Introduction
Facial pigmentary disorders are a group of heterogenous entities, sharing a common clinical feature of altered pigmentation of the face and thus easily visible cosmetic disfigurement. Pigmentation disorders of the skin can either be hyper-melanotic or hypo-melanotic. Hyper-melanotic disorders include a diverse group of disorders including melasma, lichen planus pigmentosus (LPP), Riehl's melanosis and periorbital hyperpigmentation (POH). Vitiligo, pityriasis alba, and postinflammatory hypopigmentation (PIH) are the most common hypo-pigmented disorders involving the face. Unlike most internal illnesses, skin diseases especially those on face are often immediately visible to others and, therefore, may lead to significant psychosocial consequences, and consequent dermatological consultations, thus explaining the growing importance of these disorders.[123] There are many studies in the literature about facial hyperpigmentary disorders, and few on facial hypopigmentation disorders, but rarely on both types of disorders together. Our study involved both hyper and hypo pigmentary conditions causing facial melanosis.
Methods
This was a prospective study conducted over a period of 1-year from September 2013 to August 2014 in the department of dermatology of a tertiary care hospital. After obtaining ethical clearance from the institutional review board and patient consent, all the patients attending the out-patient department for facial pigmentation disorders were enrolled in the study. After collecting demographic data, detailed clinical history regarding age at presentation, age of onset, duration of the disease, and family history was noted. The data of different predisposing factors such as sun exposure, pregnancy, cosmetic use, ovarian tumor, atopy, iron deficiency and other endocrine diseases were recorded, and relevant investigations carried out to rule out the same when required. Similarly skin biopsy and patch testing using cosmetic series was also done wherever required.
Results
The study comprised of 208 patients of altered facial pigmentation. The youngest patient was a 4-year-old male, and the oldest was 58-year-old female, with a mean age of 27.40 years. The maximum number of patients that is, 118 (56.73%) belonged to 21-40 years age group, followed by 54 (25.96%) to < 20 years and 36 (17.30%) to > 40 years of age group. There were 71 males and 137 females, with a female to male ratio of 1.92:1. Of a total of 208 patients, 132 (63.49%) belonged to rural areas [Table 1]. Housewives who also indulged in farming activities were the predominant occupational group comprising of 47 patients (22.59%), followed by students 26 (12.5%).
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Table 1: Demographic profile of patients of facial melanosis
In our study, we came across 14 different categories of altered facial pigmentation that is, both facial hypermelanosis (168) and hypo-melanosis (40) [Table 2]. Among patients of facial hypermelanosis, melasma [Figure 1] was the most common comprising of 73 patients. Pityriasis alba (22) was the most common cause of facial hypomelanosis. A case of bilateral naevus of Ota [Figure 2] was also enrolled.
Figure 1: Melasma
Figure 2: Bilateral naevus of Ota with naevus of Ito
Table 2: Types of facial melanosis
Except postinflammatory hyperpigmentation and drug-induced hyperpigmentation, all other causes of facial hypermelanoses were more common in females. Among facial hypo-melanosis, pityriasis alba had a male predominance, as described in [Table 2].
In our study, the onset of facial hypermelanoses was in the third decade in 50 (29.76%) of a total of 168 cases. Patients of LPP [Figure 3] and Riehl's melanoses reported the onset of lesions even after 50 years of age. Hypo-melanotic disorders had an earlier age of onset, with facial vitiligo [Figure 4] occurring before 20 years in 11 (57.89%) cases. All cases of pityriasis alba had onset of lesions before 15 years of age.
Figure 3: Lichen planus pigmentosus
Figure 4: Vitiligo
All cases of LPP and Riehl's melanosis, 4 (80%) cases of drug-induced hypermelanoses, 8 (80%) cases of ephelides [Figure 5], 48 (65.75%) cases of melasma and 14 (40%) cases of PIH had exacerbation of pigmentation on sun exposure. Totally, 16 (72.72%) cases of pityriasis alba [Figure 6] observed exacerbation on sun exposure.
Figure 5: Ephelides
Figure 6: Pityriasis alba
Among patients of postinflammatory facial hyperpigmentation [Figure 7], acne vulgaris was the most common preceding cause in 13 (37.14%) cases. Among PIH, herpes simplex, discoid lupus erythematosus [Figure 8], trauma and burns were the common causes.
Figure 7: Postinflammatory hyperpigmentation
Figure 8: Postinflammatory hypopigmentation
There was a history of cosmetic use in 55 (32.73%) cases of facial hypermelanosis. Majority of the patients gave history of application of topical steroids available as the over the counter fairness or skin lightening creams, followed by bleaching agents, and Ayurvedic preparations, most of the times passing through a transient stage of erythema [Figure 9]. Patch testing was done using cosmetic series on them. Two patients had a positive test one each for thiomersal and rose oil. A patient showed doubtful reaction for lavender absolute. No such significant history was reported by patients with hypo-melanotic disorders.
