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Proposing Melasma Severity Index: A New, More

Practical, Office-based Scoring System for
Assessing the Severity of Melasma

Article in Indian Journal of Dermatology · January 2016

DOI: 10.4103/0019-5154.174024

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CONCEPT ARTICLE

Proposing Melasma Severity Index: A New, More Practical, Office‑based

Scoring System for Assessing the Severity of Melasma
Imran Majid, Inaamul Haq1, Saher Imran, Abid Keen2, Khalid Aziz2, Tasleem Arif2

Abstract From the Department of

Background: Melasma Area and Severity Index (MASI), the scoring system in melasma, needs Dermatology, CUTIS Institute of
to be refined. Aims and Objectives: To propose a more practical scoring system, named as Dermatology, 1Department of Social
and Preventive Medicine, GMC
Melasma Severity Index (MSI), for assessing the disease severity and treatment response in
Srinagar, 2Department of Health,
melasma. Materials and Methods: Four dermatologists were trained to calculate MASI and J&K Health Services, Srinagar,
also the proposed MSI scores. For MSI, the formula used was 0.4 (a × p2) l + 0.4 (a × p2) Jammu and Kashmir, India
r + 0.2 (a × p2) 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 Address for correspondence:
re‑examined every 6th patient for repeat MASI and MSI scoring to assess intra‑ and inter‑rater Dr. Imran Majid, CUTIS Skin
reliability of MASI and MSI scores. Validity was assessed by comparing the individual scores Institute, Srinagar,
of each rater with objective data from mexameter and ImageJ software. Results: Inter‑rater Jammu and Kashmir, India.
reliability, as assessed by intraclass correlation coefficient, was significantly higher for E‑mail: imran54@yahoo.com
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.

Key Words: Melasma, objective measure, reliability, scoring, validity

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 Area and Severity Index (PASI).[9] Interestingly, MASI uses

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.[1,2] Melasma often causes
a significant psychological impact with a negative
effect on quality of life and emotional well‑being.[3,4]
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.[5,6]
Melasma Area and Severity Index (MASI) is the most
widely used outcome measure in clinical studies on
melasma.[7,8] MASI score, proposed by Kimbrough‑Green
et al. in 1994, has been devised on the pattern of Psoriasis
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Quick Response Code:
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.[9] 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 Figures 1 and 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 [Figures 1a and 2a] comes out to be less than
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
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Website: www.e‑ijd.org For reprints contact: reprints@medknow.com

DOI: 10.4103/0019-5154.174024
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.
Received: August, 2015. Accepted: September, 2015.

© 2016 Indian Journal of Dermatology | Published by Wolters Kluwer - Medknow 39

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Majid, et al.: MSI score as an outcome measure for assessing melasma severity

that of the patients on the right [Figures 1b and 2b]

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.
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 a b
area involvement between 2 patients of psoriasis carries a
Figure 1: MASI scores do not represent the severity of disease correctly. (a) MASI
lot of significance for the treating physician with regard score is 10.8 and mMASI is 6.0. (b) MASI score is 24.9 and mMASI is 8.4
to overall prognosis and choice of treatment.[10] 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.
In this paper, we wish to propose a new scoring system
for melasma that not only corrects the above‑mentioned a b
fallacies, but is also easier to perform in routine outpatient Figure 2: (a) MASI is 10.5 and mMASI is 4.5. (b) MASI is 19.8 and mMASI is 7.8

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 × p2) l + 0.4 (a × p2) r + 0.2 (a × p2) n
In the formula, “a” stands for “area of involvement,” “p”
a b
for “severity of pigmentation,” “l” for left face, “r” for
right face, and “n” for nose. 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
The area involved, as well as the severity of pigmentation with other involved areas

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.

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Majid, et al.: MSI score as an outcome measure for assessing melasma severity
Table 1: Proposed MSI score
MSI score
MSI = 0.4(a×p2)l+0.4(a×p2)r+0.2(a×p2)n
‘a’ stands for ‘area of involvement’, ‘p’ for
‘severity of pigmentation’, ‘l’ for left face,
‘r’ for right face and ‘n’ for nose
In cases with uniform pigmentation score can be
further simplified as
MSI = a×p2
MSI: Melasma Severity Index
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 (MexameterR 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).
Statistics
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 2nd 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
Scoring of pigmentation Scoring for area of involvement
Score 0: No visible pigmentation ≤10% area involved ‑ score 1
Score 1: Barely visible pigmentation 11-30% ‑ score 2
Score 2: Mild pigmentation 31-60% ‑ score 3
Score 3: Moderate pigmentation >60% ‑ score 4
Score 4: Severe pigmentation
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].
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
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Majid, et al.: MSI score as an outcome measure for assessing melasma severity

