A New Insight on Atopic Skin Diathesis:

Is It Correlated with the Severity of Melasma

Danar Wicaksono

, Rima Mustafa

, Sri Awalia Febriana

, Kristiana Etnawati

Dermatovenereology Department, Faculty of Medicine

Universitas Gadjah Mada – Dr. Sardjito General Hospital, Yogyakarta-Indonesia

Clinical Epidemiology and Biostatistics Unit, Faculty of Medicine Universitas Gadjah Mada –Dr. Sardjito General

Hospital, Yogyakarta-Indonesia

Keywords: Melasma, atopic skin diathesis (ASD), MASI score, atopic dermatitis (AD)

Abstract: Melasma is a macular lesion of light brown to dark on the sun-exposed area, especially on the face. Atopic

Skin Diathesis (ASD) is a clinical term to describe skin atopics with previous, present or future atopic

dermatitis (AD). Dennie-Morgan infraorbital folds are secondary creases in the skin below the lower eyelids

with a sensitivity of 78% and a specificity of 76% to diagnose AD. Melasma skin is characterized by

impaired stratum corneum integrity and a delayed barrier recovery rate. Barrier dysfunction will stimulate

keratinocyte to secrete keratinocyte-derived factor, which plays role in skin pigmentation process in

melasma. To analyze correlation between ASD and Melasma Area Severity Index (MASI) score in melasma

patient. This study is an observational analytic study with cross sectional design. Measurement of ASD and

MASI score were done in 60 subjects with melasma who went to dermatology outpatient clinic Dr. Sardjito

General Hospital from July 2017 to Januari 2018. The correlation between ASD and MASI score was

analyzed using Pearson correlation. The result of this study showed no significant correlation between ASD

and MASI scores (r: 0.02, p: 0,85). Crude Relative Risk (RR) for Dennie-Morgan infraorbital folds and

MASI score was 4 (1.01-15.87). There was no correlation between ASD and MASI scores. Patient with

Dennie-Morgan infraorbital folds has 4 times higher risk for developing severe melasma.

1 INTRODUCTION

Melasma is a hyperpigmented disorder of macular or

patches lesions with light brown to dark, irregular

edges and firm borders. Lesions are usually

symmetrical on the sun exposed area especially on

the face, primarily affects female patients and tends

to be chronic and relapsing. In Indonesia the

prevalence of melasma is estimated about 0.2 - 4%

of all cases of skin diseases (Kim et al., 2007;

Hernández-Barrera et al., 2008).

Melasma can cause

pigmentation which is detrimental to patients’

psychological well-being and bring adverse

consequences in their social life, recreational

activities, and emotional well-being for a long

period of time (Kang et al., 2002). Due to the

chronicity of the disease, treatment of melasma

should take a minimum of 8 weeks with a

considerably high cost. Despite the high cost of

treatment, this disease is chronic and recurrent

without any guarantee of full remission. Most

clinician usually use (Melasma Area Severity Index)

MASI score to evaluate treatment in melasma. The

MASI score showed good reliability within and

between raters and was found to be valid when

compared with the melasma severity scale,

mexameter scores, and area measurements

(Berardesca & Maibach,1996).

The cause of melasma is not yet known, but

several factors are thought to play a role in the

etiopathogenesis of melasma.

The interaction of

keratinocytes may also be involved in melasma: the

activation of inducible nitric oxide synthase (iNOS)

and Keratinocyte Derived Factor (KDF) within

keratinocytes particularly after ultraviolet (UV)

radiation, has a role in melanogenesis process (Reed

et al., 1995). Impaired skin barrier is one of the

underlying mechanism in melasma pathogenesis.

This condition is also commonly found in atopic

dermatitis patients. Several scoring systems have

been proposed to assess the degree of skin barrier

impairment. Among the most commonly used

190

Wicaksono, D., Mustafa, R., Febriana, S. and Etnawati, K.

A New Insight on Atopic Skin Diathesis: Is It Correlated with the Severity of Melasma.

