JOURNAL READING

Risk Factors for Facial Melasma in

Women: A CaseControl Study
Pembimbing : dr.Eko Krisnarto, Sp.KK
Oleh : Julita Suhardi
406138033
 Abstract
Background Objective
Melasma is a localized chronic To evaluate risk factors for
acquired hypermelanosis, developing facial melasma in
common in adult women and women.
which has an important impact
on their life quality. Its
pathology is unknown, despite
some recognized triggering
factors.
Methods

This was a casecontrol

study involving adult
women with or without
facial melasma, paired
by age.
 personal
characteristic
data

Variables

links to hormonal
stimuli and the exposure
State-Trait variables
Anxiety Inventory
questionnaire
 Evaluated 207 patient
207 Controls Time exposed to sun in leisure activities (OR 104)
Mean age 38 years
years of beach or rural residence (OR 106)

anxiety scores (OR 108)

years of oral contraceptive use (OR 123)

time exposed to sun at work (OR 165)

Results
pregnancy history (OR 359)

menstrual irregularity (OR 383)

antidepressant/anxiolytic use (OR 496)

A family history of melasma 13% (OR 1040).

 Conclusions Facial melasma is independently
associated with elements linked to :
pigmentation capacity
family ancestry
chronic sun exposure
sexual hormone stimuli
psychotropics and anxiety traits
Introduction

localized hyperactivity of the epidermal melanin

unit leading to epidermal hypermelanization.

Melasma an acquired symmetrical

dyschromia affecting photoexposed areas.

Lesion development and maintenance are

influenced by many factors depending on the
interaction of environmental and hormonal
elements, with a susceptible genetic substrate.
 Some patients also report lesion development
or worsening after stressful events generating
anxiety.
There are few epidemiological casecontrol
studies on melasma, and until now, none that
systematically explore the risk factors.
 Material and Methods
A casecontrol study was performed between February
2012 and May 2013 involving women aged 18 years
selected from patients attending the dermatology
outpatient clinic at Botucatu School of Medicine, UNESP,
and staff from Botucatu School of Medicine, UNESP
campus.
Cases were determined by the presence of facial melasma,
clinically confirmed by a fully qualified dermatologist during
medical consultation. Controls were defined as patients or
professionals who worked on the UNESP Botucatu
university campus, who did not have any previous history
of facial melasma. Controls were paired with each case (1:
1) according to sex and age group ( 5 years).
 Those with active facial dermatitis, and
albinos were excluded.
Cases and controls were interviewed using a
structured questionnaire (clinical,
demographic and exposure data) and the
IDATE-T questionnaire. The project was
approved by our Institution's Research Ethics
Committee (no. 54/2012), and all subjects
gave their informed consent.
 The main dependent variable was the presence of facial
melasma. The independent variables were grouped into
hierarchical levels
 Results
We evaluated 207 cases and their controls. Onset during fertile age
(50% of cases started between the ages of 23 and 34 years),
frequent family history of melasma (61%), hormonal and solar
influence for triggering the disease, and a centrofacial
topographical preference for lesions; pregnancy occurred in 163
(79%) of cases, and gestation-induced melasma was reported by 87
(53%) of these patients.
There was a difference in topographical region for lesion
disappearance with more frontal occurrences (P < 001). Melasma
topography was not associated with family history, or induction by
hormones, pregnancy or sun exposure (P > 02).
Personal characteristics show that cases presented higher
phototype, body mass index (BMI) and differences in reported
family ancestry
 Mental and
mandibular

Temporal
Nasal
Supralabial
Zygomatic
 Of the 68 controls who reported information certainty,
family history was identified in 132% (OR 104, 95% CI 53
203; P < 001). As > 10% of controls did not present reliable
family information, this variable was not imputed or
included in the multivariate analysis.
In relation to exposure elements and comorbidities, there
was a history of rural or beach residence, higher sun
exposure at work and in leisure, and higher use of sunblock
and antidepressants/anxiolytics.
For sexual hormone-related elements, cases presented
lower ages for first pregnancy, more history of becoming
pregnant, and higher number of pregnancies .
 Exploratory analysis from the conditional multiple
logistic regression model for hierarchical
structure identified an independent association
of risk between groups for: phototype,
indigenous ancestry, history of rural or beach
living, work and leisure sun exposure,
antidepressant/anxiolytic use, menstrual
irregularity, pregnancy history, time using
combined oral contraceptives (COC) and anxiety
trait score.
 Discussion
This study demonstrated multiple factors independently
associated with facial melasma in women, such as
phenotype, family ascendency, sun exposure, medication,
hormones and anxiety traits, and measured their risk
association with the disease.
More common in tropical regions and in patients with more
melanized phenotypes. Hispanic, Asiatic (China, Korea,
Japan, India, Pakistan), Mediterranean African and Middle
Eastern populations are more affected than those with
whiter skin
The genetic component has a strong influence in melasma.
Our sample showed a high frequency of affected families,
with indigenous ancestry more commonly reported in cases
 The risk of developing melasma increases with
exposure to UV radiation.Pregnant mothers who
perform activities in the sun have a higher chance
(27%) of developing melasma during pregnancy.
In a group of 250 Indian women, melasma was
trigged by pregnancy in 22%, and pigmentation
exacerbated in 14%.[35] Other studies have
reported that between 5% and 50% of patients
identified pregnancy as a triggering factor
 Patients with melasma in our study presented
a higher proportion of menstrual
irregularities, bordering on significant when
BMI was higher
Stressful events have been reported as disease
triggers in 47%, and aggravating factors in
263% of cases in Brazil
 In our study, this could have occurred with
family history, ascendency, comorbidities,
medication use, alcohol and tobacco, weight
and height, use of sunblock, and work and
leisure sun exposure. Except for family history
of melasma, we hope that there was similar
imprecision of information between cases and
controls, which should not greatly influence
our final results