Disorders of Hyperpigmentation Are More

CORRESPONDENCE

Methods. A series of questions was first developed in En- RESEARCH LETTERS glish and then translated into Chinese. Some questions were reworded based on the rules of Chinese syntax. The resulting translations were reviewed by a panel of Chinese teachers for accuracy and comprehensibility. After ap- Validation of a Questionnaire proval was obtained from the institutional review board, for Self-reporting of Hyperpigmentation an initial test with a focus group was carried out with a group Disorders in Chinese-Speaking Women of 6 Chinese women aged 18 to 55 years. They were sampled randomly from the waiting room of a Chinese-speaking pri- of Chinese Descent mary care physician. Only women were chosen for this study because disorders of hyperpigmentation in Asians, such as isorders of hyperpigmentation are more com- melasma, are more common in women.2 Furthermore, in 1 mon in darker-skinned individuals such as the our experience, women are more concerned about facial 2 D Chinese. A few studies have been performed disorders of hyperpigmentation than men. in dermatology clinics attempting to determine the preva- After obtaining feedback from the focus group, we lence of lentigines, postinflammatory hyperpigmenta- evaluated the questions and altered them to improve com- 3,4 tion (PIH), and melasma. However, the prevalence of prehension. These were then back-translated to English these conditions in most populations is unknown. The and then reviewed by one of us (A.G.P.), who con- goal of the present study was to develop and validate a firmed that the meaning of the original English ques- questionnaire for self-reporting of hyperpigmentation dis- tion was not lost (Figure 1). The questionnaire was then orders in Chinese women. administered to women at the 2006 Chinese Health Fair in Houston, Texas. After they completed the questionnaire, the women were examined individually for the pres- Original question Chinese English translation ence or absence of melasma, lentigines, and PIH by an Do you have Do your face or examiner experienced in the diagnosis of these disor- lentigines on your hands have spots ders. The examiner was blinded to the results of the ques- face or hands, also that measure more known as liver than 0.5 cm, also tionnaire at the time of the examination. All patients in spots, age spots, or known as old age the focus group as well as those at the health fair gave sun spots? spots or sun spots? They should written informed consent prior to participation. not be present in childhood, are Results. The number of people who entered the health fair darker in color than surrounding skin, was 172, with 73 fitting the inclusion criteria (Chinese and are smooth to women aged 18-55 years). The total number of subjects the touch. who answered the questionnaire and were examined was 69; therefore, the participation rate was 95%. The average age of the participants was 42 years. A total of 67 of the 69 were born outside the United States, with an average age of immigration of 32 years. The 2 American-born Chinese women had their questionnaires read to them owing to their Do you have spots Does your face on your face from have spots lack of Chinese reading skills, and both expressed full un- acne, disease, resulting from derstanding. Most of the women were from China (70%) injury, or a burn? acne, disease, and Taiwan (17%), while the remaining were from Viet- injury, or a burn? nam, Singapore, Cambodia, and Malaysia. The sample con- tained 44 and 31 cases of lentigines and PIH, respectively, but only 11 cases of melasma (Figure 2). The question regarding self-report of lentigines had a mean (SD) sensi- Do you have Does your face tivity of 93.2% (3.8%) and specificity of 96.0% (3.9%). For melasma on your have a liver spot or face, also known a pregnancy spot PIH, sensitivity was 100.0%, and specificity was 92.1% as chloasma in which the (4.4%), whereas the question on melasma had a sensitiv- or mask of pigment became ity of 81.8% (11.6%) and a specificity of 93.1% (3.3%). pregnancy? visible during the period around which you were Comment. A Spanish language instrument to determine pregnant? the prevalence of melasma has been developed and suc- cessfully administered to a large population of Hispanic women.3 However, the prevalence of melasma, lentigines, Figure 1. Evolution of the questionnaire used in the study. and PIH is largely unknown in other populations. We at-

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Physical Examination Physical Examination Physical Examination

Self-report Yes No Total Self-report Yes No Total Self-report Yes No Total Figure 2. Sensitivity and specificity of self-reports of skin-pigmentation conditions Yes 41 1 42 Yes 31 3 34 Yes 9 4 13 compared with findings of physical examination. No 324 27 No 035 35 No 254 56 PIH indicates postinflammatory hyperpigmentation. Sensitivity and specificity Total 44 25 69 Total 31 38 69 Total 11 58 69 are reported as mean (SD) percentages.

