The melasma is a type of hyperchromia that appears more regularly on the facial area, but can also be extra-facial, such as the genital area1. Genital hyperchromia directly interferes with self-image and can affect the sexual function and quality of life of the population studied, despite being poorly documented on the literature2. The causes are still not clear; therefore, the identification of the associated factors can help on the prevention and/or treatment of this common complaint. Nowadays, there are no studies describing the prevalence of the genital hyperchromia, arising the necessity of listing the frequency of this affection, thus showing its importance. The aim of this study is to evaluate the risk factors for genital hyperchromia and the impact on women’s quality of life.

This is a case-control study, involving 135 women. The case was defined on women with the complaint of darkening of the genital area and confirmed by the team of physicians and physiotherapists of the service. For the control group, women with no complaints of darkening in the genital region, picked up in the attendance list of educational events held by the Pelvic Floor Care Center (CAAP) in Salvador and the metropolitan region, were included. Those who were not proficient in Portuguese, pregnant women, or women with genital congenital malformations were excluded of the study.
The participants were directed to an individualized room and answered a questionnaire with sociodemographic information and variables that the researchers considered to be related to hyperchromia of the genital region, such as hypothyroidism, facial Melasma, folliculitis, dermatitis, other dermatological pathologies, sun exposure, use of tight clothing, composition of underwear and type of hair removal.
The study participants also answered the Melasma Quality of Life Scale questionnaire in the version adapted for Portuguese (MelasQol-BP). MelasQol-BP assesses quality of life in women with melasma. This questionnaire consists of ten specific items for measuring the quality of life of people with melasma. It comprises three areas: social life, recreation / leisure and emotional well-being. On a scale of 1 (not at all disturbed) to 7 (disturbed all the time), the patient must inform how she feels about each item. The final MELASQoL-BP score can vary between 7 and 70, with higher values indicating worse quality of life.
The data collection was carried out from June to August 2020 at the Patrícia Lordelo Institute (PLI), in Salvador – Bahia, and also through an online questionnaire due to the pandemics. 
The logistic regression model was used to assess the risk factors in the occurrence of the outcome of genital hyperchromia. After a univariate analysis, the independent variables were inserted into the logistic model if they had a p <0.20, remaining in the model if they continued with the statistically significant of p <0.05. The results were presented using Oddsratio and its respective 95% confidence interval. This research was approved by the Research Ethics Committee and all participants signed the Free and Informed Consent Form.

A total of 91 women were evaluated in the group with genital hyperchromia and 44 women in the control group. The average age for the groups was, respectively, 31.3 ± 11.7 and 26.4 ± 10.7 years. The variables facial melasma (p = 0.043), type of hair removal (p = 0.004), sun exposure (p = 0.026) and underwear composition (p = 0.020) were directly related to the condition of hyperchromia. After the logistic regression analysis of the independent variables melasma facial, type of hair removal, sun exposure, underwear composition and age, there was an influence of the variables of age (p = 0.033) and type of hair removal (p = 0.000) as risk factors for genital hyperchromia. The score of the MelasQol questionnaire in the group of women with hyperchromia had an average of 29.03 ± 13.78 points.

It has already been described that, in the facial region, the use of oral contraceptives or hormone replacement therapy, pregnancy, sun exposure, endocrinopathies and genetic predisposition are triggering factors for the development of melasma3. For the genital region, it is possible to consider age and type of hair removal as risk factors for genital hyperchromia. It is believed that age is related to the influence of hormonal factors and the type of hair removal to the physiopathological mechanisms of melasma, which is the increase of melanin production as a response of the tissue to aggression.
The sun exposure and underwear composition are also aggressions to the tissue and should be investigated in patients with hyperpigmentation in the genital region. The presence of facial melasma can be a factor to be evaluated, since women are more susceptible to excessive production of melanin in certain regions of the body. The MelasQol score obtained in this study may not have been so high when compared to the other studies. However, it is important to note that the analyzed area is the genital, which is a body area that is less exposed to UV radiation in everyday life when compared to other bodily domains such as the face.

Based on our results, can be inferred that age and the type of hair removal have influence for this dyschromia. In addition, we demonstrate that intimate aesthetics has a strong impact on women's quality of life, especially in relation to self-esteem. Because of this, the search for constant treatments has been growing in order to resume this emotional well-being, which is associated with what the media establishes as a standard of beauty in the present times.

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MULLER, I.; RESS, A. Melasma and Endocrine Disorders, Pigmentary Disorders, v. 1, n. 6, p. 1–4, 2014
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