Figure 9: Transient erythema
History of drug intake was seen in 32 (15.38%) cases. All these patients presented with hyperpigmentation, with no case of hypopigmentation. Of these, patients attributed their facial hyperpigmentation to drugs in 6 cases. Of these 6 cases, 4 patients gave a history of taking multibacillary multi drug therapy (MB-MDT) for lepromatous leprosy and 1 case each of anti-tuberculosis therapy and phenytoin.
Eighteen (15.78%) cases of females with facial hyperpigmentation reported that their disease precipitated during pregnancy. One patient of melasma had a benign ovarian tumor. Eight patients out of 73 cases of melasma and 5 cases out of 19 cases of vitiligo had associated hypothyroidism. Three (21.42%) patients of POH [Figure 10] gave history of atopy and error of refraction each. Two (14.28%) patients of POH had associated iron deficiency anemia. A personal history of atopy was seen in 4 (18.18%) cases of pityriasis alba also. A patient with diffuse hyperpigmentation also had underlying Addison's disease [Table 3].
Figure 10: Periorbital hyperpigmentation
Table 3: Associations of facial melanosis
Family history was significant in 15 (20.54%) cases of melasma, 4 (40%) cases of ephelides, 2 (14.28%) cases of POH, 1 (5.26%) case of vitiligo and 5 (22.72%) cases of pityriasis alba.
Among 208 patients, pigmentation was localized in 129 (62.01%) of cases. Diffuse pigmentation was observed in only 79 (37.98%) cases. All cases of drug-induced hypermelanoses and Riehl's melanoses had diffuse pigmentation. Only 6 out of 34 cases of PIH and 14 out of 73 cases of melasma had diffuse pigmentation. Rest of the disorders including vitiligo and pityriasis alba had localized pigmentation of the face.
The most common site of altered pigmentation (hyper or hypo), in our study was the cheeks in 137 (65.86%) cases followed by nose in 91 (43.75%), forehead in 76 (36.53%), temporal in 21 (10.09%) and periocular in 19 (9.13%).
Thirty-three (15.86%) cases of altered facial pigmentation had pigmentation in other parts of the body as well. However, in melasma, POH, ephelides and pityriasis alba, the pigmentation was limited to face only.
Gray/slate/blue color which indicates dermal pigmentation was seen in 100 (59.52%) and brown color that is epidermal pigmentation, was seen in 68 (40.47%) cases of facial hypermelanosis. All cases of ephelides, 10 (71.42%) cases of POH, 50 (68.4%) cases of melasma and 13 (37.14%) of PIH had epidermal pigmentation. Rest of all cases had dermal pigmentation. This was based on clinical assessment only.
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 37 (50.68%) cases. Other types noted were centrofacial and mandibular in 34 (46.57%) and 2 (2.74%) cases respectively. Melasma area severity index scoring was not done, as it was not a study exclusively on melasma.
Discussion
Facial pigmentary disorders are a common group of disorders with a great degree of psychosocial impact due to their easy visibility. Due to increased patient awareness, greater use of cosmetics and over the counter drugs, their incidence and importance is growing rapidly. They form one of the major causes of dermatology consultations, especially in young women.
Our study involving facial pigmentary disorders was completed over a span of 1-year and involved 208 patients. The mean age of patients in our study was 27.04 years. Age of onset was <20 years for all hypopigmented diseases and in the third decade for hyperpigmented lesions except for LPP and Riehl's melanosis, which had onset even in the fifth decade.
Patients of facial dyspigmentation were categorized into 14 groups, melasma, a common acquired symmetrical hypermelanosis, being most common, consisting of 35.09% of cases. The average age of melasma patients was 34.22 years in our study, which was similar to 33.45 years in a study by Achar and Rathi as against 42.3 years reported in a study from Singapore.[45] We found about 15.06% involvement of men in our study compared to 19.87% and 10% in different studies.[46] About 65.75% of our patients with melasma described sun exposure as exaggerating factor, similar to previous studies.[7] Pregnancy and oral contraceptive pills (OCPs) caused aggravation in 16% and 6% of female patients, respectively. The figures of pregnancy are comparable, but those of OCPs are lower as compared to previous studies, perhaps due to lesser use or false reporting by female patients.[78] One patient also implicated ovarian tumor as an aggravating factor and reduction in pigmentation on treatment of the disease. Associated thyroid dysfunction was seen in 10.95% of patients, mostly hypothyroidism which was comparable to previous studies.[4] In 61.64% of patients, there was a history of association with the application of various cosmetic products and topical steroids, available as over the counter fairness creams, leading to typical steroid facies. This association of melasma with these cosmetic products has also been reported by Achar and Rathi[4] , and Grimes.[9] In our study, malar pattern was most common. This was similar to studies from south India, and to a study by Goh and Dlova, but in contrast to other studies, which reported centrofacial to be most common.[571011] This can be explained by regional and environmental variations.
