Fig. 18.1
Facial melasma in an adult (a) female patient (b) male patient
The quality of life measures used for the evaluation of melasma impact on everyday life are summarized. In addition, the way that melasma may influence everyday life is also addressed.
18.2 Melasma and Quality of Life Measures
Quality of life (QoL) is considered to be a broad concept that encompasses subjective evaluations of both positive and negative aspects of life and conveys an overall sense of well-being. Health-related quality of life (HRQoL) is a more specific determinant of QoL, which includes those aspects of overall quality of life that can be clearly shown to affect health (physical or mental) [3].
Overall, the instruments used for determining QoL in melasma patients can be divided into two main categories: those that are non-disease-specific and those that are disease-specific.
18.2.1 Non-disease-specific QoL instruments
A number of QoL measures have been used in order to determine the impact of skin disease in patients. These include the Dermatology Life Quality Index (DLQI), the Dermatology Quality of Life Scales (DQoLS), the Family Dermatology Life Quality Index (FDLQI), and the Skindex-29, Skindex-17, and Skindex-16, among others [4]. Out of these, the two most commonly used instruments are the DLQI and the Skindex-16 questionnaires.
The DLQI questionnaire was developed by Finlay and Khan and is comprised of ten items that explore various aspects of an individual’s everyday life. These include disease-associated restriction of daily activity, personal feelings, interpersonal relationships, leisure, and treatment efficacy evaluations [5].
The Skindex questionnaire was developed by Chren et al. and was initially comprised of 61 items that explored both the physical and psychosocial impact of dermatological conditions. The design of this instrument focused mainly on assessing the disability caused by the disease rather than the emotional well-being of the patients. In recent years, the Skindex instrument was condensed to a 30-item (Skindex-29) version and later to a 16-item (Skindex-16) version [6]. The newer versions explore many aspects more relevant to the dermatological disease (such as feelings of irritation, stinging, and itching) as well as feelings of embarrassment, frustration, and difficulty in socializing with others. In this way, disease symptoms and emotional and functional well-being can be assessed [7, 8].
18.2.2 Disease-Specific QoL instruments
The main disadvantage of DLQI and Skindex-16 in evaluating QoL in melasma is that these instruments give equal attention to the assessment of physical and psychosocial distress. Melasma, on the other hand, is a disorder that impacts the psychosocial well-being of patients far more than their physical well-being since it is asymptomatic. This diagnostic void is filled by the disease-specific QoL measure, Melasma Quality of Life (MELASQoL) scale.
The MELASQoL measure was initially introduced by Balkrishnan et al. and is comprised of ten items [9]. MELASQoL focuses mainly on questions relevant to melasma HRQoL and uses a combination of items from the Skindex-16 (seven items) and the skin discoloration questionnaire (three items). Each item is rated on a 7-point Likert scale with possible answers ranging from “not bothered at all” (score = 1) to “bothered all the time” (score = 7). Scores are summed up to produce a total score of 7–70, with higher scores corresponding to a lower quality of life. MELASQoL centers mainly on the evaluation of the patient’s feelings on skin appearance, emotions of frustration or embarrassment, and the burden of melasma in interpersonal relationships [10]. MELASQoL is the most popular instrument used in the evaluation of QoL in melasma patients, as it has shown high discriminatory power, validity, and internal consistency and has been translated in a number of languages [9].
18.2.3 Overview of Disease Severity Instruments
An interesting characteristic of dermatological QoL measures is that they are highly subjective, and the results obtained depend heavily on the patient’s perception of themselves. That said, QoL in dermatologic patients may not be directly correlated with the actual severity of their dermatological condition. For this reason, various instruments that can assess disease severity may be used concomitantly with QoL instruments. These measures are also rather subjective, as the assessment is performed by a dermatologist and not an “objective” instrument, such as a DermaSpectrometer [10]. Nevertheless, they are most commonly used in clinical practice and include the melasma severity scale, the Munsell color chart for melasma, the physician’s global assessment, the patient’s global assessment scales [11], and the Melasma Area and Severity Index (MASI) score, among others. The MASI score is the most popular disease severity assessment instrument for melasma. Developed by Kimbrough-Green et al., it was based on the Psoriasis Area and Severity Index calculation concept [12]. However, the complex relationship between patient psychological well-being and disease severity is further highlighted by the inability of MASI to capture the considerable emotional and psychological effects of melasma on patients. This is another reason why both types of instruments should be used in order to achieve a more complete approach to patients.
18.3 Melasma and Impact in Quality of Life
A number of studies have been performed in order to assess the impact of melasma in everyday life. In the study by Balkrishnan et al., 102 women were evaluated with the use of MASI, DLQI, Skindex-16, skin discoloration questionnaire, and MELASQoL instruments. It was shown that patients felt that their social life, recreation ⁄ leisure, and emotional well-being were severely affected by the condition (mean reported MELASQoL score: 36). Overall, there was a moderate correlation of MASI scores with the MELASQoL scores and a high correlation of MELASQoL scores with the DLQI, the Skindex-16, and the skin discoloration questionnaires [9]. Similar results were reported by Dominguez et al. in a study that included 99 women of Hispanic origin, recruited from an outpatient clinic in Texas. Social life, physical health, and emotional well-being were reported to be influenced by the presence of melasma. In addition, the financial cost of treating the disorder was also reported as a major concern (mean reported MELASQoL score: 42) [13].
In another study by Dogramaci et al., 114 Turkish women were evaluated with the use of MASI and MELASQoL instruments. It was reported that melasma was considered an important source of frustration, decreased patient freedom, and feeling of unattractiveness (mean reported MELASQoL score: 29.9) [14]. Similar results were reported in a recent study by Ikino et al. that included 51 patients from Brazil. The vast majority of patients (94.11 %) felt bothered about their skin appearance, while most expressed feelings of depression, frustration, and embarrassment. In addition, 78.43 % felt unattractive due to the presence of melasma. Interestingly, patients did not feel that melasma had a severe impact on their freedom, social life, or interaction with others (mean reported total MELASQoL score: 34.40) [15]. Almost identical results were reported by other studies that included Brazilian women [16–18]. Overall, young age, mild psychiatric disorders (i.e., anxiety) and lower educational levels of patients were associated with higher MELASQoL scores [19].
MELASQoL has also been used in the evaluation of melasma treatment efficacy. In a study by Cestari et al. that included 300 patients from Brazil, feelings of unattractiveness (43 %), frustration (55 %), embarrassment (57 %), and an influence of the disease on interpersonal relationships (42 %) were reported. However, after treatment with a triple combination cream (hydroquinone, fluocinolone acetonide, and tretinoin) for 8 weeks, the MELASQoL scores of the patients on the treatment arm had improved significantly. More specifically, 12.2 % of patients continued to experience frustration, 9.3 % continued to experience embarrassment, and 5.8 % reported an impact on interpersonal relationships, compared to 59.7 %, 56 %, and 35.3 % of the no treatment arm patients, respectively [20].
Related posts:
Pathogenesis of Vitiligo
Camouflage for Brown Skin with Melasma or Vitiligo
Vitiligo: Definition, Incidence, Etiology
Classification and Clinical Presentations of Melasma in Brown Skin
Iontophoresis and Mesotherapy in Melasma
Diagnosis of Melasma in Brown Skin: Wood’s Lamp, Dermoscopy, and Confocal Microscopy
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