Clinical spectrum of facial hypermelanosis: a descriptive study from a tertiary care centre

INTRODUCTION

Facial melanotic disorders are a diverse group of altered pigmentation over the face thus is an easily visible cosmetic problem and affects the quality of life of the affected individuals.^1-3 There is an increased incidence of such pigmentation in Indian population due to the presence of diverse ethnic groups, climatic condition, and social parameters. The altered facial pigmentation can be black, blue or brown in colour depending upon the distribution of melanin pigmentation. Due to the impact in social life the facial melanotic disorders are gaining more importance in recent days. In spite of its common occurrence a proper classification and clinical studies in this context is still lacking. Our study is aimed to describe the various clinical types of facial hypermelanosis and to find its associations with lifestyle changes.

METHODS

This is a prospective observational study conducted in the dermatology outpatient department (OPD) of Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry, for a period of one and half years i.e., from September 2017 to March 2019. The study was conducted after obtaining ethical clearance from the institutional committee. After obtaining informed consent, patients with facial dyschromias attending the dermatology OPD were included in this study. After obtaining demographic data, a detailed clinical history regarding the onset, duration, familial association, occupational exposure, photoexposure, hair dye and cosmetic usage and associated systemic illnesses were taken and were noted in a pre-structured proforma. Statistical analysis was done using Epi info software ver 3.5.4. Clinical examination was performed and photographs of all the patients were recorded. Relevant blood investigations and skin biopsy were performed wherever required.

RESULTS

This study comprised of 1024 participants with facial melanosis, the minimum age of enrolled participants was 16years and the maximum age was 73. Maximum number of patients belonged to the age group 21-30 years were 322 (31.4%) and minimum number belongs to above 60 years (3.6%) (Table 1). Less than 20 years of age there were 86 (8.4%) participants. The mean age was found to be 35.64±12 years. Significantly females 688 (67.2) were more in numbers than male 336 (32.8) (<0.005).

*<0.05 significance.

Table 2 shows, authors came across 13 varieties of facial melanosis. Out of 1024 participants, post inflammatory pigmentation was significantly common about 362 (35.3). Significantly, males 231 were more in numbers than females 131. Followed by other facial melanosis such as melasma 177 (17.2), peri orbital melanosis 161 (15.7), seborrheic melanosis 77 (7.5), perioral melanosis 71 (6.9), facial acanthosis nigricans 60 (5.85), frictional melanosis 50 (4.88), photo melanosis 41 (4), lentigines 9 (0.87), freckles 7 (0.68), riehl’s melanosis 4 (0.39), lichen planus pigmentosus (LPP) 3 (0.29) and erythema dyschromicum perstans 2 (0.19).

*<0.05 significance.

In melasma, female patients were significantly more in numbers than male patients. According to the distribution of lesions, three clinical patterns of melasma were observed and among these, the malar type was the most common, seen in 106 (59.6) cases (Figure 1). Other types noted were centrofacial and mandibular in 64 (35.7) and 7 (4.5) cases respectively. Most common site of facial melanosis in our study cheek (74.6%) followed by forehead (47.6%). Least common site was temporal region (3.1%) and nasolabial fold (1.8%). The facial melanosis, about the pattern 487 (47.5) patients had diffuse pattern and 537 (52.5) had patchy pattern.

The most common cause for post inflammatory pigmentation was post acne pigmentation 204 (56.3%) which is significant compared to the other causes such as contact dermatitis 67 (18.5), post traumatic pigmentation 47 (12.9), secondary to varicella 7 (1.9), secondary to tinea faciei 9 (2.4), polymorphic light eruption 9 (2.4) and blister beetle dermatitis 7 (1.9).

Table 3 explains the aggravating factors and the associated conditions for the facial melanosis. Maximum number of cases post inflammatory pigmentation and melasma gave history of acne vulgaris and sunlight exposure respectively.

Patients of periorbital melanosis (161) gave a history of associated atopy. Constitutional type of POM (Figure 2) was the common type followed by vascular type. Obesity was found to be significantly associated with patients of facial AN. Patients with frictional melanosis (Figure 3) gave a positive history of constant rubbing of the face.

Patients with Riehl’s melanosis and LPP (Figure 4) gave history of usage of topical steroids, whitening creams and ayurvedic medications. Patch testing with cosmetic series was done which showed a positive finding in patients with Riehl’s melanosis.

Table 4 describes the characteristic colour of facial melanosis with proportion of participants. The commonest colour noted was brownish black 638 (62.3) which is significantly higher than the Reddish black 328 (32), Brown 54 (5.3), Reddish brown 2 (0.19) and bluish black 2 (0.19). Skin texture was found to be significantly normal in 874 (85.6) and few patients had thick skin texture 88 (8.59) (Figure 5) and velvety 62 (6). The thick and velvety skin texture may be due to the climatic conditions and friction.

