than vitiligo, lichen planus, bullous pemphigoid, acne scarring, and pityriasis rosacea.24 This data only further supports the need for a melasma specific QOL scale in order to truly capture the effects that melasma has on patients. Because the DLQI considers physical symptoms that are not relevant to pigmentary disorders, such as pain and pruritus, this comparison data that does not use a melasma specific scale can be misleading and potentially result in minimizing disease burden.
Given this need for a melasma specific QOL scale, Balkrishnan and colleagues created a Melasma QOL scale that consists of 10 questions to measure the QOL impact of melasma based on a Likert scale.2 The MelasQOL was developed by modifying the SKINDEX-16 and using the melasma and discoloration questionnaire.4 Balkrishnan et al conducted a survey on 102 women with melasma and found the life areas most impacted included social life, recreation and leisure, and emotional well-being.16 The impact on a patient’s emotional well-being can subsequently have a negative effect on social functioning, productivity at work or school, and lowered self-esteem.16 Additionally when asked about their QOL in regard to work, family relationships, social life, sexual relationships, recreation and leisure, physical health, money matters, and emotional well-being, many patients felt that these areas in their life would improve if they did not have melasma.16 Melasma is a chronic condition that can be extremely difficult to manage with expensive treatment options that are typically not 100% successful. Simply dismissing melasma as a cosmetic condition serves as a detriment to patients and discourages the quest for finding tailored therapy plans that can at least minimize the burden of disease for each patient.6
Pollo et al notes that currently only one specific QoL measure for melasma is available and points out that this scale did not follow the classic construction stages for psychometric instruments (it was constructed from previous questionnaires and