A Cross-Sectional Study on the Dermatoses in Postmenopausal Patients at a Rural-Based Tertiary Health Care Center.

CONTEXT: There is still a dearth of knowledge regarding the types of dermatoses occurring in postmenopausal women. The common disorders occurring in postmenopausal women and the probable effects of hormonal fluctuations on the skin have to be considered while treating postmenopausal women. AIMS: To study clinical patterns of dermatosis in menopausal women. SETTINGS AND
DESIGN: It was a cross-sectional study conducted in the dermatology department from May 2017 to June 2018 after approval from ethical committee.
MATERIALS AND METHODS: All postmenopausal patients having dermatoses were included in the study after taking their written consent in vernacular language. STATISTICAL ANALYSIS USED: All findings were analyzed using STATA (14.2).
RESULTS: The study included 150 postmenopausal women. Most of the patients belonged to the age group of 61-70 years (38.67%) with a mean age of 61.52 years. The age of menopause was most commonly achieved between 40 and 50 years (57.33%). The genital dermatoses were found in 90 (60%) subjects and included atrophic vaginitis (21, 33.33%), lichen sclerosus et atrophicus (14, 15.55%), lichen simplex chronicus (14,15.55%) and tinea cruris (10,11.11%) among others. The extragenital dermatoses were found in 96 (64%) cases and common ones were dermatophytosis (16, 16.33%), lichen planus (11, 11.22%), psoriasis (9, 9.18%) and eczema (8,8.16%).
CONCLUSION: This study is useful in understanding the various clinical patterns of postmenopausal dermatoses and thereby help the physician, dermatologist, and gynecologist to effectively manage the conditions.

Introduction

Every year the life expectancy of individuals in our country is increasing, courtesy to better healthcare and better economic average. An average female life expectancy is 68 years and is projected to increase upto 73 years by 2021.[1] Menopause is defined as the permanent, irreversible cessation of menses (not having a menstrual period for 12 consecutive months) by a decline in ovarian follicular activity.[2] It is usually caused by decreasing estrogen level.

Dermatoses associated with menopause can be classified as follows:[3]

Physiological changes

Dermatoses associated with estrogen deficiency include atrophic vulvovaginitis, vulvar lichen sclerosus, hirsutism, and so on

Dermatoses not specific to menopause include localized/generalized pruritus, pemphigus vulgaris, psoriasis, lichen planus (LP), dermatophytosis, and so on

Dermatoses associated with hormone replacement therapy include melasma, darkening of nevi, and acanthosis nigricans.

The purpose of this study was to evaluate the common dermatosis occurring in perimenopausal and menopausal women.

Materials and Methods

This cross-sectional study was carried out from May 2017 to June 2018 after ethical approval from institutional Human Research Ethics Committee. In all, 150 patients with dermatoses involving any area of the body in the menopausal age group were included in the study, after taking their consent in vernacular language. A detailed history was taken, and thorough general, physical, local, and systemic examination was carried out according to a prestructured proforma. Investigations including KOH smear, Wood's lamp examination, and biopsy were done as and when required. Exclusion criteria included patients who were immunocompromised due to any cause. The statistical analysis was done using STATA (14.2).

Results

The age of 150 patients ranged from 42 to 84 years, with a mean age of 61.52 (±9.38) years. Fifty-eight (38.67%) patients belonged to the age group of 61–70 years. In all, 104 (69.33%) belonged to the lower class and 82 were housewives (54.67%). Eighty-six (57.33%) patients reached menopause between 40 and 50 years of age [Table 1].

Table 1

Demographic data

Age at menopause (years)	No. of patients (%)	Age (years)	No. of patients (%)
25-39	5 (3.33)	40-50	21 (14)
40-50	86 (57.33)	51-60	51 (34)
51-60	58 (38.67)	61-70	58 (38.67)
61-70	1 (0.67)	71-80	18 (12)
		81-90	2 (1.33)
Occupation	No. of patients (%)	Socioeconomic status	No. of patients (%)
Housewife	82 (54.67)	Upper middle	1 (0.67)
Sedentary	64 (42.67)	Lower middle	5 (3.33)
Laborer	2 (1.33)	Upper lower	40 (26.67)
Farmer	2 (1.33)	Lower	104 (69.33)
Total	150 (100)	Total	150 (100)

The height of the patients ranged from 150 to 178 cm with a mean of 162.33 cm. A total of 84 (56%) patients were between 161 and 170 cm. The weight of the patients ranged from 44 to 85 kg with a mean of 64.88 kg and 71 (47.33%) patients were between 61 and 70 kg.

Out of 150 patients, 63 (42%) patients had complaints for less than a month. Eighty-five (56.67%) patients did not have any comorbidities, while 30 (20%) patients had diabetes and 20 (13.33%) patients had hypertension. Fifty (33.33%) patients had more than two living children [Table 2]. Seventy-two (48%) patients had wrinkle folds and 146 (97.33%) patients had skin sagging.

