|Year : 2016 | Volume
| Issue : 1 | Page : 39-44
|Proposing melasma severity index: A new, more practical, office-based scoring system for assessing the severity of melasma
Imran Majid1, Inaamul Haq2, Saher Imran1, Abid Keen3, Khalid Aziz3, Tasleem Arif3
1 Department of Dermatology, CUTIS Institute of Dermatology, Srinagar, Jammu and Kashmir, India
2 Department of Social and Preventive Medicine, GMC Srinagar, Srinagar, Jammu and Kashmir, India
3 Department of Health, J&K Health Services, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||15-Jan-2016|
CUTIS Skin Institute, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Melasma Area and Severity Index (MASI), the scoring system in melasma, needs to be refined. Aims and Objectives: To propose a more practical scoring system, named as Melasma Severity Index (MSI), for assessing the disease severity and treatment response in melasma. Materials and Methods: Four dermatologists were trained to calculate MASI and also the proposed MSI scores. For MSI, the formula used was 0.4 (a × p 2 ) l + 0.4 (a × p 2 ) r + 0.2 (a × p 2 ) n where "a" stands for area, "p" for pigmentation, "l" for left face, "r" for right face, and "n" for nose. On a single day, 30 enrolled patients were randomly examined by each trained dermatologist and their MASI and MSI scores were calculated. Next, each rater re-examined every 6 th patient for repeat MASI and MSI scoring to assess intra- and inter-rater reliability of MASI and MSI scores. Validity was assessed by comparing the individual scores of each rater with objective data from mexameter and ImageJ software. Results: Inter-rater reliability, as assessed by intraclass correlation coefficient, was significantly higher for MSI (0.955) as compared to MASI (0.816). Correlation of scores with objective data by Spearman's correlation revealed higher rho values for MSI than for MASI for all raters. Limitations: Sample population belonged to a single ethnic group. Conclusions: MSI is simpler and more practical scoring system for melasma.
Keywords: Melasma, objective measure, reliability, scoring, validity
|How to cite this article:|
Majid I, Haq I, Imran S, Keen A, Aziz K, Arif T. Proposing melasma severity index: A new, more practical, office-based scoring system for assessing the severity of melasma. Indian J Dermatol 2016;61:39-44
|How to cite this URL:|
Majid I, Haq I, Imran S, Keen A, Aziz K, Arif T. Proposing melasma severity index: A new, more practical, office-based scoring system for assessing the severity of melasma. Indian J Dermatol [serial online] 2016 [cited 2019 Jan 15];61:39-44. Available from: http://www.e-ijd.org/text.asp?2016/61/1/39/174024
What was known?
- Melasma Area and Severity Index (MASI) is the most common outcome measure used in melisma
- The reliability and validity of MASI has been tested in a single study that recommended a modified MASI without homogeneity component.
| Introduction|| |
Melasma is an acquired disorder of skin pigmentation that is more common in people of Oriental, Hispanic, and Indo-Chinese origin and affects females much more commonly than males. , Melasma often causes a significant psychological impact with a negative effect on quality of life and emotional well-being. , As with other skin disorders, valid and reliable scoring systems are needed to assess the severity of disease and efficacy of therapeutic options in melasma. Moreover as in other diseases, this scoring system should not only be able to assess the severity, but it should also aid us in predicting the prognosis and choosing the right treatment option. ,
Melasma Area and Severity Index (MASI) is the most widely used outcome measure in clinical studies on melasma. , MASI score, proposed by Kimbrough-Green et al. in 1994, has been devised on the pattern of Psoriasis Area and Severity Index (PASI).  Interestingly, MASI uses an almost similar formula for the face as is used for the whole body in PASI score. Moreover, the three variables of area, induration, and scaling in PASI are replaced by area, pigmentation, and homogeneity in MASI score.  While the variables of "pigmentation" and "area of involvement" are certainly important to consider in melasma the fallacy lies in how these variables are applied in MASI.
