Melasma (a term derived from the Greek word “melas” meaning black) is a common acquired hypermelanosis that occurs exclusively in sun exposed areas, mostly in the face and rarely in the neck and forearms.1 Melasma is more common in women. Men have been reported to represent 10% of cases and demonstrate the same clinical and histologic characteristics as women. Melasma is characterized by symmetrical hyperpigmented macules, which may be blotchy, irregular, arcuate, or polycyclic and rarely have a linear or a starburst distribution.2 Centrofacial pattern is the most common and consist of lesions on the forehead, cheeks, nose, upper lip or chin. Malar pattern describes lesions located primarily on the cheeks and nose. Mandibular pattern consists of lesions on ramus of the mandible.3 The exact cause of melasma remains elusive, but the two most important factors implicated in its etiopathogenesis are sunlight and genetic predisposition. Exacerbations of melasma are seen after a period of sun exposure and, conversely, melasma gradually fades during periods of sun avoidance. Genetic factors are also involved as suggested by familial occurrence and higher prevalence among Hispanics and Asians. Other factors like pregnancy, oral contraceptives, estrogen-progesterone therapies, thyroid dysfunction,cosmetics, phototoxic and antiseizure drugs are contributary.4 Using Wood‘s light examination, melasma can be classified into four histologic Types : 5,6 1. Epidermal type. The pigmentation is intensified under Wood‘s light examination. It is the most common type of melasma. Melanin is increased in all epidermal layers. Only a few scattered melanophages can be observed in the papillary dermis. 2. Dermal type. The pigmentation is not increased under Wood‘s light examination. There are many melanophages throughout the entire dermis. 3. Mixed type. Under Wood‘s light examination, the pigmentation becomes more apparent in some areas while in others there is no change. Melanin is increased in the epidermis, and there are many dermal melanophages. 4. Indeterminate type. Wood‘s light examination is of no benefit in individuals with skin type VI.

Source of Data: Study source comprised of those seeking the outpatient services at the department of Dermatology. Method of collection of data All female patients, who presented with the primary symptoms, suggestive of facial dermatoses, attending the OPD were subjected to detailed history and clinical examination. During the study period, a total of 300 cases were selected randomly after taking their consent. Ethical clearance was obtained before commencing the study. Inclusion criteria: Female patients aged more than 15 years presenting with facial skin lesions to the dermatology OPD. Exclusion criteria: • Patients younger than 15 years of age • Patients with congenital skin disorders involving face • 3)Patients with sole involvement of mucosa of oral cavity, lips and conjunctiva • Facial lesions due to physical or chemical injury and burns CLINICAL STUDY: In each case, a detailed history was elicited, including basic epidemiological data, symptoms, onset, duration and type of lesion, pre-disposing factors like sun exposure, drug intake, topical application of medicines and cosmetics etc., genetic and occupational factors and systemic diseases. A thorough cutaneous, physical and systemic examination was carried out according to a prestructured proforma taking into account the type of lesion, site and other associated features. LABORATORY STUDY: Diagnosis was made primarily based on history and clinical examination. However, specific investigations helpful in diagnosing the condition or underlying systemic abnormalities were carried out wherever applicable. Investigations including biopsy, Wood‘s lamp, dermoscopy, KOH mount, Giemsa stain and Tzanck smear were carried out to aid in diagnosis. Complete hemogram, thyroid function tests, refractive error testing, androgen hormone panel amongst others were done to rule out systemic involvement in the primarily facial disorders. The results of the study were tabulated, analysed and discussed. Simple proportions and percentages for comparing different variables like age, incidence etc., were used. Final outcome was expressed as the percentage of facial skin disorders among the study group as a whole and as the percentage of individual facial skin disorders.

Table – 1: Age incidence in Melasma Age group No. Percentage 16-25 9 14 26-35 35 53 36-45 17 26 46-55 4 6 56-65 0 0 >65 1 1 66 100 As melasma was the most common (66 patients) pigmentary condition in our study, we studied further about its types, patterns and predisposing factors.It accounted for 66(64.7%) of total facial pigmentary disorders. It had its onset and presentation in 3rd and 4th decade of life in majority of patients as showed in table -16. Our oldest patient was aged 68 years while our youngest was 22 years. Table – 2 : Aggravating factors for Melasma Melasma (n=66) Aggravating factor Number Percentage Sun exposure 25 37.87 Cosmetics 16 24.24 Family history 07 10.60 Hypothyroidism 04 06.06 Pregnancy 12 18.18 Drug history 02 03.03 Total 66 100 The most important aggravating factor was found to be sun exposure seen in 25 (37.87%) patients. A family history of melasma was present in 7 patients (10.60%). Among 66 patients, 12 (18.18%) developed melasma during pregnancy. A history of drug intake was found in 2 (3%)patients among them, 1 was on OCP, 1 patients was on MB- MDT. Other predisposing factors were probably the use of cosmetics like fairness creams 16(24.24%) and associated systemic disease like hypothyroidism reported in 4 cases (6.06%). Table – 3 : Pattern of Melasma Melasma pattern Total Percentage(%) Malar 48 72.72 Centrofacial 18 27.27 Mandibular 00 00 Total 66 100 Common pattern observed was malar pattern(72.72%) followed by centrofacial pattern in 18 (27.27%) patients . Table – 4 : Woods lamp pattern of Melasma Melasma pattern Total Percentage (%) Epidermal 42 63.63 Mixed 17 25.75 Dermal 7 10.60 Total 66 100 The most common Wood‘s lamp pattern of melasma observed in our study was epidermal in 42 (63.63%), followed by mixed 17 (25.75%) and dermal 7(10.60%).

Melasma constituted the most common facial melanosis in the present study forming 64.7% of all cases which is in concordance with a study by Hassan et al7. The youngest patient in our study was a 22-year-old female and oldest patient was a 68-year-old female. According to observations made by Achar et al8, the age of melasma patients ranged from 14 to 55 years. This presentation in our study can be explained, based on the geographical variation and local cultural influences. The most common pattern of melasma in our study was malar type 48 (72.72%), followed by centrofacial type seen in 18 (27.27%) patients, which was in concordance with the observations made by Hassan et al7 and Goh et al9. In contrast, Achar et al8 in his study reported centrofacial (54.44%) pattern as the most common type followed by malar pattern (43.26%) of melasma. A positive family history was present in 7 patients (10.6%) in contrast to 20.54% reported by Hassan et al7. In our study, about 25 (37.87%) patients had significant sun exposure, which they felt was an aggravating factor. Achar et al8 in his study reported that 55.12% had sun exposure related aggravation, which was almost similar to our study. Appearance of melasma during pregnancy was observed in 12 (18.18%) patients which is comparable to Hassan et al7 (16%) whereas Tamega et al10 observed 36.4% pregnant females with melasma in their study. Hypothyroidism was seen in four patients (6.06%) which was in concordance with Achar et al8, who observed 6.4% of melasma patients with hypothyroidism. Out of 66 patients of melasma, 2(3%) were on OCP’S for a mean duration of 2 years in contrast to 6 % in Hassan et al7 .This may be explained as less usage of OCP’S or false reporting by patients. We observed 1 (0.98%) patient with Riehl‘s melanosis ,sensitizing agent was cosmetics. Hassan et al7 in his study on facial melanoses reported 5.7% cases of Riehl’s melanosis.

• I Most common type of melasma was malar (72.72%) followed by centrofacial (27.27%). • On Wood‘s lamp examination, 63.63% had epidermal type, 10.6% had dermal type and 25.75% had mixed type of melasma.

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