Quality of Life of the Patients with Melisma
Received Date: Apr 22, 2018 / Accepted Date: May 05, 2018 / Published Date: May 14, 2018
Background: Melasma, one of the most common causes of acquired hyperpigmentation, is characterized by light to dark, irregular macules on sun-exposed areas of face skin, mainly the cheeks, forehead, upper lip, nose, and chin. In our study, we evaluated quality of life of patients with melasma, using both DLQI and MQol.
Objective: We aim to have a reliable scientific data about this subject and contribute to the literature.
Methods: We included the patients, aged 20-63. We asked them about their age, gender, occupation, salary per month (added all salaries of family members for per patient), duration of melasma, marital status, education status and psychological diseases, calculated MASI, DLQI and MQoL for each patient.
Results: We included the patients, aged 20-63 who came to the dermatology polyclinic of Bozyaka Research and Training Hospital between February 2017 and October 2017. We asked them about their age, gender, occupation, salary per month (added all salaries of family members for per patient), duration of melasma, marital status, education status and psychological diseases, calculated MASI, DLQI and MQoL for each patient. MASI, DLQOL and MQoL were calculated by the same dermatologist.
Conclusion: Melasma is a common and recurrent disease that can effect quality of life of patient. According to our research, if the salary of patients increases, MQoL increases, too. When MASI scales up, MQoL scales up, too. According these results, we think that women who are married and have high salary, should protect themselves against melasma more carefully.
Keywords: Melisma; Quality of life; Hyperpigmentation
Melasma is one of the most common causes of acquired hyperpigmentation. It occurs especially as hyperpigmented macules on the cheeks, forehead, upper lip, nose, and chin . These macules aren’t scalely and distributes symmetrically . Melasma’s prevalence varies according to ethnic composition, skin phototype, and intensity of sun exposure . There are multiple factors that take part in the pathogenesis of the disease, including ultraviolet (UV) radiation, hormonal therapy, genetic background, pregnancy, thyroid dysfunction, cosmetics, and medications containing phototoxic agents .
The word melasma originates from the Greek root “melas”, which means black, and refers to its brownish clinical presentation. The designations: “mask of pregnancy”, liver spots, uterine chloasma, chloasma gravidarum, and chloasma virginum do not fully characterize the disease, nor are semantically appropriate, although the term “chloasma” (derived from the Latin chlóos and the Greek cloazein: greenish) is still used in the medical literature .
Melasma can have a significant effect on an individual’s quality . The Melasma Area Severity Index (MASI) is used by physicians to evaluate the severity of melasma; however, this index does not indicate the effect of melasma on the patients’ quality of life . The Dermatology Life Quality Index (DLQI) is a generic health status measurement for all dermatological diseases. This questionnaire contains general questions and may not be specific enough to detect important aspects of a particular disease . The Melasma Quality of Life (MQoL) is a diseasespecific health status measurement. Previous studies demonstrated that the discriminatory ability of MQoL is superior to that of the DLQI index [6,7]. The MQoL scores were highly correlated with DLQI and MASI scores .
In our study, we evaluated quality of life of patients with melasma, using both DLQI and MQol. We aim to have a reliable scientific data about this subject and contribute to the literature.
Materials and Methods
We included the patients, aged 20-63 who came to the dermatology polyclinic of Bozyaka Research and Training Hospital between February 2017 and October 2017. The patients signed the informed consent form. We asked them about their age, gender, occupation, salary per month (added all salaries of family members for per patient), duration of melasma, marital status, education status and psychological diseases, calculated MASI, DLQI and MQoL for each patient. MASI, DLQOL and MQoL were calculated by the same dermatologist.
The Melasma Area and Severity Index is an outcome measure developed to provide a more accurate quantification of the severity of melasma and changes during therapy, was developed by Kimbrough- Green et al, who based it on a similar scoring system devised for subjective assessment of 3 factors: area (A) of involvement, darkness (D), and homogeneity (H), with the forehead (f), right malar region (rm), left malar region (lm) and chin (c), corresponding to 30%, 30%, 30% and 10% of the total face. The area of involvement in each of these 4 areas is given a numeric value of 0 to 6 (0= no involvement; 1=<10%; 2=10%-29%; 3=30%-49%; 4=50%-69%; 5=70%- 89% and 6=90%-100%). Darkness and homogeneity are rated on a scale from 0 to 4 (0=absent, 1=slight, 2=mild, 3=marked and 4=maximum). The MASI score is calculated by adding the sum of the severity ratings for darkness and homogeneity, multiplied by the value of the area of involvement, for each of the 4 facial areas.
