Facial hyperpigmentation management in skin of colour
Many prescription and non-prescription modalities can support patients with melasma or other pigmentary disorders (Issue #229; 1,400 words; 7 minutes)
Melasma is one of the most common disorders of hyperpigmentation, Dr. Andrew Alexis said during a presentation at the 10th annual Skin Spectrum Summit in Toronto. He provided an overview of several treatment modalities for melasma and other hyperpigmentation conditions.
Dr. Alexis is a professor of clinical dermatology and vice chair for diversity and inclusion at Weill Cornell Medicine in New York City. He was also the former chair of the Department of Dermatology at Mount Sinai Morningside and Mount Sinai West.
Once a condition has been diagnosed as a disorder of hyperpigmentation, hydroquinone is often used as a first-line agent, usually in a 4% formulation, said Dr. Alexis. Hydroquinone is frequently combined with a retinoid and corticosteroid in the Kligman-Willis formula. In stubborn cases, the formulation may have a hydroquinone concentration higher than 4%.
However, Dr. Alexis noted that hydroquinone has limitations. It may lead to a halo effect of hypopigmentation on the perilesional skin, irritant contact dermatitis, or exogenous ochronosis, particularly at higher concentrations. Dr. Alexis said that after six months of treatment with hydroquinone, he will transition the patient to non-hydroquinone agents.
Dr. Alexis said alternatives to hydroquinone can be beneficial for the long-term management of pigmentary conditions. These alternatives can include prescription topical retinoids such as tazarotene or prescription azelaic acid.
Dr. Alexis said that non-prescription topical cosmeceuticals such as cysteamine, which is applied for 15 minutes and then washed off, are effective (Desai S, Hartman C, Grimes P, Shah S: Topical stabilized cysteamine as a new treatment for hyperpigmentation disorders: Melasma, post-inflammatory hyperpigmentation, and lentigines. J Drugs Dermatol Dec. 1, 2021; 20(12):1276-1279).
Dr. Alexis said a newer topical agent for treating hyperpigmentation contains 2-mercaptonicotinoyl glycine (2-MNG), which quenches precursors to melanin synthesis, reducing eumelanin and pheomelanin production. 2-MNG can be found in a non-prescription serum.
Dr. Alexis said these prescription and non-prescription treatments may be used sequentially or concurrently.
It may sometimes be necessary to use treatments beyond topical therapies, said Dr. Alexis. These can include oral tranexamic acid, which is being increasingly used. Patients should be screened for any family history of prothrombotic conditions before using this medication off-label. In the U.S., tranexamic acid is available as a 650 mg tablet. Patients often cut this in half to approximate the 250 mg dose twice daily, which studies have shown to be effective. (Del Rosario E, et al: Randomized, placebo-controlled, double-blind study of oral tranexamic acid in the treatment of moderate-to-severe melasma. J Am Acad Dermatol Feb. 2018; 78(2):363-369).
It is sometimes also necessary to incorporate procedural therapies such as laser or light treatment, chemical peels or microneedling to manage hyperpigmentation, said Dr. Alexis. This is often the case with primarily dermal pigmentation types or post-inflammatory hyperpigmentation cases, which frequently persist when found in areas other than the face.
Dr. Alexis said photoprotection against ultraviolet and visible light is essential for all treatments. Tinted sunscreens, which contain iron oxides, protect against visible light.
Bottom line: Disorders of hyperpigmentation are common in skin of colour. Physicians have access to a range of prescription and non-prescription, topical, oral, and procedural treatment options so they can tailor care for a patient’s needs. In all cases, broad-spectrum photoprotection is also needed.
From the literature on pigmentary disorders in skin of colour
The burden of melasma: Race, ethnicity, and comorbidities
Researchers used a large global health research network database (TriNetx) of data from 108 healthcare organizations to quantify the associations between race, ethnicity, and comorbidities in patients with melasma.
The investigators identified 41,283 patients with melasma (93% female, mean [SD] age 48.8 [12.6] years).
The most frequently associated risk factors for the pigmentary disorder included hypertension (25% of the melasma cohort) and hormonal contraception (24%). Rosacea (odds ratio [OR]=5.1), atopic dermatitis OR=3.3), lupus (OR=2.5), history of skin cancer (OR=2.5), history of internal malignancy (OR=2.1), and hormonal contraception use (OR=2.1) possessed the highest odds ratios for development of melasma (all p<0.01). Researchers also identified a statistically significant association for melasma in Asian or Other/Unknown races (OR=2.0 and OR=1.7, p<0.01), as well as Hispanic ethnicity (OR=1.3, p<0.01). White, Black/African American, and Not Hispanic groups all revealed slightly lower odds (all 0.8, p<0.01).
Efficacy of subdermal poly-d,l-lactic acid injections for the treatment of melasma
In this preliminary study, researchers evaluated the efficacy and safety of poly-d,l lactic acid (PDLLA) subdermal injections for treating moderate melasma.
Investigators treated three female patients (age range: 45 to 59 years) with Fitzpatrick skin types III and IV. Patients received three PDLLA injection sessions at three-week intervals. The authors assessed treatment outcomes at a 12-week follow-up visit using the Melasma Area and Severity Index (MASI) and patient satisfaction scores.
