Hypermelanoses are a group of disorders characterized by abnormally darker skin that results from increased melanin production from a normal number of melanocytes. Hypermelanoses may result from increased melanin in the epidermis(epidermal hypermelanoses), the dermis (dermal hypermelanoses) or both (mixed hypermelanoses). Possible mechanisms for increased epidermal melanin without an increase in the number of melanocytes include the following:1,2 1. Increased melanosome production and transfer to keratinocytes ; 2. Increased melanosome size; and 3. Decreased keratinocyte turnover, resulting in overloading of the keratinocyte with melanosomes. In dermal hypermelanoses, melanosomes are formed in the epidermis by epidermal melanocytes and are transferred to the dermis, where they are found mostly within macrophages (melanophages). This phenomenon is called “ epidermal melanin incontinence”. Most facial melanoses are commoner in darker races with both light and photosensitizing chemicals playing an important role. Based on the location of melanin three types of hypermelanosis are identified:3,4 • Brown hypermelanosis: Wherein excess melanin is in basal and suprabasal (rarely throughout epidermis including the horny) layers and the pigmentation is accentuated under Wood‘s lamp . The increased epidermal melanin can be a: • Melanotic hypermelanosis: due to increased melanin production by normal number of melanocytes. • Melanocytic hypermelanosis: due to increased number of melanocytes. • Blue hypermelanosis (ceruloderma): Wherein excess melanin is in dermis and the pigmentation is not accentuated under Wood‘s lamp. Mixed hypermelanosis: due to increased epidermal and dermal melanin.

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: Incidence of pigmentary disorders Pigmentary disorders (n=102) Number of cases Percentage(%) Melasma 66 64.7 Perorbital melanoses 12 11.76 Freckles 6 5.88 Seborrheic melanoses 5 4.9 Lichen planus pigmentosus 4 3.92 Riehls melanoses 1 0.98 Post chikangunya pigmentation 1 0.98 Exogenous Ochronoses 1 0.98 Solar melanoses 1 0.98 Drug induced pigmentation 1 0.98 Post inflammatory hypopigmentation 2 1.96 Vitiligo 2 1.96 102 100 In the present study, out of 300 patients, 102 patients had pigmentary disorders. The most common pigmentary condition on face was melasma (64.7%) with 66 patients followed by 12 (11.76%) patients with periorbital melanosis. There were 6 (5.88%) cases of freckles, 5 (4.9 %) cases of seborrheic melanosis, 4 (3.92%) cases of lichen planus pigmentosus and 2 cases each of vitiligo and post inflammatory depigmentation (1.96%). One case each of Riehls melanosis , solar melanosis, drug induced pigmentation and exogenous ochronosis was seen (0.98%). Table – 2 : Age incidence in pigmentary disorders Age No. of cases Percentage (%) 16-25 24 23 26-35 51 50 36-45 19 19 46-55 5 5 56-65 2 2 >65 1 1 102 100 Maximum cases of pigmentary disorders were seen in the age group of 26-35 years (50 %) and least incidence was seen in age group above 65 years (1 %). Table – 3 : Pattern of pigmentation Pattern Total Percentage (%) Localised 97 95 Diffuse 5 5 102 100 In the present study majority had localised (95%) pigmentation and 5 (5%) had diffuse pigmentation. Table – 4 : Predisposing factors in pigmentary disorders Pigmentary disorders (n = 102 ) Predisposing factor Number Percentage (%) Sun exposure 36 35.29 Anemia 04 3.92 Cosmetics 17 16.66 Family history 08 7.8 Refractive errors 03 2.9 Stress 04 3.92 Pregnancy 12 11.76 Drug history 04 3.92 Hypothyroidism 04 3.92 In the present study the most common predisposing factor was sun exposure seen in 36 cases (35.29%), cosmetics in 17 cases (16.66%). Family history was present in 8 (7.8%), stress factor, drug history, hypothyroidism and anemia was present in 4(3.92%) cases each. Refractive error was present in 3 cases (2.9%) and 12 patients (11.76%) developed pigmentary disorders during pregnancy.

Among the 104 patients, majority belonged to age group of 26-35 (50%) years and 16-25 (29.34%) years. This is in concordance with the study conducted by Hassan et al5 in which, 56.73% patients were between the age group of 21-40 years. These findings are also similar to those in the review article of Perez-Bernal et al6 , where it has been quoted that facial hypermelanosis is common in middle-aged women. This prepondernace may be due to endogenous factors such as hormones and exogenous factors like cosmetics and perfumes. In this study, out of 102 patients with pigmentary disorders, 36 (35.29%) patients reported aggravation on sun exposure. Out of 66 cases of melasma in our study, 25 (37.87%) cases had a history of exacerbation of pigmentation following sun exposure. According to Tamega et al7 48.5% of their study population with melasma had history of exacerbation of pigmentation on sun exposure, which is comparable to our study. One patient of Riehl’s melanosis, 1 patient of exogenous ochronosis, 1 patient of drug induced pigmenatation, 6 cases of freckles and 4 patients of LPP, also reported exacerbation of pigmentation on exposure to sunlight. Perez-Bernal et al6 and Hassan et al5 have proposed exposure to solar radiation as an important exogenous factor in the exacerbation of facial hypermelanosis which is in concordance with our study.8 Among 102 patients, pigmentation was localized in 97 (95.09%) of cases and 5 (4.90%) cases had diffuse pigmentation.

• Among pigmentary disorders, the most common age group was 26-35 years(50%). • Predisposing factors of pigmentary disorders were sun exposure(35.29%), cosmetics (16.66%), pregnancy(11.76%), family history (7.8%), stress (3.92%), hypothyroidism (3.92%), anemia (3.92%), drug intake (3.92%), refractive errors (2.9%). • 95% had localized pattern of pigmentation and 5% had diffuse pattern of pigmentation.

1. Nordlund JJ, Ortonne JP, Cestari T, Grimes P, Chan H. Confusions about color: formulating a more precise lexicon for pigmentation, pigmentary disorders, and abnormalities of “chromatics” J Am Acad Dermatol 2006;54(5 Suppl 2):S291–7. 2. Mosher DB, Fitzpatrick TB, Ortonne JP. Hypomelanoses and hypermelanoses. In: Freedberg IM, Eisen AZ, Wolff K, et al, editors. Dermatology in general medicine. 5th edition. New York: McGraw-Hill; 1999. p. 945–1016. 3. Khanna N, Rasool S. Facial melanoses: Indian perspective.Indian J Dermatol Venereol Leprol 2011;77:552-564. 4. Vashi NA, Kundu RV. Facial hyperpigmentation: causes and treatment. Br J Dermatol 2013;169(Suppl.3):41–56. 5. Hassan I, Aleem S, Bhat YJ, Anwar P. A clinico-epidemiological study of facial melanosis. Pigment Int 2015;2:34-40. 6. Pérez-Bernal A, Muñoz-Pérez, Miguel A, Camacho, Francisco. Management of Facial Hyperpigmentation. Am J Clin Dermatol 2000;1(5):261-8. 7. Tamega Ade A, Miot LD, Bonfietti C, Gige TC, Marques ME, Miot HA. Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women. J Eur Acad Dermatol Venereol. 2013 Feb;27(2):151-6. 8. Achar A, Rathi SK. Melasma: A clinicoepidemiological study of 312 cases. Indian J Dermatol 2011;56:380-2.