DOI: 10.5220/0008153701900194

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 190-194

ISBN: 978-989-758-494-7

scoring system is Atopic Skin Diathesis (ASD) score

which are calculated based on atopic symptoms and

signs for practical use and for clinical or

epidemiological studies (Kompaore et al., 1993). A

total of 13 components are assessed in the

calculation of ASD score, many of which are

associated with imparied skin barriers, including

keratosis pilaris, xerotic skin, pityriasis alba, and

Dennie-Morgan infraorbital folds. However, the

scoring system is usually used to diagnose atopic

dermatitis.

Given that skin barrier impairment is found in

both melasma and atopic dermatitis we thought that

ASD score might also be of use in assessing

melasma patients. In this study, we would like to

investigate the correlation betwen the ASD score

and severity of melasma.

2 METHOD

This is an analytic cross-sectional study that

included 60 melasma patients who went to

dermatology outpatient clinic at Dr. Sardjito General

Hospital from July 2017 to Januari 2018.

Measurement of both ASD and MASI score were

done for those patients. Descriptive characteristics

for the subjects were presented. The correlation

between ASD and MASI score was analyzed using

Pearson correlation. Further, MASI score was

divided into two categories, <18 (low) and ≥18

(high). Crude relative risk (RR) was calculated to

assess the risk of higher MASI score associated with

each component of ASD score.

3 RESULT

The descriptive summaries of enrolled subjects were

presented in Table 1. The age of the subjects ranged

from 32 to 61 years old with an average of 46.65

years old. Centrofacial was the most common type

of melasma (83.3%) followed by malar type

(16.67%). Skin type IV accounted for 70% of the

subjects.

Table 1. Descriptive summaries of the subjects

Mean ± SD

Number of subjects (%)

Age, years

46.65  5.96

Minimum age 32 -

Maximum age 61 -

Length of disease, years 7.8 -

Minimum duration 0.5 -

Maximum duration 20 -

Skin Type

III - 10(16.67)

IV - 42(70)

V - 8(13.33)

Melasma Type

Mala

- 10(16.67)

Mandibula

- 0

Centrofacial - 50(83.3)

MASI score

<18 - 53(88.83)

≥18 - 7 (11.67)

ASD score

<10 - 55(91.67)

≥10 - 5(8.33)

ASD: atopic skin diathesis

MASI: melasma area severity index

A relatively large proportion of subjects were found

to have lower scores of MASI (88.83%) and ASD

91.67%,). While the majority of subjects were in the

group of having lower MASI and ASD scores, a

Pearson correlation test that had been carried out did

not result in a significant correlation between ASD

and MASI scores (r:-0.02, p:0.85) (Figure 1).

A New Insight on Atopic Skin Diathesis: Is It Correlated with the Severity of Melasma

191

Figure 1. The scatterplot of ASD score vs MASI score.

Additional analysis was also carried out to

analyze the relationship between ASD score and

MASI score after categorizing them into two groups

(lower or higher score groups) as in Table 1.

However, we did not find any significant association

between those two categorical variables (results not

presented here).

This figure did not show any pattern of

correlation between both scores, as later supported

by a Pearson correlation test (r:-0.02, p: 0.85).

Further, we calculated the crude relative risks (RR)

for having more severe melasma, indicated by a

higher category of MASI score (≥18), for each

component that contributed to the calculation of

ASD score. Of all components, the presence of

intraorbital folds was the only factor that appeared to

be significantly associated with higher risk of severe

melasma (RR: 4.00(1.01-15.87)).

Except for keratosis pilaris, other components of

ASD score related with skin barrier impairments (the

presence of xerotic skin and pityriasis alba) showed

a trend towards a higher risk of severe melasma,

even though the relationship did not appear to be

statistically significant (Table 2). In particular, we

could not calculate the RR for keratosis pilaris since

none of our subjects in this study were found with

that condition.