If we take some examples like in [Figure 1] and [Figure 2], patients of melasma with different intensities of pigmentation and area of involvement of face are shown. As clinicians, we appreciate that patients with more severe pigmentation not only need a more potent and prolonged treatment, but also have worse prognosis than the other cases. However, if we score these 4 patients with MASI, we can see that MASI score of the patients on the left [Figure 1]a and [Figure 2]a comes out to be less than that of the patients on the right [Figure 1]b and [Figure 2]b in spite of the former group having practically more severe disease than the latter. The reason for this is that the "area of involvement" gets a much higher share in calculating MASI as compared with the intensity of pigmentation and this constitutes one of the most important fallacies of MASI score.
|Figure 1: MASI scores do not represent the severity of disease correctly. (a) MASI score is 10.8 and mMASI is 6.0. (b) MASI score is 24.9 and mMASI is 8.4|
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|Figure 2: (a) MASI is 10.5 and mMASI is 4.5. (b) MASI is 19.8 and mMASI is 7.8|
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While we know that percentage area of body surface involvement in psoriasis has an overbearing effect on the assessment of severity of disease, as well as on selecting the treatment option, the same cannot be said about melasma. A 10% or 20% difference in the body surface area involvement between 2 patients of psoriasis carries a lot of significance for the treating physician with regard to overall prognosis and choice of treatment.  The same difference in percentage area involvement of face between patients of melasma does not hold such significance.
Finally, we appreciate that the severity of pigmentation in melasma is usually uniform over all the affected areas of the face. Moreover, if there is a nonuniform pigmentation or response to treatment, it is usually the central part of the face, especially the nose that is more pigmented or less responsive to treatment than other involved areas [Figure 3]. However, nose is included as a part of the "cheek" in MASI scoring. This makes it impossible to score the pigmentation or response to treatment on the nose separately from that of the cheeks.
|Figure 3: (a) Melasma with more severe pigmentation on nose as compared with other involved areas. (b) Melasma with more severe pigmentation on face as compared with other involved areas|
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In this paper, we wish to propose a new scoring system for melasma that not only corrects the above-mentioned fallacies, but is also easier to perform in routine outpatient department (OPD) practice. We propose the name of "Melasma Severity Index" (MSI) for this scoring system.
Melasma Severity Index score
The proposed MSI score is calculated by multiplying the area of involvement with the square of pigmentation as given in the formula:
MSI = 0.4 (a × p 2 ) l + 0.4 (a × p 2 ) r + 0.2 (a × p 2 ) n
In the formula, "a" stands for "area of involvement," "p" for "severity of pigmentation," "l" for left face, "r" for right face, and "n" for nose.
The area involved, as well as the severity of pigmentation is scored from 0 to 4 [Table 1].
| Materials and Methods|| |
Thirty patients of melasma attending the OPD of our institute were recruited for this study. Patients of both sexes were recruited, and their baseline data were recorded after an informed consent. All the 30 patients were pooled and called on a specific day for scoring and objective assessment.
Training was imparted to 4 qualified dermatologists by means of power point presentations and practical demonstration for calculation of MASI, modified MASI (mMASI) (without homogeneity component), and proposed MSI score. The participants were shown examples of different levels of "darkness" and "area" as well as "homogeneity" of pigmentation during the training process and were then made to calculate MASI, mMASI, and MSI scores for few index cases. All the participating dermatologists had a thorough knowledge of MASI scoring and were involved with the routine treatment of melasma patients.
On a single day, all the enrolled patients were called to the institute and were individually examined by each of the trained dermatologists randomly in separate examination rooms. In the first round, all the raters calculated mMASI and MSI scores for each of the enrolled patients. Score sheets from all the raters were collected at the end of the first round. In the next round, every sixth patient in each rater's series was sent for re-examination, and both mMASI and MSI scores were calculated again in each of these cases. Thus, each rater examined and calculated mMASI and MSI scores for five patients in the next round.
After calculation of mMASI and MSI scores all the patients were photographed digitally in the front, left, and right side profiles using standard light settings. Each patient was then objectively assessed by means of a narrowband reflectance spectrophotometer (Mexameter R Courage and Khazaka, Germany) to quantify the degree of melanin pigmentation present on the affected areas of the face. All the affected areas like the forehead, nose, cheeks, and chin were assessed separately by the mexameter and the difference between involved and uninvolved areas was noted. Finally, the area of involvement of the face was objectively measured by using digital image analysis software (ImageJ 1.48 version from National Institute of Health USA).