Postinflammatory hyperpigmentation was the second most common cause of altered facial pigmentation (16.34%). It showed a slight male predominance. Most common etiology was secondary to acne vulgaris and had associated similar lesions on trunk. This was similar to a study by Taylor et al., who evaluated 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 postinflammatory hyperpigmentation.[12]
POH constituted 6.7% of the patients in our study, and 21.42% of patients had positive family history of POH. Ranu et al., and Sheth et al., reported 42.2% and 63% patients with a positive family history of POH respectively.[1314] In our study, 21.42% of patients gave a history of atopy, compared to 33% in other studies.[1314] In the present study, 7.14% patients reported lack of adequate sleep in contrast to 51.1% and 40% in other studies.[1314] Error of refraction that is, myopia was seen in 21.42% of patients, as compared to 30% in a study by Sheth et al.[14] According to Gathers, exhaustion of periorbital muscles may play a significant role in causation of POH.[15] In the present study, 14.28% patients of POH had associated iron deficiency anemia as compared to 50% in a study by Sheth et al.[14] In these patients, POH may be either because enough oxygen is not reaching the periorbital tissues or due to facial pallor which makes the periorbital region look comparatively darker. The difference in our study and previous ones may be due to lesser number of patients with POH (14) in our study.
Ephelides had an early age of onset. They were more common in fairer people with positive family history in 40% of cases.
Lichen planus pigmentosus, a rare variant of lichen planus, constituted 4.8% of patients in our study, involving patients in their third to sixth decade of life. Earlier studies conducted by Bhutani et al. and Vega et al. have also reported its occurrence at a similar age group in their patients.[1617] Females constituted 80% of the cases which was similar to Vega et al., who also reported female preponderance.[17] Bhutani et al. observed no difference in sex distribution in their patients.[16] Pigmentation in different patients varied from slate gray to brownish-black but was diffuse in the majority. The forehead and temples were the predominant sites involved in our study. Bhutani et al. and Vega et al. also noted similar findings in their patients.[1617] Although lesions are generally asymptomatic, mild pruritus and photosensitivity were present in 48% of patients in our study. In earlier reported series, pruritus was present in 50% to 62% of the patients.[1617] Lichen planus was associated in 10% of cases of LPP in our study, while Bhutani et al. and Vega et al. observed lesions of LP in 11 [Fraction Slash] 40 (27%) and 1 [Fraction Slash] 11 (9%) of their patients, respectively.[1617]
Riehl's melanoses constituted 5.7% of total cases. The mean age was 42.43 years and more common in females (62.5%). All the cases had a history of cosmetic use for a mean duration of 3.2 years and the various cosmetics used were fairness creams, hair dye, hair oils and steroid creams. Rorsman also stated that the commonest cause was sensitizing chemicals in cosmetics.[18] In our study, pruritus was observed in 5 cases (41.66%). The lesions were more pronounced over forehead, temporal, and cheeks. Patch test was positive only in 2 (25%) cases using cosmetic series of patch testing.
In our study, we observed 6 cases of drug-induced skin pigmentation. The mean age was 36.44 years and majority of patients were males (83.33%). All the patients in our study had diffuse pigmentation, more prominent on sun-exposed areas, and the pigmentation varied from black to violaceous-brown shades. The most common drugs implicated in our study were MB-MDT in 4 cases (80%), who had generalized violaceous brown pigmentation probably due to clofazamine.
Pityriasis alba is a relatively common skin disorder. Pityriasis alba was seen in a younger age group with the majority below 15 years of age in our study. Onset more in springs was seen in 60% of cases in our study. A personal history of atopy was seen in 18.18% of cases. In a study by Vinod et al., atopic background was detected in 85.5% of cases.[19]
Vitiligo as such has a predilection for regions such as the face, groin, axillae, areolae and genitalia.[20] Similarly in our study also, facial vitiligo was common cause of facial hypopigmentation (38%). Facial vitligo was most commonly focal, followed by periorbital, perioral and segmental. Associated extrafacial involvement was seen in 47.36%, and 15.78% had associated thyroid disorders, as compared to 40% prevalence of thyroid disorders in vitiligo patients in a study by Kumar et al.[21]
Conclusion
This preliminary study, involving both hyper-pigmented and hypo-pigmented disorders of the face was the first of its kind, to the best of our knowledge. These disorders have variable but overlapping clinical presentations and associated with significant distress and psychological impact.
Among the hyperpigmented conditions, melasma, postinflammatory hyperpigmentation, POH, ephelides, LPP, Riehl's melanosis and drug-induced hyperpigmentation, are the common conditions. Among the hypopigmentation disorders, pityriasis alba, vitiligo, PIH are the common ones.
The limitations of our study were smaller cohort size and diagnosis by clinical means only. More widespread and large scale studies pertaining to the subject should be conducted to refine the conditions associated with facial melanosis.
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