Among 1024 participants, 804 (78.6) had photosensitivity out of which only 52 patients had used cosmetics and 61 patients had used hair dye. Positive family history of facial melanosis was found in 19 (1.9) individuals whereas significantly 1005 (98.15) patients had no family history of facial melanosis.

DISCUSSION

This study was done as a cross sectional study, to assess the demographic and clinical profile of patients with facial melanosis and factors associated with it in the Department of Dermatology and Venereology. In this present study among 1024 patients with facial melanosis, maximum number of patients of about 322 were in the age group of 21-30 years, in a similar study conducted by Kavya et al had mean age 35.04 which is consistent with our study.⁴ In this study the mean age was found to be 35.64±12.0 years. Similarly Achar et al reported the mean age of patients with melasma was 33.45 years, ranging from 14 to 54 years.⁵ In our study 67.2% of the patients were females and males were 32.8% similarly Achar et al in their study they reported that they found female preponderance with a female to male ratio of approximately 4:1.⁵ In a study conducted by Hassan et al found that female to male ratio of 1.92:1.⁶

In this study on facial melanosis, post inflammatory pigmentation 362 (35.3%) was the commonest cause followed by melasma 177 (17.2%). This contradicts with the study conducted by shah et al and Gupta et al.^6,7 They concluded that the melasma was the most common cause among facial melanosis. According to shah et al found PIH was the second most cause for facial melanosis.⁶ Both the studies showed melasma as the commonest cause which is second commonest cause in our study Among post inflammatory pigmentation (PIH), post acne pigmentation was the commonest 204 (56.3%) followed by contact dermatitis 67 (18.5%) and post traumatic pigmentation 47 (12.9%). In a study done by Taylor et al on acne in skin of color and found that 65.3% of African‑American, 52.7% of Hispanic and 47.4% of Asian patients developed acne induced post inflammatory hyperpigmentation.⁸ This study had 15.7% peri orbital melanosis which is similar to the study conducted by Gupta et al showed periorbital melanosis in 10.7% patients.⁷

The aggravating and predisposing factors for each type of facial melanosis were assessed. Among 362 patients with post inflammatory melanosis commonest predisposing factor was found to be acne vulgaris (63%), followed by pyodermas (19%), dermatitis (16%) of various nonspecific causes and trauma (2%). These findings correlates with the study done by Hassan et al Aggravating factors for melasma (177) were found to be chronic sunlight exposure (47%), pregnancy (25%) and oral contraceptive pills ((11%).⁹ Similar findings were observed in the studies done by Jagannathan et al.¹⁰ Regarding POM (161) cases constant rubbing of eyes (52%) and spectacle usage (10%) was found to be frequently associated which correlates with the study done Sheth et al by Winter seasonal exacerbation of seborrheic melanosis was observed in our study.¹¹ AN and frictional melanosis patients gave a history of constant rubbing of face. As seen in the literature prolonged sunlight exposure were observed in patients with photomelanosis, lentigines, freckles, Riel’s melanosis.

In the present study out of 177 melasma participants, malar melasma, Centrofacial melasma and mandibular melasma was seen 59.6%, 35.74% and 4.5% patient respectively. Malar pattern was commonly seen in this study which is similar to other studies from south India but contradicts with other studies which stated centrofacial pattern to be the commonest.^9,12-17 Usage of facial cosmetics was the possible precipitating factors of facial hypermelanosis. Use of cosmetics and hair dye, and its proportion with photosensitivity was calculated. Photoexposure and photosensitivity was seen in 804 (78.6) patients; in which 52 (6.5%) patients used cosmetics and 61 (7.6%) have used hair dye. The predominance of cosmetic usage in melasma was also reported in studies done by Achar et al and Grimes.^5,15 The most common site of facial melanosis in our study was cheeks (74.6%) followed by forehead (47.6%). The least common site was temporal region (3.1%) and nasolabial fold (1.8%). In a similar study conducted by Hassan et al, correlates with our study found that (65%) patients had lesion over the cheeks.⁹ The distributions of facial melanosis were patchy in 52.5% patients and diffuse in 47.5% patients. The colour of facial melanosis was brownish black in 62.3% patients, reddish brown in 32% patients, brown in 5.3% patients, slate grey in 0.19% patients and bluish black in 0.19% patients. Skin texture was found to be normal in 85.6% patients, thick among 8.59% and velvety in 6% patients.

CONCLUSION

Facial hypermelanosis is a clinical feature of a diverse group of disorder most commonly encountered in females who expose to sunlight and using over the counter cosmetic creams. Etiology in most facial hypermelanosis is unknown, but some factors such as UV radiation, use of cosmetics and hairdye, genetic predisposition can contribute to it. Diagnosis is based on detailed personal, family history and clinical features aided with relevant investigations depending on individual case. It is important to have a comprehensive understanding and information on the epidemiological and ecological factors of various clinical entities of facial hyperpigmentation for better managements of patients.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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