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Clinical Updates

Melasma in Men

Haneol S Jeong, Amit G. Pandya, MD

Tuesday, September 01, 2015

Introduction

Melasma, also known as chloasma or the mask of pregnancy, is a common acquired pigmentary disorder that manifests in affected individuals as confined, symmetrical, hyperpigmented macules primarily on sun-exposed areas, particularly the forehead, cheeks, upper lip, nose, and chin (Figures 1 and 2). Although it affects all skin types, darker individuals tend to have more severe and recalcitrant melasma. Melasma is reported to affect as many as 5 million people just in the United States and severely impacts patients' self-reported quality of life as measured by validated quality-of-life indices.1


Fig1

Figure 1. Hyperpigmented macules distributed across the forehead of a male with melasma.  Original photograph from DermQuest Image Library. Available at: https://www.dermquest.com/image-library/image/5044bfd0c97267166cd631bd. Last accessed: 9 September 2015.



Fig2

Figure 2. Hyperpigmented macules on the left malar area of a male with melasma. Original photograph from Dr. Amit G. Pandya.

 

Prevalence rates for melasma vary from 8.8% in certain populations in the Southern United States2 to as high as 40% in some Southeast Asian populations.3 However, the true incidence and prevalence rates are difficult to determine, as few studies have pursued random sampling of the general population.


Virtually all demographic studies have sampled predominantly female patients, reflecting the fact that melasma is generally considered a disease of this gender. Men make up a comparative minority of those afflicted with melasma as reported and confirmed in multiple studies across different populations (Table 1).4-11 As a result of this discrepancy, investigative work in determining the unique characteristics of melasma in men has lagged behind similar studies in female patients. However the prevalence of melasma is higher in studies conducted in India compared to similar work in other countries, a finding that is only partially explained by the prevalence of darker skin tones in Indian populations.

 

Table 1. Prevalence of melasmain men worldwide 

Author Location No. of patients sampled Percent of cases of melasma in men
Vasquez et al. South America Not reported 10%
Hexsel et al. Brazil 953 3%
Sarkar, Jain et al. India 120 26%
Sarkar, Puri et al. India 200 21%
Achar et al. India 312 20%
Jang et al. South Korea Not reported 4%
Goh et al. Singapore 205 5%
Guinot et al. Tunisia 197 5%

 

The major suspected etiology behind the discrepancy in prevalence rates is chronic outdoor sun exposure. Many patients report outdoor occupations (58.5%) or frequent sunlight exposure (48.8%), and a study in Latino males noted greatly elevated rates of melasma (36%) in one group of outdoor migrant workers.12  Another possible contributory factor is the application of mustard oil, a cutaneous photosensitizer, for body and hair massage, a cosmetic nuance unique to Indian culture. Although its photosensitization properties suggest a possible role for mustard oil in the development of melasma, it has not been investigated in great depth in other studies. Furthermore, reports of similarly high levels of melasma prevalence in other study populations with frequent sun exposure diminish the role mustard oil might play in comparison to other risk factors such as ultraviolet radiation exposure.


Pathogenesis

The mechanism of lesion pathogenesis in melasma is incompletely understood at present. Current hypotheses include activation of fibroblasts and up-regulation of stem cell factor and c-kit secondary to dermal inflammation from ultraviolet radiation leading to increased melanogenesis,13 as well as a possible vascular component based on findings of increased vascularity in melasma lesions.14 Alternatively, UVB exposure promotes keratinocyte production of interleukin 1, endothelin 1, alpha-melanocyte stimulating hormone, and adrenocorticotropic hormone - all signaling molecules that may stimulate melanogenesis.15 Although the precise cause is unknown, prior investigation in women has identified strong associations between melasma and certain risk factors, among them UV radiation exposure, genetic influences, oral contraceptives and other estrogen-progesterone therapies, pregnancy, thyroid dysfunction, cosmetics, and medication.16


Based on currently available research, male melasma may be associated with many of the same risk factors and pathogenic features that influence lesion formation and characterize lesion morphology in afflicted females. Although some risk factors are preserved across genders, the weight of influence of the different risk factors appears to vary considerably between males and females. Demographic studies noted sun exposure (66.6%) and familial predisposition (70.4%) as the two most significant etiologic factors in male patients,4 a finding later confirmed (48.8% and 37%, respectively).5 These are largely in concordance with percentages recorded in female melasma patients.1


Hormonal influences most likely play minor roles in men, as few men use hormonal therapy, unlike in females, where contraception use and pregnancy are risk factors. Despite this fact, there is preliminary evidence of a hormonal component that may influence the interplay of factors leading to lesion formation in men. A small study of 15 male melasma patients in India noted significantly elevated levels of luteinizing hormone and follicle-stimulating hormone with concomitant depression of serum testosterone in affected individuals.17 Luteinizing hormone and follicle-stimulating hormone levels in these patients were thought to be physiologically elevated through a natural response to low testosterone levels, indicating the malfunction rests at the level of the sexual organs. These findings suggest a component of subtle testosterone resistance, perhaps a male analog to a subtle ovarian resistance with similar characteristics previously reported in women with melasma.18


Histopathologic evaluation of melasma lesions in male patients reveals consistent patterns of increased vascularity and elevated c-kit and stem cell factor expression in lesional skin compared to control samples taken from adjacent unaffected skin.8 Levels of stem cell factor expression in male melasma patients are in excess of those demonstrated in affected females, perhaps suggestive of the increased UV exposure necessary to induce lesion formation in the absence of a permissive hormonal milieu. However, the size of each cohort (eight men with melasma, ten women with melasma, and five men and women each with solar lentigines) in this report was too small to conclusively make this determination.
 

