Indian Journal of Dermatology, Venereology and Leprology Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) ISSN: 0378-6323 EISSN: 0973-3922 Vol. 69, Num. 3, 2003, pp. 251-252

Indian Journal of Dermatology, Venereology & Leprology, Vol. 69, No. 3, May-June, 2003, pp. 251-252

Letter to Editor

Chronic pelvic inflammatory disease and melasma in women

M. P. S. Sawhney, R. Anand

Departments of Dermatology and STD and Obstetrics and Gynaecology, Command Hospital (EC), Kolkata-700027, India.
Address for correspondence: Lt. Col. M. P. S. Sawhney, Base Hospital, Barrackpore-700120, India. E-mail: mpssawhney@hotmail.com

Code Number: dv03023

Sir,

Melasma is a photosensitive dermatosis of the sun-exposed areas of the face, characterized by light or gray brown pigmentation.¹ The exact cause of this dermatosis is not known in a large proportion of cases. The majority of cases are considered to arise in pregnancy² and in patients on oral contraceptives.³ The infrequency of melasma in post-menopausal women on oestrogen replacement therapy suggests that it alone is not the causative factor, although some of the patients on combination therapy with progesterone and oestrogen have been found to develop melasma.¹ Though, some of the patients of idiopathic melasma had mild ovarian dysfunction⁴, plasma concentration of b-melanocytic-stimulating-hormone in these patients and those on oral contraceptives have been found to be normal.^4,5 Genetic factors, thyroid dysfunction, cosmetics, phototoxic and antiseizure drugs have been implicated as other etiological factors.¹ It was further shown by the study of Sawhney⁶ at high altitudes, where the levels of UVB were 250% of those at sea level at mid noon, that melasma develops as a protective mechanism to either high levels of UVB or in those with photosensitive skin. Although it is seen predominantly in females, women even at high altitudes had a slightly higher incidence of melasma than men.⁶ The question that needs to be answered is what makes the skin in females more photosensitive than in males. This study was thus designed to go into the details of the history and examination in cases of melasma in females.

A study was conducted in 127 cases of melasma in women who reported to the dermatology OPD from Jan to Mar 2003, to find out the possible underlying cause of this photosensitive disorder. The average age of the patients was 34.29 (range 19-65) years and the average duration of melasma was 45.72 (range 1-204) months. Seventy (55.12%) patients had received some form of topical therapy from a qualified dermatologist for an average duration of 4.28 (range 1-24) months with temporary/incomplete relief.

Seventy four (60.63%) patients of melasma had evidence of chronic pelvic inflammatory disease (PID), in 35 (27.56%) of them in association with Fitz-Hugh-Curtis (FHC) syndrome. The average age and duration of melasma in patients with FHC syndrome, PID alone and only melasma with no clinical evidence of PID was 37.06 (SD 8.49) and 48.77 (SD 57.56); 34.77 (SD 7.54) and 43.64 (SD 43.91); and 32.06 (SD 7.56) years and 38.79 (SD 38.00) months respectively. Patients with melasma with FHC syndrome were found to be significantly older (p < 0.05) than those with only melasma. Three (2.36%) had Reiter's syndrome, 2 (1.57%) conjugal melasma and 1 (0.79%) each had primary and secondary infertility.

Melasma was found in only 4 (3.15%) cases during pregnancy and in one with history suggestive of antepartum PID.

This study highlights that melasma in women is possibly due to photosensitivity in patients with chronic PID in a majority of cases. The association of melasma with pregnancy and oral contraceptives reported earlier was possibly due to increase proliferation of chlamydia during pregnancy due to lowered body immunity and milder nature of PID in those on oral contraceptives,⁷ respectively.

References

1. Mosher DB, Fitzpatrick TB, Ortonne JP, Hori Y. Hypomelanosis and Hypermelanosis. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al, editors, Fitzpatrick's Dermatology in general medicine. 5th ed. New York: McGraw-Hill; 1999. p. 945-1018.
2. Winton GB, Lewis CU. Dermatoses of pregnancy. J Am Acad Dermatol 1982;6:977-8.
3. Rasnik S. Melasma induced by oral contraceptive drugs. JAMA 1967;199:95-9.
4. Perez M, Sanchez JL, Aguito F. Endocrinological profile of patients with idiopathic melasma. J Invest Dermatol 1981;81:543-5.
5. Smith AG, Shuster S, Thody AJ, Peberdy M. Chloasma, oral contraceptives, and plasma b-melanocytic-stimulating-hormone. J Inves Dermatol 1977;68:169-70.
6. Sawhney MPS. Chronic actinic dermopathy - A clinical study in Ladakh. Indian J Dermatol Venereol Leprol 2002;68:38-9.
7. Wolner-Hanssen P. Oral contraceptive use modifies the manifestations of pelvic inflammatory disease. Br J Obstet Gynaecol 1986;93:619-24.

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