Table 2

Obstretic history of post menopausal women

Living children	No. of patients (%)	Abortion	No. of patients (%)
0	13 (8.67)	0	141 (94)
1	17 (20)	1	6 (4)
2	50 (53.33)	2	3 (3)
3	34 (76)	Total	150 (100)
≥4	36 (24)
Total	150 (100)

Out of 150 patients, 90 (60%) had genital involvement, of which 21 (23.33%) had atrophic vaginitis. Extragenital skin lesions were seen in 96 (64%) patients, of which 16 (16.33%) had superficial dermatophytosis.

A total of 146 (97%) patients had hair involvement, 50 patients had female pattern hair loss (FPHL), while 67 patients (44.67%) had hair depigmentation. Nail involvement was seen in 102 (68%) patients, of which 49 (48.03%) had onychoschizia. Oral cavity involvement was seen in 80 (53.33%) patients, of which 34 (42.50%) had burning mouth syndrome (BMS) [Table 3].

Table 3

Diagnosis of various dermatoses

Extragenital dermatoses (n=96)		Genital dermatoses (n=90)
Diagnosis	No. of patients (%)	Diagnosis	No. of patients (%)
Superficial dermatophytosis	16 (16.33)	Lichen sclerosus et atrophicus	14 (15.55)
Psoriasis	9 (9.18)	Lichen simplex chronicus	14 (15.55)
Lichen planus	11 (11.22)	Genital lichen planus	4 (4.44)
Eczema	8 (8.16)	Flexural psoriasis	2 (2.22)
Melasma	7 (7.14)	Bacterial infection	4 (4.44)
Seborrheic keratoses	3 (3.06)	Atrophic vaginitis	21 (23.33)
Mole	3 (3.06)	Tinea cruris	10 (11.11)
Bacterial infections	2 (2.04)	Candidial intertrigo	6 (6.66)
Vitligo	4 (4.08)	Vitiligo	1 (1.11)
Diabetic dermopathy	2 (2.04)	Squamous cell hyperplasia of vulva	1 (1.11)
Pemphigus vulgaris	1 (1.02)	Pemphigus Vulgaris	1 (1.11)
Herpes zoster	3 (3.06)	Candidiasis	8 (8.88)
Acanthosis nigricans	2 (2.04)	Genital warts	2 (2.22)
Hirsutism	4 (4.08)	Herpes progenitalis	1 (1.11)
Lichen/macular amyloidosis	5 (5.10)	Hailey-Hailey disease	1 (1.11)
Pityriasis lichenoides chronica	1 (1.02)	Total	90 (100)
Sjogren’s syndrome	1 (1.02)
		Oral cavity dermatoses (n=80)
Intertrigo	1 (1.02)	Diagnosis	No of patients (%)
Senile comedones	3 (3.06)	Lichen planus	11 (13.75)
Hailey-Hailey disease	1 (1.02)	Pemphigus vulgaris	1 (1.25)
Senile pruritus	5 (5.10)	Aphtha (major/minor)	5 (6.25)
Photodermatitis	3 (3.06)	Burning mouth syndrome	34 (42.50)
Keloid	1 (1.02)	Dryness of mouth	21 (26.25)
Total	96 (100)	Tooth pain (periodontal disease)	8 (10)
		Total	80 (100)
Appendageal structure diseases
Nail disorders (n=102)	No. of patients (%)	Hair disorders (n=146)	No. of patients (%)
Onychomycosis	22 (21.56)	Diffuse hair loss	6 (4.10)
Pitting	3 (2.94)
Dystrophic nails	3 (2.94)	Androgenic alopecia (male pattern)	15 (10.27)
Onychomadesis	1 (0.98)
Paronychia	1 (0.98)	Female pattern hair loss	50 (34.24)
Subungal hyperkeratosis	1 (0.98)
Onychoschizia	49 (48.03)	Alopecia areata	8 (5.47)
Onychorrhexis	12 (11.76)
Both onychoschizia and onychorrhexis	7 (6.86)	Depigmentation	67 (45.89)
Koilonychia	2 (1.96)
Pterygium	1 (0.98)	Total	146 (100)
Total	102 (100)

Discussion

Menopause is a normal, physiological process in women with declining estrogen levels. The skin and genitals are areas which are heavily influenced by estrogen receptors and hence show the effects of estrogen deficiency.

Of 150 patients, 54.67% were housewives and 42.67% had a sedentary lifestyle. It may be accounted for by the fact that most of our patients belonged to the age group of 61–70 years, where usually the women are not very active, either in the home or at work outside. This was in comparison to a study by Aboobacker et al.,[4] where most of the patients were agricultural laborers.

