Melasma in Men
Tuesday, September 01, 2015
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
Figure 1. Hyperpigmented macules distributed across the
forehead of a male with melasma. Original photograph
from DermQuest Image Library. Available at:
Last accessed: 9 September 2015.
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
||No. of patients
||Percent of cases of melasma
|Vasquez et al.
|Hexsel et al.
|Sarkar, Jain et al.
|Sarkar, Puri et al.
|Achar et al.
|Jang et al.
|Goh et al.
|Guinot et al.
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%),5 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.
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
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
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
- Sheth VM, Pandya AG. Melasma: a comprehensive update: part I.
J Am Acad Dermatol 2011;65:689-97.
- 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
- Sivayathom A. Melasma in Orientals. Clin Drug Invest
- Vasquez M, Maldonado H, Benmaman C, Sanchez JL. Melasma in men.
A clinical and histologic study. Int J Dermatol 1988; 27:
- 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.
- Sarkar R, Jain RK, Puri P. Melasma in Indian males.
Dermatol Surg 2003;29:204.
- 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.
- 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.
- Achar A, Rathi SK. Melasma: a clinico-epidemiological study of
312 cases. Indian J Dermatol 2011;56:380-2.
- 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.
- 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
- 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
- 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.
- Kim EH, Kim YC, Lee ES, Kang HY. The vascular characteristics
of melasma. J Dermatol Sci 2007;46:111-6.
- Costin GE, Birlea SA. What is the mechanism for melasma that so
commonly accompanies human pregnancy? IUBMB Life
- Pandya AG, Guevara IL. Disorders of hyperpigmentation.
Dermatol Clin 2000;18:91-8,ix.
- Sialy R, Hassan I, Kaur I, Dash RJ. Melasma in men: a hormonal
- Perez M, Sanchez JL, Aguilo F. Endocrinologic profile of
patients with idiopathic melasma. J Invest Dermatol
- Sheth VM, Pandya AG. Melasma: a comprehensive update: part II.
J Am Acad Dermatol 2011;65:699-714.