INTRODUCTION

Melasma is an acquired disorder of facial pigmentation presenting with symmetric hypermelanotic macules and patches, usually appearing as brown to gray-brown discoloration on sun-exposed facial areas. Although medically benign, melasma frequently follows a chronic, relapsing course and continues to pose therapeutic challenges. Its tendency to involve visible facial areas contributes to a marked psychosocial impact that is often disproportionate to clinical severity. The reported prevalence of melasma varies considerably across different populations, with estimates ranging from 8.8% to 40%, reflecting the influence of ethnic background, geographic location, occupational ultraviolet exposure, and hormonal factors [1].

The condition shows a marked female predominance, particularly among women of reproductive age. Hormonal influences such as pregnancy, use of oral contraceptives, and other estrogen-related factors have been recognized as important triggers or exacerbating factors [2]. The etiopathogenesis of melasma is multifactorial and not fully understood, involving interactions between ultraviolet radiation, genetic susceptibility, hormonal factors, inflammatory mediators, vascular changes, and alterations within the dermal microenvironment [3]. Among these, UV radiation is regarded as the most significant environmental contributor, promoting melanocyte stimulation through oxidative stress, paracrine signalling pathways, basement membrane disruption, and upregulation of melanogenic cytokines such as stem cell factor and endothelin-1 [4,5].

Melasma most commonly affects individuals with Fitzpatrick skin phototypes III to V, with intermediate skin types demonstrating increased vulnerability [6]. In tropical regions such as India, sustained UV exposure, outdoor occupational activities, and darker skin phototypes collectively contribute to a high disease burden. Indian studies have documented prevalence rates ranging from 30% to 41% in selected cohorts, emphasizing the clinical and public health relevance of melasma in routine dermatology practice [7,8].

In addition to its visible pigmentary manifestations, melasma has a pronounced effect on patients’ psychological health, self-esteem, social functioning, and overall quality of life (QoL). The conspicuous facial involvement frequently leads to emotional responses such as embarrassment, frustration, anxiety, depressive symptoms, and social avoidance [9]. Notably, the extent of psychosocial distress reported by patients does not consistently parallel objective assessments of disease severity, underscoring the limitations of relying solely on clinician-based assessment tools [10].

The modified Melasma Area and Severity Index (mMASI) is a validated clinical scoring system widely employed to quantify disease severity and is considered more user-friendly and reproducible than the original MASI score [11]. However, mMASI predominantly assesses objective clinical parameters and does not account for the subjective emotional and psychosocial burden perceived by patients. In contrast, the Melasma Quality of Life (MELASQoL) questionnaire is a disease-specific, validated patient-reported outcome measure developed to evaluate the psychosocial and emotional impact of melasma from the patient’s perspective [12].

Evaluating the relationship between clinical severity and quality-of-life impairment is essential for adopting a comprehensive, patient-centred approach to melasma management. Although several international studies have investigated this association, reported findings remain variable, with correlations ranging from weak to strong [13–15]. Furthermore, there is a relative lack of well-designed Indian studies that systematically examine the relationship between mMASI and MELASQoL using adequate sample sizes and rigorous statistical methodology.

The present study was therefore conducted to assess the impact of melasma on quality of life and to examine the correlation between disease severity, measured using mMASI, and quality-of-life impairment, assessed using MELASQoL, among patients attending a tertiary care dermatology center in India

