Gaps in hyperpigmentation knowledge
Gaps in hyperpigmentation knowledge
Room to improve in areas of prevention and treatment of unwanted excess pigmentation (1,800 words, 9 minutes)
Hyperpigmentation is a significant concern to patients with skin of colour, but gaps remain in medical knowledge related to the prevention and treatment of this common condition. Gaps exist regarding the best sun protection agents, lightening agents, and cosmetic procedures to reduce unwanted pigmentation.
These were some topics covered in a keynote presentation by Dr. Pearl Grimes at the 2022 Summer of Dialogue Colloquium, Focus on the Black Dermatology Patient.
“Certainly, from a historical perspective, we know that skin of colour patients often take fewer photoprotection measures,” said Dr. Grimes. “I think as dermatologists, it is so important for us to re-educate our deeply pigmented patients on the importance of using sunscreens.” She also said that there is a need for more cosmetically acceptable sunscreens since many dark-skinned patients complain that sunscreens make their skin look ashy.
There is a “significant need to optimize shades and colours for darker skin tones,” she said.
Dr. Grimes is the founder and director of the Vitiligo & Pigmentation Institute of Southern California and a clinical dermatology professor at the University of California, Los Angeles.
For lightening skin medically, topical hydroquinone remains popular even 60 years after its introduction, Dr. Grimes said. She noted that triple combination formulations that combine hydroquinone with tretinoin and a steroid are the most common ways to use hydroquinone.
However, “clearly there is a paradigm shift to non-hydroquinone agents,” she said. “Many patients will come into my office requesting non-hydroquinone formulations.”
Research is being done into new, effective non-hydroquinone medications for hyperpigmentation, Dr. Grimes said. Among those she discussed, she listed:
4-N-butylresorcinol
Methimazole
Melatonin
Silymarin
Cysteamine
Tranexamic acid
Dr. Grimes and her research team have been investigating malassezin, she said. “It is part of the natural skin microbiome and is an AhR agonist and a powerful antioxidant.”
Regarding oral tranexamic acid, Dr. Grimes said that an important consideration related to this agent is the possibility of causing thromboembolic phenomena.
“I think it is very important that physicians screen their patients for any propensity to have clotting disorders if the patient is on oral contraceptives or any hormonal therapy.”
She noted that dose-ranging studies of oral tranexamic acid have shown a lack of improved outcomes and increased relapse rates at doses higher than 250 mg. In her practice, “we typically use a lower dose of 325 milligrams—half a tablet—once a day in combination with an aggressive topical regimen.”
Another knowledge gap Dr. Grimes identified is that relapses remain common for patients with melasma. She noted that in a proof-of-concept study in 20 patients with either photodamage or melasma, after 14 weeks of treatment with malassezin the participants remained relapse-free for eight weeks.
Bottom line: Several gaps exist in treating pigment disorders in dark skin. These include but are not limited to the need for better photoprotection and new and better topical agents to reduce hyperpigmentation with greater efficacy and durability.
From the literature on cosmetic treatments for dark skin
Evaluation of oral tranexamic acid as a novel treatment for melasma with a high benefit-risk ratio
The authors of this study note that in some East Asian countries, oral tranexamic acid (TXA) is widely administered to alleviate hyperpigmentation during and after childbirth.
To evaluate the safety and baseline efficacy of oral TXA as a treatment for melasma, the researchers retrospectively surveyed 42 patients with Fitzpatrick skin types III-VI who had been prescribed to take half of a 650 mg TXA tablet twice daily.
The authors found that most patients saw a noticeable improvement in their melasma. Of the 42 patients, only seven experienced side effects. The side effects noted were headaches, malaise and nausea, gastrointestinal upset, congestion, numbness in the legs, hypomenorrhea, and hypermenorrhea.
No long-term side effects were seen. Patients who did experience side effects had those effects resolved after discontinuing TXA treatment.
The protective effect of a novel sunscreen against blue light
The authors of this study assessed the efficacy of a sunscreen product (TDF Blu Voile Sunscreen) in protecting against the harmful effects of blue light irradiation. They tested this product in vivo and through the in situ quantitative and qualitative evaluation of protein carbonylation in human skin explants.
Investigators exposed treated and non-treated explants to 14 J/cm2 of 460 nm blue light. After exposure, researchers measured protein carbonylation.
To determine whether the test product could protect against the immediate and persistent pigmenting effect of blue light, researchers conducted two randomized in vivo studies, which included 17 subjects with Fitzpatrick skin phototypes IV and V and 22 subjects with skin phototypes IV, V, and VI. For this study, specific zones on the subjects' backs were either untreated or treated with the test product and then exposed to a unique dose of 415 nm blue light. The researchers assessed the onset of pigmentation between the treated and exposed zones relative to the non-exposed treated zone.
