Melasma in men and its homoeopathic management

Dr Jain Poonam Suresh 

ABSTRACT:
Melasma is an acquired pigmentary disorder characterised by symmetrical hyper pigmented macules on the face. Melasma is a common skin condition that affects both the men and women. However, more commonly seen in women and dark skinned individuals such as in Asians and African Americans who live in areas with intense ultraviolet radiation. It is a commonest skin condition characterised by the presence of symmetrical, macular and irregular light to dark brown hyper pigmentation over the sun exposed areas commonly on the face. Melasma has been studied in detail in women but there is a paucity of studies on the clinico-etiopathology as well as its prevention and therapeutics in males. This article discusses the important clinical, etio-pathology, clinical classification, prevention and homoeopathic management of melasma in men which is usually neglected.

Hyperpigmentation on exposed areas especially on the face is a source of cosmetic concern for the affected patients that can negatively impact quality of life. Treatment for melasma in modern method includes topical steroid creams, injections and chemical peels which is painful and has numerous side effects. Homeopathy is a holistic system of medicine that treats patients considering as a whole and not merely their parts affected. It is based on individualisation of every case with a detailed case taking with minimum side effects. Therefore it is essential to understand the importance of various homoeopathic remedies that can be of helpful in the treatment of melasma in men.

OBJECTIVES: 

1. To understand important clinical, etio-pathological, classification, prevention and treatment aspects of melasma in men.
2. To understand the homoeopathic management of melasma with the help of Materia medica and Repertory.   

KEYWORDS: Melasma, Men, Homoeopathy medicines.

INTRODUCTION:
Melasma is a common skin condition characterised by the presence of symmetrical, irregular, macular, and light to dark brown hyperpigmentation involving sun exposed areas, especially on face. Although melasma affects all races and both sexes, but more commonly seen in women of child bearing age and in dark skinned individuals exposed to intense ultraviolet radiation. Exact prevalence of melasma including men and women is not known due to underreporting of affected patients. In Indian patients, two studies show a higher prevalence of melasma in men 25.8% and 20.5%.

ETIOPATHOGENESIS:
It is multifactorial. Most common factors include sun exposure, hormonal influences, and genetic susceptibility. Less common factors include cosmetics, drugs like phenytoin, food items, thyroid diseases, hepatopathies, parasitic infections and stressful events. Melasma is caused by a complex interplay of environmental factors in genetically predisposed individuals. 

The etiological factors causing melasma in men are likely the same as implicated in women, except for certain differences like pregnancy, ovarian tumours and oral contraceptive pills. Mean age in men ranges from 19-53yrs and in women from 20-45yrs. Following are the most common causative factors encountered in men with melasma.

1. Genetic history in an Indian study showed 39% of men had a family history of melasma compared to 20.1% in women.
2. Hormonal evaluation in men with melasma showed low levels of testosterone and high levels of luteinising hormone in India. Hormonal imbalance between testosterone and estradiol had important role in men.
3. Sun exposure is an important etiological factor in causing melasma irrespective of sex. An ultraviolet radiation (UVA and UVB) increases proliferation and melanocyte activity causing epidermal pigmentation. Prevalence is high in tropical regions and worsens during summer months. It is documented in many studies as main cause in men with 45.16% and 81.4% of subjects with chronic sun exposure.
4. Consumption of certain drugs like phenytoin leading to melasma induction.
5. Mustard oil use for body and hair massage was more common in men with melasma with 43.9% than women with 31.4% observed in one Indian study. Mustard oil acts as photosensitise facial pigmentation on forehead and temporal regions of face labelled as ‘Toxic Melanoderma’ in India.
6. Cosmetics use like soaps, after shave creams and gels, perfumes were documented in 92.6% of men with melasma.
7. Certain chronic illnesses like thyroid disorders, inflammatory bowel disorder and typhoid in men with melasma was documented.

CLINICAL FEATURES:

1. Melasma typically presents as well defined, symmetrical, brown black hyper pigmented patches on sun exposed areas of skin.
2. Clinical presentation of melasma in men is similar to women with subtle differences.
3. Age of onset in men ranges between 18-72yrs with average onset of 30-31 yrs.
4. Based on the predominant lesions on face, three patterns of facial melasma recognised clinically are: malar, centrofacial and mandibular. In the malar type cheeks and nose are affected whereas in centrofacial pattern melasma distributes on the forehead, cheeks, nose, upper lip and chin are affected, and the mandibular pattern covers mandibular ramus. Among men the malar pattern is most common representing in 44.1 to 61 percent of male patients. The second most common pattern in males is centrofacial variant.