Sensitivity 41/44 = 93.2 (3.8) 31/31 = (100.0) 9/11 = 81.8 (11.6) Specificity 24/25 = 96.0 (3.9) 35/38 = 92.1 (4.4) 54/58 = 93.1 (3.3)

tempted to validate a tool that can be used to determine Previous Presentation: This study was presented in poster the prevalence of hyperpigmentation disorders in Chi- form at the annual meeting of the Society for Investigative nese women. We refined the language and syntax by con- Dermatology; May 9-12, 2007; Los Angeles, California. sulting with Chinese teachers, and then we administered 1. Sanchez MR. Cutaneous diseases in Latinos. Dermatol Clin. 2003;21(4):689-697. the questionnaire to a focus group to maximize compre- 2. Jimbow M, Jimbow K. Pigmentary disorders in Oriental skin. Clin Dermatol. hensibility. The results of the study in 69 female Chinese 1989;7(2):11-27. subjects show that this questionnaire is valid for self- 3. Werlinger KD, Guevara IL, Gonzalez CM, et al. Prevalence of self-diagnosed melasma among premenopausal Latino women in Dallas and Fort Worth, Texas. reporting of lentigines and PIH. Arch Dermatol. 2007;143(3):424-425. Limitations include lack of a broad sample (most of 4. Sivayathorn S. Melasma in Orientals. Clin Drug Investig. 1995;10(suppl 2): the patients were middle-aged women) and the use of only 24-40. 1 examiner. Reliability testing (test-retest) was not performed in this study by the subjects or the examiner. The focus of the study was to determine concordance be- Adherence to a Topical Regimen tween the subject and the examiner. Because of the low of 5-Fluorouracil, 0.5%, Cream number of subjects with melasma, more Chinese women with melasma must be evaluated to determine the valid- for the Treatment of Actinic Keratoses ity of this questionnaire for melasma. In addition, the melasma question specifically related melasma to preg- everal different methods can be used to treat actinic nancy. This question may need to be refined, since many keratoses (AKs), including cryosurgery, curettage women develop melasma without any relation to preg- S and electrodessication, phototherapy with ami- nancy. The lentigines and PIH questions may be used in nolevulinic acid, chemical peels, and various topical medi- future studies to determine prevalence of these disor- cations. Many topical medications either produce hypopig- 1 ders in Chinese women. Determining the prevalence of mentation or are irritating to the skin. One would expect pigmentary disorders and their impact on quality of life adherence to a treatment regimen of irritating and unpleas- will assist in understanding the full impact of these dis- ant topical medications to be worse than that demonstrated orders in various populations worldwide. with a regimen of nonirritating topical agents for atopic der- matitis and psoriasis.2 In many cases, nonadherence rather Alice Wuu, BS than nonresponse underlies treatment failure.3,4 Robert W. Haley, MD While studies of topical 5-fluorouracil have demon- Amit G. Pandya, MD strated good efficacy for AK treatment,5,6 few data are avail- able on patients’ compliance with therapy. Since most pa- Correspondence: Dr Pandya, Department of Dermatol- tients overestimate their actual use of medication, electronic ogy, The University of Texas Southwestern Medical Cen- monitors are more reliable assessment tools than pa- ter, 5323 Harry Hines Blvd, Dallas, TX 75390-9190 (amit tients’ self-reports of usage.7,8 This study assesses patient [email protected]). compliance with a regimen of topical 5-fluorouracil, 0.5%, Author Contributions: Drs Wuu and Pandya had full ac- cream for the treatment of AKs by using electronic moni- cess to all of the data in the study and take responsibil- tors hidden in the caps of the medication. ity for the integrity of the data and the accuracy of the data analysis. Study concept and design: Wuu, Haley, and Methods. After institutional review board approval, 20 Pandya. Acquisition of data: Wuu. Analysis and interpre- patients, 50 years or older, with moderate to severe AKs tation of data: Wuu, Haley, and Pandya. Drafting of the of the face and scalp were enrolled in this prospective manuscript: Wuu and Pandya. Critical revision of the manu- study. Each participant was given fluorouracil, 0.5%, script for important intellectual content: Haley and Pan- cream (Carac; Dermik Laboratories, Berwyn, Pennsyl- dya. Statistical analysis: Haley. Administrative, technical, vania, a subsidiary of Sanofi-Aventis) with an attached or material support: Pandya. Study supervision: Pandya. Medication Event Monitoring System cap (MEMS; Aar- Financial Disclosure: None reported. dex Corp, Geneva, Switzerland). Subjects were directed Funding/Support: This study was supported by the De- to apply the medication at bedtime each day for 4 weeks. partment of Dermatology, University of Texas South- They were assessed at baseline and at weeks 2, 4, and 8 western Medical Center. for skin quality, local skin reaction, and number of AK

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