The authors found that the human skin explants treated with the test product showed significantly lower levels of accumulated carbonylated proteins after blue light exposure, representing 82% protection. Findings of the in vivo studies also indicated the test product presented substantially better protection against immediate and persistent blue light-induced pigmentation.
Efficacy and safety of picosecond laser for wrinkles in Indonesian skin
The authors of this paper note that the increased melanin content in Indonesian skin can decrease therapeutic efficacy and promote poor outcomes from laser-based dermatologic treatments.
To investigate the efficacy and safety of picosecond 755 nm laser with a diffractive lens array (DLA) for treating wrinkles on the forearm of Indonesian patients, the investigators enrolled 20 patients with Fitzpatrick skin types III to V.
Investigators assessed wrinkles based on photographs at baseline and one month after treatment, and the patients rated their overall satisfaction.
The researchers noted a significant improvement in the appearance of wrinkles at one month (p<0.05). 75% of the patients said they were extremely satisfied, and 5% said they were satisfied. No serious adverse events were reported.
Evaluation of the efficacy and safety profile of long-pulsed 1,064 neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in hemangioma and vascular malformation in darker skin types
This study was conducted to evaluate the efficacy and safety of long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in treating vascular lesions in patients with Fitzpatrick skin types IV and V.
Researchers enrolled 29 patients presenting with vascular lesions. The patients were called once a month for sessions for six months, and their lesions were evaluated using the Clinician Global Impression (CGI) score.
Three of the 29 patients dropped out for logistic reasons, and 26 completed the treatment.
After six months of follow-up, the investigators found that 12 (46.15%) patients had shown complete healing (CGI=4, 70% to 100% improvement in lesions). The remaining 14 (53.84%) patients showed good improvement (CG1=3, reduction of 50% to 70% of lesions). No permanent side effects were noted.
VIDEO: How to get rid of hyperpigmentation, melasma, acne, rough texture: Black, dark skin—Chemical peels
At the intersection of skin and society
The Yukon’s First Nation School Board—the first of its kind in Canada—has just begun its inaugural academic year, reports CBC’s The Current.
The board includes eight schools and was launched after a referendum vote last January. According to the news outlet, the board's goal is to give Indigenous people more say in education and bring cultural knowledge into the classroom. Students of any background can attend.
Schools in the new board will follow the British Columbia curriculum, as do the other schools in the Yukon. This will complement land-based, traditional learning that draws from community knowledge-holders and elders.
Melanie Bennett, executive director of the Yukon First Nation Education Directorate and member of the Tr’ondёk Hwёch’in First Nation told the news outlet that many Indigenous people have not had a chance to have classes outside and to learn about the environment and traditions of Indigenous peoples.
According to The Current, Bennett played a significant role in bringing in the new school board. She has high hopes for what the education program will mean for Indigenous students.
“I think the biggest thing is confidence and being OK knowing who you are,” Bennett said. She noted she and her classmates had to learn an Indigenous language secret from her grandmother.
“She taught us sewing, but she closed the door and taught us how to speak the language at the same time. Those are the warriors we didn’t see.”
Melissa Flynn, the interim director of the new board, told The Current that launching the First Nation School Board is the next step toward reconciliation. She noted that most of Canada’s school boards do not utilize the community- and family-based education that is a traditional part of Indigenous learning.
“We had our own ways of knowing and being. How we taught children and how they learned from multigenerational people in their lives,” said Flynn.
This week
Sept. 12-18 is National Eczema Week in the U.K.
Sept. 12-18 is Sexual Health Week in the U.K.
Sept. 15 is World Afro Day
Something to think about in the week ahead…
Next week
We return to our coverage of the 2022 Indigenous Skin Spectrum Summit with Dr. Jordanna Roesler’s presentation on diabetic skin disease among North American Indigenous populations.
Last-minute registration is still available for the 2022 Skin Spectrum Summit
Registration is still open for the 8th annual Skin Spectrum Summit. The Skin Spectrum Summit is dedicated to improving dermatologic care for skin of colour, recognizing that optimal care differs across skin types. It will feature presentations by Canadian and international experts.
The conference provides education on treating patients across all six Fitzpatrick skin types, emphasizing care for Types IV-VI.
This year’s Summit will be held in person at the Chestnut Conference Centre in downtown Toronto. If you can’t attend in person, a live stream of the event is also available!
As a reader of Skin Spectrum Weekly, you are receiving a discount on the Skin Spectrum Summit. Just use the code FLASHSALE50 or click here.
Date: Saturday, September 17, 2022
Time: 8:00 a.m. – 4:00 p.m. EDT
Location: Chestnut Conference Centre, 89 Chestnut St., Toronto
Pictured: Dr. Danielle Marcoux, Dr. Andrew F. Alexis, Dr. Gary Sibbald, Dr. Rachel N. Asiniwasis, Dr. Jaggi Rao, Dr. Monica Li, Dr. Geeta Yadav, Dr. Shafiq Qaadri, Dr. Renée A. Beach
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