Table 2. Relative risk for having higher MASI score (≥18) for each component of ASD score

ASD Score Components Relative Risk (95% CI)*

Total number of subjects = 6

Cradle cap 0.94 (0.13-6.94)

Intraorbital fol

4.00 (1.01-15.87)

Perleche 0.39 (0.02-6.29)

Pityriasis alba

1.83 (0.27-12.36)

Ear rhagade 2.00 (0.17-24.17)

Palmar hyperlinearit

0.94 (0.13-6.94)

White Demographism 3.03 (0.72-12.76)

Xerosis

2.00 (0.45-8.89)

Itchy while sweating 0.21 (0.01-3.45)

Fotofobia 0.55 (0.07-4.17)

Wool Intolerance 3.03 (0.72-12.76)

Food Intolerance 0.31 (0.02-5.02)

Allergic Rhinitis 0.29 (0.04-2.24)

Asthma 1.50 (0.22-10.46)

Sensitivity to Metal 0.33 (0.04-2.58)

Atopic History in Famil

3.11 (0.77-12.51)

ASD: atopic skin diathesis

*Values are crude (unadjusted) relative risk (95% confidence interval)

Components that are related with skin barrier impairment

4 DISCUSSION

Our study contributes to building evidence on the

use of ASD score in evaluating melasma. To our

knowledge, this is the first study that assess the

relationship between ASD score and severity of

melasma. A larger sample size would be required for

a more comprehensive analysis on the use of ASD

score in evaluating melasma. In our study, more than

80% of subjects were found to have both lower

MASI and ASD score. This is one of the major

limitations of our current study. Since the patients

recruited for this study were regular patients at Dr.

Sardjito General Hospital who had received

treatment based on the standard protocol, i.e, they

were not newly diagnosed patients with melasma.

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192

The mean duration of disease of the subjects were

7.8 years, so it was very likely that the disease has

evolved throughout those years.

The characteristic of the subjects in this study

showed that centrofacial type was the most common

type of melasma (83.3%) followed by malar type

(16.67.%), in accordance with previous research

which reported that most types of melasma were

centrofacial type followed by malar and mandibular

type (Kim et al., 2007; Hernández-Barrera et al.,

2008). Centrofacial type is most often found in

women, whereas malar type is more often found in

men. This is thought to be related to the predominant

occupational activity outside the home in male

patients.

The result of this study is similar to the previous

studies with majority of the subjects aged between

40 to 50. However, as we only included patients who

went to Dr. Sardjito Hospital during our study

period, our sample could not be considered as

representative of the real melasma patients in the

population. Our study, in which the majority of

subjects were found to have skin type IV, is in

accordance with previous studies in Brazil. Our

subjects (70%) have skin type IV and little portion

of skin type III (16.67%) and type V (13.3%) (Reed

et al., 1997; Kang et al., 2010).

Our results suggest Dennie-Morgan infraorbital

folds as the only ASD score component being

significantly associated with higher risk of severe

melasma. However, interpretation of our results

should be done very cautiously. The relative risks

calculated in this study were crude relative risks, i.e.,

the calculation was carried out without taking into

account (adjusting to) any other parameters that

might simultaneously affect the risk of having more

severe melasma. Further analysis with adjustment to

other potential confounders is, therefore, necessary.

Dennie-Morgan infraorbital folds

are secondary

creases in the skin below the lower eyelids. They are

a minor criterion of AD and are present in up to 84%

of patients with AD, with a sensitivity of 78% and a

specificity of 76%. They are also described in

patients with allergic rhinitis and/or asthma without

AD (Kang et al., 2006; Merle et al., 2010). The

pathophysiology is not clearly established. They

may be related to skin edema and the continuous

spasm of the Muller eyelid muscle resulting from

hypoxia linked to poor blood circulation. Finally,

our research supports the idea that impaired skin

barrier might be a common underlying mechanism

that mediates the link between atopic conditions

with melasma. Further investigation is necessary to

provide the evidence on this relationship.

5 CONCLUSION

We did not find any correlation between ASD and

MASI scores. More in-depth research on ASD score

can be used to investigate the alleged causal

relationship in melasma.Examination of ASD score

is not a routine examination of melasma patients and

other oxidative stress disorders, so another indicator

is required in measuring skin barrier function.

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