Most patients in our study (57.33%) reached menopause between the ages of 40 and 50 years. Ahuja M. et al.'s study identified 46.2 ± 4.9 years as the age of natural menopause in India.[5] Jahan et al. identified the mean age at menopause in two different groups as 48.24 ± 2.70 and 46.60 ± 2.47 years, respectively.[6] Other Indian studies also found similar results.[789] Indian women tend to have an earlier age of menopause compared with their counterparts, which is linked to various causes such as marital status, parity, and body mass index. In our study, most of the patients were in the weight range of 61–70 kg (47.33%). This leads to an increased risk of diseases associated with menopause.

The most common chief complaints found in our study were skin lesions (57.33%) followed by pruritus in 38% patients. Pruritus is commonly seen in elderly women due to skin aging and may be the cause among postmenopausal women. Complaints since less than a month were seen in 42% of patients, while 26% had complaints between 1 and 6 months of duration. This is in concordance with the fact that fungal infections, LP, eczema, and psoriasis were found to be the most common diagnosis among the skin lesions, and patients usually present to the outpatient department instead of waiting and delaying.

Most of the patients (56.67%) did not have any comorbidities, while 20% had diabetes and hypertension, respectively. Diabetes was present in our study in dermatoses like senile pruritus, infectious bacterial conditions, fungal infections, and pemphigus vulgaris. Our study included newly diagnosed cases based on fasting blood glucose and known cases of diabetes on treatment. Diabetes can increase insulin secretion, insulin sensitivity, and activity that can predispose to the development of type 2 diabetes mellitus (T2DM) independently of, and additively to, aging. This is also supported by the fact that hormone replacement therapy (HRT) has a favorable effect on glucose homeostasis both in women without and with T2DM.[10] Weiss suggested a relationship between menopause and both hypertension and serum cholesterol.[11] As menopause approaches, decrease in the estrogen leads to an increased risk of cardiac events as well. About 33% of patients had more than two living children, while 24% of patients had more than four living children. An inverse correlation was observed in a study between the number of children and the age of menopause in a study by Maninder et al.[5] This was also found in our study where a majority of patients reached menopause early between 41 and 50 years of age and had at least two children or more. Another Indian study conducted by the National Family Health Survey also reported a higher prevalence and earlier onset of menopause by multiple parity.[12] Abortion was found to have no correlation with the menopausal age in a study done by Maninder et al.[5] which was similar to the results in our study, where 94% patients had no abortion.

Wrinkle folds were seen in 48% of patients where 25% and 26% of patients had dynamic and static wrinkles, respectively. Overall, a close association with skin wrinkles and the time since menopause (a measure of the length of time with reduced endogenous estrogen exposure) was not seen in our study which was also the same as Wolff et al.[13] Wrinkles seem to be related more to aging since it occurs with gradual but continuous exposure to sunlight, pollution, nicotine, repetitive muscle movements like squinting or frowning, and miscellaneous lifestyle components such as diet, sleeping position, and overall health. Most patients (97.33%) had skin sagging in our study.

Among the 102 patients with extragenital dermatoses, the common dermatoses were superficial dermatophytosis (16.33%), LP (11.22%), psoriasis (9.18%), and eczema (8.16%). This was in contrast to a study conducted by Aboobacker et al., where the most common dermatoses were eczematous dermatitis (23.9%) followed by urticaria (12.3%) and papulosquamous disorders (10.9%). The most common papulosquamous disorder in their study was psoriasis vulgaris (40.7%), followed by palmoplantar psoriasis (25.1%) and LP (15.4%).[4]

Of the 90 patients with genital dermatoses, atrophic vaginitis was present in 23.33% cases. Symptoms of atrophic vaginitis such as dryness, itching, burning, soreness, discharge per vaginum, dyspareunia, burning micturition, and painful micturition were enquired along with local examination. Vaginal maturation value assessment was not done which was a limitation of our study. In a study by Jahan et al. of postmenopausal women, vaginal maturation value (VMV) was also considered which increased the prevalence of atrophic vaginitis.[6] So, if VMV had been considered in our study, then the number of patients having atrophic vaginitis might have increased significantly. In a study by Mac Bride et al.,[14] the incidence was reported it to be up to 50%, while in a study by Kaur and Kalsy,[15] it was 27.5%. Infections such as candidiasis, trichomoniasis, or bacterial vaginosis may exacerbate symptoms of atrophic vaginitis.

In our study, the prevalence of lichen sclerosus among genital dermatoses was found to be 15.55% which was lower than a study done by Sener et al. showing a prevalence of 33.3%.[16] Singh et al. studied all patients presenting with vulvar lichen sclerosus over a period of 22 months and found that over 69.2% of those women were postmenopausal.[17] It can be suggested that lichen sclerosus et atrophicus is a condition which needs to be actively examined when a postmenopausal woman presents with, since it may not always be associated with a genital complaint.