MASI total score=0.3A (f) [D(f)+H(f)]
+0.3A (lm) [D(lm)+H(lm)]
+0.3A (rm) [D(rm)+H(rm)]
+0.1A (c) [D(c)+H(c)]
The total score range is 0 to 48. The MASI is the most commonly used outcome measure for melasma trials but has never been validated. The purpose of this prospectively designed study was to determine the reliability and validity of the MASI score .
The DLQI is a short quality of life (QoL) instrument that can be used in all skin diseases, allowing comparison between them. It is selfadministered with a mean completion time of 2 min. It consists of 10 questions concerning impact of skin diseases on different aspects of patient’s QoL over the last week. The DLQI items include symptoms and feelings, daily activities, leisure, work or school, personal relationships and the side effects of treatment. Each item is scored on a 4-point scale: not at all/not relevant, a little, a lot and very much. Item scores (0-3) are added to give a total score (0-30); higher scores indicate greater impairment of QoL .
A melasma-specific scale, the melasma quality of life scale is highly correlated with the discoloration questionnaire. The discriminatory abilities of MQoL were found to be superior to those of DLQI for melasma. The three life domains most adversely affected by melasma (social life, recreation/leisure, and emotional well-being) have been highlighted by MQoL. MQoL was constructed in English, and crosscultural adaptations were then made in Spanish, Brazilian Portuguese and Turkish . This questionnaire consist of nine questions
1. The appearance of your skin condition
2. Frustration due to the appearance of your skin condition
3. Embarrassment about the appearance of your skin condition
4. Feeling depressed about your skin condition
5. The effects of your skin condition on your interactions with others (e.g.: interactions with family, friends, close relationships etc.)
6. The effects of your skin condition on your desire to be with people
7. Your skin condition making it hard to show affection
8. Skin discoloration making you feels unattractive to others
9. Skin discoloration making you feel less vital or productive
10. Skin discoloration affecting your sense of freedom
Each of these questions is determined by patient as numeric from 1 to 7 (1. Not bothered at all 2. Mostly not bothered 3. Sometimes not bothered 4. Neutral 5. Bothered sometimes 6. Bothered most of the time 7. Bothered all the time). Total score range from 10 to 70 .
Categorical variables were summarized in terms of counts and relative frequencies. Numeric variables were summarized in terms of man ± SD (standard deviation). We used Spearman and Pearson correlation tests for our study. All data were analyzed using SPSS version 17.0 for Windows. P<0.05 was deemed statistically significant.
This study was conducted in accordance with the ethical principles derived from the Declaration of Helsinki and on Harmonization Good Clinical Practices and in compliance with local regulatory requirements and was reviewed and approved by the local ethics committees for these institutions. All patients provided their written informed consent before entering the study.
One hundred and two patients were enrolled in this study. All the patients were women and the mean age at diagnosis was 39.35 ± 8.95 yrs (min 20 yrs, max 63 yrs). The mean melasma duration was 6.78 ± 5.21 years (min 1 y, max 20 yrs). The mean salary per month was 482 ± 327.62 euros (min 111 euros, max 2220 euros). Thirty-three patients had a job, sixty-six patients didn’t have a job and three patients were retired.
Eighty-nine patients were married and thirteen of them weren’t married. Two patients weren’t literate, four patients were literate, 46 patients were primary school graduate, 15 of them were secondary school graduate, 25 patients were high school graduate, and 10 of them all were university graduate. 92 patients didn’t have any psychiatric diseases and 10 patients had one disease about psychiatry. The mean MASI was 5.64 ± 4.98 (min 2, max 36). The mean DLQI was 6.02 ± 3.99 (min 0, max 19). The mean MQoL was 37.9 ± 15.11 (min 10, max 70) (Table 1).
|Age (yrs)||Educational status n(%)|
|mean age||39.35 ± 8.95||not literate||2 (1.96%)|
|age range||20-63||literate||4 (3.92%)|
|Occupation, n (%)||Primary school graduate||46 (45.09%)|
|working||33 (32.35%)||primary school graduate||15 (14.7%)|
|not working||66 (64.7%)||secondary school||25 (24.5%)|
|retired||3 (2.94%)||high school graduate||10 (9.8%)|
|Salary per month (euro)||University graduate||46 (45.09%)|
|mean salary||482 ± 327.62||MASI|
|salary range||111-2220||mean MASI||5.64 ± 4.98|
|Melasma duration (yrs)||MASI range||Feb-36|
|mean duration||6.78 ± 5.21||DLQI|
|duration range||Jan-20||mean DLQI||6.02-3.99|
|Marital status, n (%)||DLQI range||0-19|
|not married||13 (12.74%)||mean MQoL||37.9-15.11|
Table 1: Demographic data of patients and features of lesions
We found significant correlation between salary per month and MQoL (p=0.006), between MQoL and MASI (p=0.028), between DLQI and MQoL (p=0.0001), MASI and marital status (p=0.004) and DLQI and educational status (p=0.037). We found no significant correlations between other variables (Table 2).