Data were analyzed using SPSS version 20.0 (IBM SPSS Statistics for Windows, Version 20.0. Amronk, NY: IBM Corp.). Inter-rater reliability was assessed separately for mMASI and MSI using absolute agreement, single measures, and two-way random intraclass correlation coefficient (ICC [2,1]). Ninety-five percent confidence interval (95% CI) for ICC was also reported to allow for comparison of ICC for mMASI versus MSI. For assessing the intra-rater reliability of mMASI and MSI scores, the values obtained from each of the raters during the 2 nd round of examination were compared with the corresponding values from initial scoring by again using ICC (2,1).
Next, the validity of MSI and mMASI scores was tested by comparing the scores from individual raters with the objective values from the mexameter and ImageJ software. Spearman's correlation was used as the statistical test, and bias-corrected accelerated 95% CI was reported for the rho values.
| Results|| |
Age of the enrolled patients ranged from 23 to 43 years with a mean ± standard deviation of 28.97 ± 5.385 years. The demographic profile of enrolled patients is given in [Table 2].
While MSI scores ranged from 1.7 to 51.2, the range of mMASI scores was 0.9-19.4 [Table 3]. Thus, all the grades of melasma were represented in the study group.
As can be judged from the values in [Table 3], there was a strong degree of agreement among the 4 raters for both mMASI (ICC = 0.816, 95% CI 0.709-0.897) and MSI (ICC = 0.955, 95% CI 0.923-0.976) scores.
The ICC values suggested a much stronger inter-rater reliability for MSI when compared with that of mMASI for all four raters [Table 4].
|Table 4: Inter-rater reliability of mMASI and MSI for individual raters |
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Of the 30 patients enrolled there were five cases of centrofacial melasma in whom the intensity of pigmentation was judged to be more on the nose than on other involved areas of the face while in the rest, uniform degree of pigmentation was seen on all the involved regions of the face [Figure 3].
Mexameter values for melanin pigmentation on the involved area on the left and right cheek ranged from 262 to 588 (mean = 387.96 ± 88.06) and 274-565 (mean of 392.43 ± 84.4), respectively. These values suggested that the severity of pigmentation did not differ significantly on the two sides of the face (P = 0.842).
On analyzing the digital images with ImageJ software the area of involvement on the left and right sides of the face ranged from 3.6% to 52.4% (mean = 24.51 ± 11.77%) and 3.6% to 52.0% (mean = 24.56 ± 12.39%), respectively. On calculating the area of involvement of the whole face from a frontal view of the image the values ranged from 3.6% to 50.8% with a mean of 24.58 ± 11.807%. Statistical analysis using independent-samples t-test revealed no significant difference between the values for the area of involvement on the left and right sides of the face (P = 0.968). This practically means that melasma affects the two sides of the face in a symmetrical fashion in most of the cases.
The validity of MSI, as well as mMASI scores was assessed by comparing the individual scores of each rater with the corresponding mexameter reading and image analysis software values using Spearman's correlation [Figure 4].
|Figure 4: Inter-rater reliability of modified Melasma Area and Severity Index and MSI for individual raters|
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For each rater, both mMASI and MSI scores were fairly correlated with the objective data from mexameter and image analysis software [Table 5]. However, the validity of MSI was found to be superior as the Spearman's rho values were higher for MSI than those for mMASI for all the four raters [Table 5].
| Discussion|| |
Melasma is a chronic, commonly recalcitrant disease of skin pigmentation that varies in severity from one patient to another and within a single patient over time as well. MASI is the predominant outcome measure that has been employed in melasma over the last 2 decades to assess the severity of disease and response to treatment. ,,, Surprisingly, there is only a single clinical study available in the world literature on the subject of validity and reliability of MASI as a scoring system in melasma.  The authors of this study, while validating the score as a whole, found a high degree of intra- and inter-rater variability in rating the homogeneity component of MASI score and proposed mMASI score without this variable. 