Lichen simplex chronicus is a common pruritic skin disorder characterized by lichenified plaques resulting from irresistible and persistent scratching or rubbing.[18] Our study showed a frequency of 15.55% which was significantly lower than a study by Kaur and Kalsy where it was 42.5%.[14]

Tinea cruris showed a prevalence of 11.11% among patients with genital dermatoses in our study, which was higher than Kaur and Kalsy, who showed a prevalence of 7.5%.[15] The increased prevalence of fungal infections in various studies including ours can be attributed to the rampant increase in the fungal infections, especially among the low socioeconomic strata of society associated with overcrowding and poor hygiene.

Candidial infection in our study was 8.88% which was comparable to Nwokolo and Boag who showed a prevalence in postmenopausal age group of 6%–7%.[19] Kaur and Kalsy also revealed a similar frequency of around 5%.[15]

As far as we can ascertain, there has been no such study to distinguish the nail changes associated with menopausal women. These nail changes are also associated with aging however, and it is difficult to conclude with certainty whether they are due to menopause or simply as a result of aging.

Brittle nail syndrome is a phenomenon reported to occur in elderly population. It is characterized by soft, dry, weak, easily breakable nails that show onychorrhexis and onychoschizia.[20] A study by Lubach et al.[21] on elderly patients of 60 years and above revealed a prevalence of brittle nails as 36% in females. Rao et al. showed onychomycosis in 16%, followed by chronic paronychia in 9%.[22] In our study, 32.89% of postmenopausal women with nail complaints had onychoschizia, while 8.05% had onychorrhexis. Hypocalcemia is also considered to cause brittle nails with onychorrhexis and longitudinal striations.[23] Menopause is known to be a state of calcium deficiency, and hence subsequently may cause brittle nails.

In our study, we found the prevalence of onychomycosis to be 14.67%. A majority of the patients in our study were from the lower socioeconomic strata of society. Due to unsanitary environment, their feet are vulnerable to dirt and moist conditions. In addition, household women are exposed to repeated minor traumas, water, detergents, and other irritants for longer durations. These factors might have contributed to the aging-related changes in our study group, besides contributing to onychomycosis and paronychia.

Salivary flow rates depend on the estrogen status of the individual. The female hormone estrogen influences many physiological and psychological functions. Oral discomforts like dryness and burning sensations have long been reported to be strongly associated with the menopause.[24] Lower estrogen levels seem to be significantly related to the symptoms of BMS.

Dryness of mouth was detected in 26.25% of patients in our study. Agha-Hosseini et al. studied 38 symptomatic menopausal women (oral dryness) along with asymptomatic controls and found that salivary beta-estradiol concentrations in the cases were significantly lower than that in the controls.[25] Some studies further implicate decreased salivary flow as a cause for increased incidence of root caries, oral discomfort, taste alterations, oral candidiasis, and periodontal disease in menopausal women.[26] In our study also, we found 10% cases of periodontal diseases.

BMS is a common entity in postmenopausal women seen in 42.5% of 80 women with oral lesion, which was higher than that reported by Wardrop et al. who concluded that 33% of postmenopausal women reported oral discomfort in the absence of other oral changes.[24] Gao et al. in a case–control study found that menopausal women with BMS had higher follicle-stimulating hormone levels and lower periodontal disease.[26]

Oral LP was detected in 13.75% of patients with oral lesions in our study, which was higher than Mohan et al. whose study showed that the frequency of oral LP in postmenopausal women was 10.91%.[27] Estrogens boost the humoral immunity but have a different impact on cell-mediated immunity which plays an important part in the pathogenesis of oral LP. As the level of estrogen and progesterone fluctuates and finally goes down, so does the protective effect of these hormones and increases the chances of LP. This is corroborated by the fact that the general prevalence of LP is only 0.5%–2%.

FPHL was detected in 34.23% of 146 women with hair problem, while 45.89% had hair depigmentation. In a study by Siah et al., 45% were diagnosed with FPHL across all age groups in which 42% of them were above the age of 50 years demonstrating a trend of increasing FPHL with advancing age.[28] In the United Kingdom, 6% of women less than 50 years of age were diagnosed as having FPHL, increasing to 38% in subjects 70 years of age and above.[29] In Australia, the prevalence of mid-frontal hair loss increased with age and affected 57% of women age 80 years and above.[30] Estrogen may be considered stimulatory to hair growth as evidenced by increasing prevalence of FPHL post menopause, although there are still conflicting accounts about its role.

Conclusion

There should be a broader view while approaching a menopausal patient, considering all the dermatoses which can affect them and decrease their quality of life. This study is useful in understanding the various clinical patterns and presentations of postmenopausal dermatoses and thereby help the physician, dermatologist, and gynecologist to effectively manage the conditions successfully.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.