MATERIALS AND METHODS

This hospital-based observational cross-sectional study was conducted over a one-year period in the Department of Dermatology, Venereology and Leprology of a tertiary care teaching hospital in South India. The study protocol was approved by the Institutional Ethics Committee, and all procedures were conducted in accordance with the principles outlined in the Declaration of Helsinki. Consecutive adult patients aged 18 years and above with a clinical diagnosis of melasma attending the dermatology outpatient department during the study period were screened for eligibility. Patients were enrolled after obtaining written informed consent, irrespective of previous treatment history. Individuals younger than 18 years, those with facial hyperpigmentation attributable to causes other than melasma, and patients unwilling to provide consent were excluded. Sample size estimation was based on previously published studies that reported a high correlation between MASI/mMASI and MELASQoL scores. Assuming a correlation coefficient of 0.8 with an absolute precision of 0.1 at a 99% confidence level, the minimum required sample size was calculated to be 91. To compensate for possible exclusions and incomplete data, a total of 100 patients were ultimately included. Although the assumed correlation coefficient was based on higher values reported earlier, the moderate correlation observed in the present study reflects real-world variability in psychosocial outcomes. Demographic and clinical information was recorded using a structured case record form and included age, sex, educational status, occupation, marital status, socioeconomic status, duration of disease, family history of melasma, prior treatment history, and associated systemic illnesses. All participants underwent a detailed dermatological examination. Based on the predominant distribution of lesions, melasma was clinically categorized into malar, centrofacial, or mandibular patterns. Fitzpatrick skin phototype was determined by visual assessment. Wood’s lamp examination was performed in a darkened room to classify melasma into epidermal, dermal, or mixed types based on pigment enhancement, and dermoscopic evaluation was conducted to document pigment distribution patterns. Disease severity was quantified using the modified Melasma Area and Severity Index (mMASI). This scoring system assesses four facial regions—forehead (30%), right malar (30%), left malar (30%), and chin (10)—by grading the area of involvement on a scale of 0 to 6 and the intensity of pigmentation on a scale of 0 to 4. The total mMASI score ranges from 0 to 24. For analytical purposes, patients were grouped into low (0–4), moderate (5–12), and high (13–24) severity categories, as shown in Table 1. Quality-of-life impairment was assessed using the validated Melasma Quality of Life (MELASQoL) questionnaire, which consists of 10 items addressing emotional well-being, social interactions, self-perception, and daily functioning. Each item is scored on a 7-point Likert scale, yielding a total score between 10 and 70, with higher scores indicating greater impairment. For descriptive analysis, MELASQoL scores were categorized as mild (10–39), moderate (40–54), and severe (55–70). Item-wise responses are summarized in Table 2, and the distribution of MELASQoL severity across demographic and clinical variables is presented in Table 3.

	Table 1: Distribution of mMASI severity categories.
	Table 2: Distribution of MELASQoL questionnaire responses.
	Table 3: Distribution of melasqol severity categories according to demographic and clinical variables.

RESULTS

Correlation between mMASI and MELASQoL Scores

Pearson correlation analysis demonstrated a statistically significant moderate positive correlation between mMASI scores and MELASQoL scores (r = 0.480, p < 0.001), indicating that increasing clinical severity of melasma was associated with greater impairment in quality of life. The correlation statistics are detailed in Table 4.

Table 4: Correlation Between mMASI and MELASQoL Scores.

Quality of Life Across mMASI Severity Categories

Mean MELASQoL scores showed a progressive increase with rising melasma severity. Patients with low-severity melasma had a mean MELASQoL score of 48.12 ± 11.12, those with moderate severity had a mean score of 56.77 ± 6.27, and patients with high-severity melasma had the highest mean score of 62.00 ± 2.83. This difference was statistically highly significant (p < 0.001).

The comparison of mean MELASQoL scores across mMASI severity categories is presented in Table 5, demonstrating a clear dose–response relationship between disease severity and quality of life impairment.

Table 5: Comparison of mean MELASQoL score according to mmasi severity.

DISCUSSION

Melasma is increasingly acknowledged as a chronic pigmentary condition associated with a significant psychosocial burden that extends beyond its visible clinical manifestations. In this hospital-based cross-sectional study, a statistically significant moderate positive correlation was observed between clinical disease severity and quality-of-life impairment measured by the Melasma Quality of Life (MELASQoL) questionnaire. This finding indicates that increasing clinical severity is associated with poorer quality-of-life outcomes, while also emphasizing that objective disease severity alone does not fully account for the psychological distress experienced by affected individuals. Similar variability in correlation strength has been reported across previous studies conducted in different populations and clinical settings [13–18].

The demographic profile of the study population, characterized by female predominance and peak occurrence during the third and fourth decades of life, is consistent with epidemiological patterns reported from India and other tropical regions [1,6]. The higher prevalence among women of reproductive age supports the role of hormonal influences in the pathogenesis of melasma, while the predominance of Fitzpatrick skin phototype IV reflects the increased susceptibility of intermediate phototypes to pigmentary disorders [3,7] These observations emphasize the need to assess quality-of-life impairment alongside clinical severity in routine practice.