Clinical features and treatment modalities

Regardless of the exact mechanism behind the development of melasma, the resultant tan-to-dark-brown macules and patches on the face are similar in both genders. Epidemiologic breakdown of melasma patterns in male patients has received little attention in the literature. Sarkar, Jain et al. noted centrofacial and malar patterns in their cohort (48.39% and 51.61%, respectively) with no patients demonstrating mandibular patterns,6 whereas Sarkar, Puri et al. noted malar (61%), centrofacial (29.3%), and mandibular (9.3%) patterns in their patients.5 Although these results appear to be consistent with the distribution of patterns reported in female patients,9-12 much larger male cohorts are necessary to generate more meaningful data.


The treatment of melasma in all patients involves multiple therapeutic modalities, including broad-spectrum sun protection, topical formulations, chemical peels, lasers, light sources, or a combination of the above. These therapies appear equally effective irrespective of gender. Details regarding the mechanism, side-effect profile, and utility of different treatments are discussed in greater detail elsewhere in the literature.19


Conclusion

Melasma is an acquired pigmentary disorder of complex and likely multifactorial etiology with significant adverse effects on afflicted patients. It affects both men and women, albeit unequally. In fact, as a result of this uneven impact, melasma in men has received comparatively little investigation. Based on current knowledge, it appears that melasma in men is influenced to similar degrees by the same risk factors as in affected females, with the likely exception of hormonal effects. Ultimately, further research in men with melasma is necessary to better delineate the unique clinical and pathogenic features in this subset of patients.

 

References

  1. Sheth VM, Pandya AG. Melasma: a comprehensive update: part I. J Am Acad Dermatol 2011;65:689-97.
  2. Werlinger KD, Guevara IL, Gonzalez CM, Rincon ET, Caetano R, Haley RW, et al. Prevalence of self-diagnosed melasma among pre-menopausal Latino women in Dallas and Fort Worth, Tex. Arch Dermatol 2007;143:424-5.
  3. Sivayathom A. Melasma in Orientals. Clin Drug Invest 1995;10(Suppl 2):34-40.
  4. Vasquez M, Maldonado H, Benmaman C, Sanchez JL. Melasma in men. A clinical and histologic study. Int J Dermatol 1988; 27: 25-27. 
  5. Sarkar R, Puri P, Jain RK, Singh A, Desai A. Melasma in men: a clinical, aetiological and histological study. J Eur Acad Dermatol Venereol 2010;24:768-72.
  6. Sarkar R, Jain RK, Puri P. Melasma in Indian males. Dermatol Surg 2003;29:204.
  7. Jang YH, Sim JH, Kang HY, Kim YC, Lee ES. The histological characteristics of male melasma: comparison with female melasma and lentigo. J Am Acad Dermatol 2012;66: 642-9.
  8. Goh CL, Diova CN. A retrospective study on the clinical presentation and treatment outcome of melasma in a tertiary dermatological referral centre in Singapore. Singapore Med J 1999; 40:455-8.
  9. Achar A, Rathi SK. Melasma: a clinico-epidemiological study of 312 cases. Indian J Dermatol 2011;56:380-2.
  10. Hexsel D, Lacerda DA, Cavalcante AS, Machado Filho CA, Kalil CL, Ayres EL, et al. Epidemiology of melasma in Brazilian patients: a multi-center study. Int J Dermatol 2014;53:440-4.
  11. Guinot C, Cheffai S, Latreille J, Dhaoui MA, Youssef S, Jaber K, et al. Aggravating factors for melasma: a prospective study in 197 Tunisian patients. J Eur Acad Dermatol Venereol 2010;24:1060-9.
  12. Pichardo R, Vallejos Q, Feldman SR, Schulz MR, Verma A, Quandt SA, et al. The prevalence of melasma and its association with quality of life in adult male Latino migrant workers. Int J Dermatol 2009;48:22-6.
  13. Kang HY, Hwang JS, Lee JY, Ahn JH, Kim JY, Lee ES, et al. The dermal stem cell factor and c-kit are overexpressed in melasma. Br J Dermatol 2006;154:1094-9.
  14. Kim EH, Kim YC, Lee ES, Kang HY. The vascular characteristics of melasma. J Dermatol Sci 2007;46:111-6.
  15. Costin GE, Birlea SA. What is the mechanism for melasma that so commonly accompanies human pregnancy? IUBMB Life 2006;58:55-7.
  16. Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin 2000;18:91-8,ix.
  17. Sialy R, Hassan I, Kaur I, Dash RJ. Melasma in men: a hormonal profile.J Dermatol2000;27:64-5.
  18. Perez M, Sanchez JL, Aguilo F. Endocrinologic profile of patients with idiopathic melasma. J Invest Dermatol 1983;81:543-5.
  19. Sheth VM, Pandya AG. Melasma: a comprehensive update: part II. J Am Acad Dermatol 2011;65:699-714.
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