Beyond Pigmentation: Dermoscopic Vascular Patterns Reveal Novel Risk and Protective Factors in Melasma

Objective To investigate the correlation between the dermoscopic severity of telangiectasia and key pathophysiological features in melasma, and to identify the risk factors associated with vascular pattern severity. Methods In this cross‐sectional study, 137 female melasma patients were classified into four vascular types based on dermoscopic evaluation: nonvascular change, erythema, strip‐ or branch‐shaped, and reticular. Comprehensive assessments included noninvasive skin measurements (Melanin Index [MI], Erythema Index [EI]), facial imaging, and detailed questionnaires. Multivariable ordinal logistic and multiple linear regression models were used for analysis. Results The severity of the vascular type was significantly correlated with erythema parameters ( r = 0.69) and the modified Melasma Area and Severity Index (mMASI). After multivariable adjustment, higher parity (Adjusted Odds Ratio [aOR] = 2.60) and higher Body Mass Index (BMI) (aOR = 1.38) emerged as the strongest independent risk factors for a more severe vascular type. In a separate model for mMASI, MI was the most potent positive predictor ( p < 0.001), while intriguingly, erythema area ratio was a significant negative predictor ( p = 0.026) after adjusting for MI. Conclusion The severity of dermoscopic vascular patterns in melasma is strongly associated with increased erythema and clinical severity. Higher parity and BMI are key independent risk factors for severe telangiectasia. Our findings highlight the crucial role of the vascular component in melasma and suggest that clinical scoring systems may underestimate the contribution of erythema when significant pigmentation is present.