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].
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.[8,9,11,12]
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.[13]
Table 2: Demographic profile of patients
Patient characteristic Number of cases
Skin type
Skin type 3
Skin type 4
Sex
Males
Females
Age (years)
21-30
31-40
41-50
Morphological type of melasma
Centrofacial type
Malar
Mandibular
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.[13]
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.[14] 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.[15] 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
10
20
7
23
21
8
1
22
7
Figure 4: Inter-rater reliability of modified Melasma Area and Severity Index and
1 MSI for individual raters

Table 3: Inter‑rater reliability of mMASI and MSI scores

Rater mMASI MSI
Range Mean±SD ICC (95% CI) Range Mean±SD ICC (95% CI)
Rater 1 1.2-14.4 6.82±3.158 0.816 (0.709-0.897) 1.7-51.2 19.63±11.012 0.955 (0.923-0.976)
Rater 2 0.9-19.4 6.17±3.426 1.7-48.0 19.71±11.184
Rater 3 1.8-15.6 6.32±3.036 1.7-48.0 19.69±11.269
Rater 4 0.9-15.6 6.01±3.161 1.7-48.0 20.06±11.315
mMASI: Modified Melasma Area and Severity Index, MSI: Melasma Severity Index, CI: Confidence interval, ICC: Intraclass correlation
coefficient, SD: Standard deviation

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Majid, et al.: MSI score as an outcome measure for assessing melasma severity

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 1/10th (≤10%) the score given is 1
while if the area involved is assessed subjectively to be
more than 1/10th but < 1/3rd of the face the score given
is 2 (11–30%). Similarly, if the investigator feels that
the area of involvement is between 1/3rd and 2/3rd of
the face, the score becomes 3 (31-60%). And finally,
more than 2/3rd 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
Table 4: Inter‑rater reliability of mMASI and MSI for
individual raters
Rater mMASI MSI
ICC (95% CI) ICC (95% CI)
Rater 1 0.840 (−0.008-0.982) 0.935 (0.600-0.993)
Rater 2 0.364 (−0.469-0.902) 0.957 (0.721-0.995)
Rater 3 0.834 (−0.032-0.982) 0.781 (0.001-0.974)
Rater 4 0.877 (0.353-0.986) 0.958 (0.729-0.995)
mMASI: Modified Melasma Area and Severity Index, MSI: Melasma
Severity Index, CI: Confidence interval, ICC: Intraclass correlation
coefficient
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 × p2 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].
Limitations
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.

Table 5: Validity of mMASI and MSI

Correlation levels Rater 1 Rater 2 Rater 3 Rater 4
mMASI versus Mexameter (rho, BCa 95% CI) 0.677* (0.428-0.823) 0.774* (0.595-0.874) 0.768* (0.558-0.890) 0.740* (0.531-0.857)
MSI versus Mexameter (rho, BCa 95% CI) 0.878* (0.751-0.943) 0.897* (0.828-0.927) 0.891* (0.818-0.931) 0.883* (0.810-0.924)
mMASI versus total area (rho, BCa 95% CI) 0.685* (0.426-0.852) 0.644* (0.371-0.810) 0.777* (0.608-0.885) 0.552* (0.251-0.749)
MSI versus total area (rho, BCa 95% CI) 0.436# (0.036-0.728) 0.601* (0.309-0.797) 0.490* (0.093-0.770) 0.508* (0.110-0.793)
*Correlation is significant at the 0.01 level; Correlation is significant at the 0.05 level. mMASI: Modified Melasma Area and Severity
#

Index, MSI: Melasma Severity Index, CI: Confidence interval, BCa: Bias corrected accelerated

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Majid, et al.: MSI score as an outcome measure for assessing melasma severity
Table 6: Advantages of MSI over MASI and mMASI
Fallacies of MASI
Proposed on pattern of PASI which is used in an absolutely different
skin disorder
Intensity of pigmentation gets as much value as the area of involvement
Area of involvement on two sides of the face needs to be calculated
separately
Area of involvement on different regions of the face needs to be
calculated separately
Not possible to score the pigmentation separately on nose which is at
times more severely involved
Area of involvement on different regions and on two sides of the face
need to be scored repeatedly while monitoring response to treatment
Shows more inter‑rater reliability than MASI
mMASI: Modified Melasma Area and Severity Index, MSI: Melasma Severity Index, PASI: Psoriasis Area and Severity Index
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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 × p2) r + 0.4 (a × p2) l + 0.2 (a × p2) n, where “a” stands for “area”
“p” for “p” for pigmentation, “l” for left face, “r” for right face, and “n”
for nose
• M SI is a more reliable and valid scoring system than Melasma Area and
Severity Index in addition to being simpler and easier to calculate.
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Advantages of MSI
Intensity of pigmentation gets its due importance as
it is the variable that matters the most in melasma
Area of involvement of the whole face is scored‑this
makes the scoring simpler and more practical
Area of involvement is scored simply from 1 to 4
corresponding to minimal, ≤1/3rd, ≤2/3rd and >2/3rd
involvement respectively
Pigmentation on ‘nose’ can be scored separately
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