Table 2: Significant Correlations
Melasma is a common disorder . Melasma affects all races but is especially prevalent in those with darker skin types (Fitzpatrick skin types III to VI) and has been highly reported in patients of Hispanic, African American, Arab, South Asian, Southeast Asian, and East Asian descent 11 The exact cause of melasma is unclear, but factors include genetic predisposition, ultraviolet light exposure, pregnancy, oral contraceptives, hormone replacement therapy, thyroid disease, cosmetics, and medications .
MQoL has been shown to have discriminatory power and high consistency; social life, recreation and leisure, and emotional wellbeing are the most affected domains of quality of life . MSQoL was constructed in English  and cross-cultural adaptations were then made in Spanish  Brazilian Portuguese  and Turkish . We used the same methodology to construct the Turkish version .
Dogramaci and colleagues  translated the MELASQOL to the Turkish language in 2009 following the established translation process of forward translation, an expert panel consensus translation, backtranslation, and review by the original author R. Balkrishnan .
We found significant positive correlation between MQoL and salary per month. We think about this result that if the salary of patients increases, melasma becomes prior problem for patients in their lives and they can visit doctor for treatment of melisma because they know they can reach appropriate treatment for their disease. If the salary decreases, melasma doesn’t become prior problem for patient and the patient doesn’t want to take the appropriate treatment, doesn’t visit doctor because she wants to spend money for prior needs. In the literature we couldn’t find any articles that examined the relation between MQoL and salary. As additional information, Leeyaphan et al.  studied in their study relationship between DLQI and willingness to pay-time trade off methods in Thai population. They determined that the willingness to pay method could be a useful tool with which to measure the quality of life of patients with melasma. In our study, we didn’t find any relationship between DLQI and salary per month.
We found positive correlation between MQoL and MASI. We observed if MASI increases, MQoL increases, too. In contrast to the lack of or moderate correlation found between the MASI and the MELASQOL scores in previous studies, Dogramaci and colleagues  interestingly found the MELASQOL-TR and MASI to be significantly correlated .
The DLQI has been used to determine the health related quality of life in patients with skin problems and has been considered to be superior, in terms of reliability, to general (non-dermatological) measurements in dermatological patients . In our study, there was a positif correlation between DLQI and MQoL. Validation of the MQoLTR to demonstrate equivalent or superior discriminatory power to a dermatology-specific QOL instrument such as the DLQI would also be helpful, and health-related QOL domains previously shown to be most affected by melisma should also correlate to the most affected QOL domains identified by the MQoL-TR . It confirms the importance of melasma in altering the QoL of the patients. This result clearly illustrates that appropriate treatment is fundamental to improving the QoL of melasma patients .
We found positive correlation between MASI and marital status. We know pregnancy is a reason for melasma. If the rate of marital status in a population increases, the rate of pregnancy increases, too. Therefore the rate of melasma increases. In the literature we couldn’t find any articles that examined the relation between MASI and marital status.
We found significant correlation between DLQI and educational status. We comment this result as that if educational status improves, the salary of patient increases, too and melasma becomes more prior problem for the patient because she knows she can reach appropriate treatment for melasma and therefore DLQI of the patient increases. Dogramacı et al.  didn’t find any relation between DLQI and educational status. On the contrary, we didn’t find any correlation between MQoL and educational status. There should be more studies about this topic.
There was no correlation between disease duration and MQoL and between age and MQoL. We think about this that melasma effects life quality of the patient time independent and it is such a problem that it should be solved immediately. Ikino et al.  and Dogramacı et al.  didn’t find any correlation between these variables too.
Melasma is a common and recurrent disease that can effect quality of life of patient. According to our research, if the salary of patients increases, MQoL increases too.
When MASI scales up, MQoL scales up, too. According these results, we think that women who are married and have high salary, should protect themselves against melasma more carefully.
The authors have no conflict of interest to declare.
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Citation: Coban M (2018) Quality of Life of the Patients with Melisma. J Cosmo Trichol 4: 1000133. DOI: 10.4172/2471-9323.1000133
Copyright: © 2018 Coban M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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