All three patients showed significant MASI score improvements (reduction range: 3.60-6.30 points). Patient satisfaction ratings ranged from 3 to 4 out of 4. Temporary side effects included mild edema and bruising, resolving within 72 hours.
The authors say their findings show PDLLA subdermal injections are promising as melasma treatment, potentially due to the treatment’s biostimulatory effects on collagen production and dermal remodelling. They note further research, including histopathological analysis, is needed to confirm long-term efficacy and safety and understand underlying mechanisms.
Gender, racial, ethnic, and Fitzpatrick skin type representation in acanthosis nigricans clinical trials
Researchers performed a systematic literature search across the PubMed, Embase, and Cochrane databases to identify participant characteristics in clinical trials focused on treating acanthosis nigricans.
They identified 21 clinical trials, totalling 575 participants, with a predominance of female participants (69.0%) and a surprising absence of race or ethnicity data.
Out of 11 studies that included Fitzpatrick skin type data, 1.2% of participants had Fitzpatrick skin type II, 20.6% type III, 50.0% type IV, and 28.2% type V. None had Fitzpatrick skin types I or VI.
The authors note that their paper highlights the need for improved reporting of race and ethnicity and the importance of including all Fitzpatrick skin types in clinical studies. They say that addressing this gap is critical for developing safe, efficacious, patient-centred, and equitable treatments for all acanthosis nigricans patients, and future research should prioritize comprehensive inclusion of race, ethnicity, and the full spectrum of Fitzpatrick skin types.
VIDEO: 10 ways to manage dark spots of melasma
Seattle-based dermatologist Dr. Daniel Sugai discusses 10 treatment modalities for melasma.
At the intersection of skin and society
Dr. Bolu Ogunyemi, a clinical associate professor of medicine at Memorial University of Newfoundland’s Faculty of Medicine, has been elected by his peers in Newfoundland and Labrador as nominee to be the Canadian Medical Association’s (CMA) next president-elect.
Pending General Council approval at the CMA’s Annual General Meeting in May 2025, Dr. Ogunyemi, a dermatologist, will serve as president-elect until May 2026, when he will become CMA president for one year.
According to a press release from the CMA, the president is elected by members from a different province or territory every year and acts as the primary spokesperson for the CMA’s work. They represent the CMA in the media and provincial and territorial medical associations, government, and other partner organizations.
Dr. Ogunyemi practises medical dermatology in St. John’s and has maintained a visiting specialist clinic in Labrador City since 2018. In addition to numerous leadership roles at Memorial University of Newfoundland’s Faculty of Medicine, including the inaugural Assistant Dean of Social Accountability (2020–23), he has served on the Newfoundland and Labrador Medical Association Board of Directors. He completed a Fellowship in Health Services Improvement in 2024 from the University of Alberta’s School of Public Health.
He also serves on the CMA Governance Committee and previously on the Canadian Doctors for Medicare Board of Directors. He has advised the federal government as a member of the Public Health Agency of Canada’s Public Health Ethics Consultative Group.
“My track record in medical leadership, spanning 15 years, has provided me with expertise on pressing issues facing our health care system today,” Dr. Ogunyemi said in the release. “As CMA president-elect, I will advocate for a unified and respected profession, robust health care system and healthier communities.”
Eligible CMA members in Newfoundland and Labrador voted for the president-elect from Nov. 20 to Dec. 4, choosing between two candidates—Dr. Ogunyemi and Dr. Susan MacDonald.
This week
December is National Drunk & Drugged Driving Prevention Month in the U.S.
Dec. 18 is International Migrants Day
Dec. 20 is International Human Solidarity Day
Something to think about in the week ahead . . .
—Francesco Guicciardini, Italian historian (1483 – 1540)
This newsletter will return on Jan. 13, 2025
Skin Spectrum Weekly will take a break for the holiday season, returning on January 13, 2025.
The first edition of the new year will discuss a collaboration between students, librarians, and faculty at the Hackensack Meridian School of Medicine in Clifton, N.J., addressing the shortage of pathology images on diverse skin tones in medical educational materials. The team developed a database of dermatologic conditions in people with darker skin tones.
If you enjoy Skin Spectrum Weekly, why not check out the Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Drs. Sam Hanna (Toronto), Fiona Lovegrove (London, Ont.), Yuka Asai (Kingston, Ont.), and Maxwell Sauder (Toronto) discuss new treatment options for atopic dermatitis, including topical and injected agents.
Dr. Jeffrey M. Cohen (New Haven, Conn.) describes findings that show an elevated risk of eating disorders among patients with atopic dermatitis.
Drs. Ron Vender (Hamilton, Ont.), Parbeer Grewal (Edmonton), Fiona Lovegrove (London, Ont.), and Sam Hanna (Toronto) provide an overview of essential news in psoriasis therapy, including new oral therapies and the potential to prevent psoriasis from progressing to psoriatic arthritis.
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Season three of the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode five, Dr. Vender discusses whether vitamin D influences psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
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