MASI has been designed primarily on the basis of a scoring system used for psoriasis, and this approach has led to certain fallacies in MASI. Mostly, the choice between topical and systemic treatment in psoriasis is primarily made on the basis of percentage surface area of body involved. The same does not apply in melasma where it is not the area of involvement but the intensity of pigmentation that determines our choice of treatment. Algorithms published till date for treatment of melasma do not normally mention 'area of involvement' as a criterion for selecting the appropriate treatment option.  In fact a simple easy to use scale known as Melasma Severity Scale (MSS) classifies melasma into three grades on the basis of the intensity of pigmentation alone. This scale scores melasma from 0 (none) to 3 (severe melasma) primarily on the basis of intensity/type of pigmentation.  In MASI scoring the "area of involvement" is calculated from 0 to 6 while the intensity and homogeneity of pigmentation are scored from 0 to 4 only. This approach provides more weightage to the variable of "area of involvement" in comparison with the other 2 variables, and this leads to many errors as pointed out in the earlier sections of this paper. A person with a really severe pigmentation involving a smaller area of face gets a lower MASI score as compared with a person who has a really mild pigmentation involving a relatively larger part of the face. This does not correlate with the clinical judgment of the burden of the disease.
To overcome the above-mentioned limitations of MASI, we have proposed a more practical MSI score for assessing the severity of melasma. Here, the score for the area of involvement is multiplied with the square of pigmentation score to give the latter variable its due importance in assessing disease severity. Secondly, the assessment is performed separately on the "nose" to take care of the nonuniform nature of pigmentation in some cases of melasma.
In assessing the area of involvement of face, we followed a slightly different scoring system than that used in MASI. While MASI uses a score from 0 to 6 for the area of involvement in different regions of the face, we propose a simpler score from 0 to 4 for the area involved. This modification, in addition to making scoring easier, has a definite idea behind it as well. Subjectively, if the area involved is about 1/10 th (≤10%) the score given is 1 while if the area involved is assessed subjectively to be more than 1/10 th but < 1/3 rd of the face the score given is 2 (11-30%). Similarly, if the investigator feels that the area of involvement is between 1/3 rd and 2/3 rd of the face, the score becomes 3 (31-60%). And finally, more than 2/3 rd involvement of the face gets a score of 4 (>60%) [Table 1].
While calculating mMASI and MSI scores in the present series of patients, we did find it difficult to give a single score to the 'severity of pigmentation' to all the involved areas in 16.7% cases because there was a clear-cut difference in the intensity of pigmentation on the nose in comparison with the cheeks [Figure 2]. This limitation is again taken care of by using MSI score as the "nose" area is assessed separately from the rest of the face.
In case of melasma, a positive response to treatment is most commonly seen as a gradual reduction in the intensity of pigmentation over all the areas of face simultaneously. Even a small reduction in pigment intensity is taken as an indicator of a positive response to treatment. However, because of the overdependence on the "area" variable MASI or mMASI score is not able to reflect this positive response to treatment sensitively. On the other hand, even a small change in the intensity of pigmentation alters the MSI score much more than MASI.
In this clinical study, we have tried to test the validity and reliability of the proposed MSI score and compare the same with mMASI score. Statistical analysis of our results indicates that MSI is not only a more practical score, but is also more reliable than mMASI score. The intra-rater reliability for MSI was better than that for mMASI in this study as shown in [Table 4]. Additionally, the validity of MSI score was also found to be superior to that of mMASI when both these scores were correlated with objective data from mexameter and ImageJ software readings.
An important modification that can make MSI score even easier to calculate in case the severity of pigmentation is uniform over all the affected areas of the face is just to multiply the total area of involvement of the whole face with the square of intensity of pigmentation as given below:
MSI = a × p 2 where "a" stands for the percentage area of involvement of the whole face.
We firmly believe that MSI score is a more practical and meaningful scoring system in comparison with MASI for assessment of melasma and for monitoring its response to treatment. Calculating MSI is a much easier and simpler task and can be easily performed in routine OPD practice [Table 6].
This study was performed in a single ethnic population with a limited number of patients and skin phototypes. The results need to be applied to different racial groups and larger population groups with representation from multiple skin phototypes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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What is new?
- We propose a new more practical and easier scoring system for melasma to be called as Melasma Severity Index (MSI)
- The formula used for calculating MSI is:
0.4 (a × p 2 ) r + 0.4 (a × p 2 ) l + 0.2 (a × p 2 ) n, where "a" stands for "area" "p" for "p" for pigmentation, "l" for left face, "r" for right face, and "n" for nose
- MSI is a more reliable and valid scoring system than Melasma Area and Severity Index in addition to being simpler and easier to calculate.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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