A progressive increase in mean MELASQoL scores across increasing mMASI severity categories was observed, demonstrating a dose–response association between clinical severity and psychosocial burden. Patients with high-severity melasma exhibited significantly greater quality-of-life impairment compared with those having low or moderate disease severity. Similar trends have been reported in earlier hospital-based studies and systematic reviews, although the magnitude of association has varied across different populations [13–15]. These findings underscore the clinical relevance of identifying patients with more severe disease who may be at higher risk of substantial psychosocial distress.

Item-wise evaluation of the MELASQoL questionnaire showed that appearance-related concerns, frustration, embarrassment, and emotional distress were the most severely affected domains. A large proportion of patients reported persistent distress related to facial pigmentation, in agreement with previous studies describing increased levels of anxiety, depressive symptoms, and social withdrawal among individuals with melasma [6,9] In contrast, domains related to overall life functioning and perceived attractiveness were relatively less affected, suggesting that some patients may develop functional adaptation over time despite ongoing emotional distress.

Most demographic and clinical variables, including age, sex, occupation, marital status, disease duration, prior treatment history, and socioeconomic status, did not show a statistically significant association with MELASQoL severity. This finding suggests that the psychosocial impact of melasma is pervasive and not restricted to specific demographic subgroups. Educational status, however, showed a significant association with quality-of-life impairment. Patients with higher educational attainment may have better health literacy, coping mechanisms, and access to information, potentially mitigating the perceived psychosocial burden, whereas individuals with lower educational status may experience greater distress due to limited awareness of the benign nature of the condition and available treatment options. Importantly, the strongest and most consistent association in the present study was observed between mMASI severity and MELASQoL severity categories, with all patients in the high-severity group experiencing severe quality-of-life impairment.

The moderate correlation observed between mMASI and MELASQoL supports the growing consensus that objective severity indices alone are insufficient to fully capture the burden of melasma. Although Wood’s lamp and dermoscopic patterns were documented, no meaningful association with quality-of-life scores was identified, highlighting the predominance of clinical severity over pigment depth in determining psychosocial impact. Psychological factors such as altered self-image, internalized stigma, and cultural attitudes toward facial pigmentation appear to play a significant role in shaping patient-reported outcomes [10,16]. This reinforces the importance of incorporating quality-of-life assessment alongside clinical severity scoring in routine practice.

The findings of the present study carry important clinical implications. Management of melasma should adopt a holistic, patient-centered approach that addresses both pigmentary severity and psychosocial distress, along with evidence-based procedural and chemical peel modalities [16–20]. Patients with relatively mild disease but severe quality-of-life impairment may benefit from intensified therapeutic strategies and supportive counseling, whereas those with moderate disease and preserved quality of life may be adequately managed with conservative treatment and expectation counseling. Such individualized approaches are likely to improve patient satisfaction and long-term treatment adherence.

The limitations of this study include its cross-sectional design, which precludes assessment of temporal changes in quality-of-life following treatment, and its single-center setting, which may limit generalizability. Additionally, formal psychiatric assessments were not performed, which may have provided deeper insight into psychological determinants of quality-of-life impairment. Nevertheless, the use of validated disease-specific instruments, an adequate sample size, and robust statistical analysis strengthens the reliability and clinical relevance of the findings.

CONCLUSION

The present study demonstrated a statistically significant moderate positive association between melasma severity, measured using mMASI, and quality-of-life impairment assessed by MELASQoL. While greater clinical severity was associated with increased psychosocial burden, the moderate strength of correlation indicates that factors beyond objective disease severity play an important role in determining patient well-being.

A substantial proportion of patients experienced severe impairment in quality of life, underscoring that melasma cannot be regarded merely as a cosmetic condition. These findings emphasize the importance of routinely incorporating quality-of-life assessment into the clinical evaluation of melasma and support a comprehensive, patient-focused management strategy that addresses both pigmentary severity and psychosocial distress.

Further longitudinal studies are needed to assess changes in quality-of-life following treatment and to explore psychosocial factors that may influence therapeutic outcomes. Integrating dermatological treatment with patient education, counselling, and expectation management may help improve both clinical response and overall quality of life in individuals with melasma.

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