DIAGNOSTIC CRITERIA:

1. Generally made clinically with detailed medical history.
2. Clinical examination of skin with Woods Lamp examination and dermoscopy of melasma revealed epidermal pattern to be most common in men.
3. Skin biopsy and histopathological examination revealed epidermal melasma more common in men.
4. Superficial epidermis shows melanin as dark brown with shades of light brown and dermal melasma appears blue or bluish grey colour pigment in dermis histopathological.

MANAGEMENT: 

1. Physicians to encourage affected men patients to adhere to routine regimen and treatment protocol.
2. Physician should consider patients individual needs when creating regimens for men.
3. Patient counselling is an important part of melasma management.
4. Physicians should educate patients on causative and exciting factors with treatment and preventive measures.
5. Sun avoidance is the most important part of melasma treatment for current improvement and future prevention of recurrence.
6. Use of broad-spectrum sunscreen.

    HOMOEOPATHIC MEDICINES:

1. Argentum nitricum: Melasma where the face looks sunken, old, pale and bluish. Old man’s look, sickly, sunken greyish of muddy colour. Skin is brown, tense and hard with irregular blotches.

2. Cadmium sulph: Melasma with yellow blue stains on nose and cheeks. The colour gets worse from exposure to sun and wind with itching of the face.

3. Copaiva officinalis: Melasma with brown spots on face. Presence of circumscribed lenticular patches with itching. Mottled appearance.

4. Lycopodium clavatum: Melasma with greyish yellow colour of face, with blue circles around the eyes. Withered shrivelled copper coloured eruption. Indicated in men with melasma.  Lycopodium patient always suffer from flatulent complaints and likes warm food and drinks. There is a special craving for sweets.

5. Phosphorous: Melasma with circumscribed redness in one or both the cheeks with pale, sickly complexion.

6. Sanguinaria: Red blotchy eruptions worse in spring. Circumscribed red spots over malar bones.

7. Sepia officinalis: Chloasma with yellow blotches, pale or sallow, saddle like brownish distribution on nose and cheeks. Lentigo in young women.

8. Sulphur: Suited to dirty, filthy people prone to skin affections. Best suited for skin pigmentation after local medication. Freckles. Old looking spotted face.

RUBRICS OF MELASMA UNDER VARIOUS REPERTORIES

1. Homoeopathic repertory by William Boericke

FACE, cheeks, spots, circumscribed, red, buning: Benz-ac, Bry, CINA, Ferr-m, Lachn, PHOS, Samb, SANG, Stram, Sulph

SKIN, Chloasma, liver spots, moth patches: ARG-N, Aur, Cadm-s, Card-m, CAUL, Cob, Cur, Guar, Laur, LYC, NAT-HP, Paull, Petr, Plb, SEP, Sulph, Thuj.

2. A Concise Repertory of Homoeopathic medicines by S.R. Phatak

FACE, Chloasma: caul, kali-p, sep.

3. Synthesis treasure edition by Fredrick Schroyens

SKIN, Discolouration, chloasma: Arg-n. aur. cadm-s. card-m. Caul. cob.cur. guar. laur, Lyc, nat-hp. nux-v. paull, petr, plb. raph. rob. Sep. sulph. thuj.

4. Skin diseases by M.E. Douglas

MELANODERMA:

Ferrum mag- summer freckles on back of hand and fingers.

Kali carb- freckles on face.

Lycopodium- freckles on left side of face and across nose.

Nitric acid- freckles on chest, dark freckles.

Petroleum- freckles on arms.

Phosphorous- freckles on lower limbs.

Sepia- freckles on cheeks.

Sulphur- freckles on nose. 

REFERENCES–

1. Sarkar R, Arora P, Garg VK, Sonthalia S, Gokhale N. Melasma update. Indian dermatology online journal. 2014 Oct;5(4):426.
2. Sarkar R, Ailawadi P, Garg S. Melasma in men: A review of clinical, etiological, and management issues. The Journal of clinical and aesthetic dermatology. 2018 Feb;11(2):53.
3. Douglas M.E. Skin Diseases. B. Jain Publishers (P) Ltd. New Delhi. India, 2006; pg no. 381

Dr Jain Poonam Suresh
PGT Department of Medicine
UGO- Dr P.D Praveen Kumar (HOD of Dept. of medicine)
Government Homoeopathic Medical College and Hospital, Bangalore-570069