Hypopigmentation in skin of colour
Hypopigmentation in skin of colour
Some conditions more common in patients with darker skin types (1,500 words, 7 minutes)
Several dermatologic conditions demonstrate increased prevalence of resulting post-inflammatory hypopigmentation in darker skin phototypes, including atopic dermatitis and related eczemas where underlying inflammation disrupts melanin production and homeostasis. However, targeted therapeutic options to stabilize pigment changes and address the loss of melanocytes in these patients remain underdeveloped relative to demand.
These were some of the points raised by Drs. Nada Elbuluk and Zelma Chiesa Fuxench in an interview with the U.S. National Eczema Association.
Dr. Elbuluk is an associate professor of clinical dermatology and director of the Skin of Color & Pigmentary Disorders Program at Keck Medicine of the University of Southern California in Los Angeles. Dr. Fuxench is an assistant professor of dermatology at the Hospital of the University of Pennsylvania in Philadelphia.
Dr. Fuxench noted that there are skin conditions where the presenting sign is hypopigmentation (idiopathic guttate hypomelanosis or leukoderma punctata are two of these conditions). But post-inflammatory hypopigmentation (PIH) may also occur after an injury or an inflammatory disease such as atopic dermatitis.
“There’s also what we consider a type of eczema called pytiriasis alba, where people get light or hypopigmented scaly spots,” said Dr. Elbuluk. “We tend to see it more in children, specifically children of colour.”
Hypopigmented mycosis fungoides, a type of skin cancer that can present with light-coloured, scaly spots, also happens more frequently in people of colour, she said. “Many times, people are misdiagnosed as having eczema for many years before it’s actually figured out that they have hypopigmented mycosis fungoides.”
Identifying and treating the cause of acquired PIH is often enough to improve pigmentation, possibly leading to PIH resolution in weeks or months, said Dr. Fuxench.
She noted there are a small number of studies on PIH treatment options. Those studies have reported mixed results for approaches including topical therapies or light-based therapies. “Other options include the use of camouflage makeup to help cover lesions, but this may not be feasible due to cost or for patients with extensive surface involvement,” Dr. Fuxench said.
Bottom line: Hypopigmentation, including post-inflammatory pigment changes related to eczema, is a particular concern for patients with skin of colour. Research into treatments has been limited, with mixed results.
From the literature on pigmentary disorders
Topical treatments for melasma and post-inflammatory hyperpigmentation
The authors of this paper note dyschromia is one of the most common reasons for patients to seek dermatological care, particularly individuals with skin of colour.
In this qualitative review, the authors provide an overview of topical treatments for melasma and post-inflammatory hyperpigmentation (PIH), including recent data from an investigator-initiated trial of the retinoid tazarotene.
They note topical hydroquinone (HQ) in the form of triple combination HQ 4%/tretinoin 0.05%/fluocinolone acetonide 0.01% cream is the gold-standard treatment for melasma and PIH but should not be used long-term due to safety concerns.
Additionally, efficacy data for over-the-counter and cosmeceutical products are limited or lacking.
Topical retinoids are efficacious and safe, the authors write, noting dose and formulation differences may affect tolerability. Regarding tazarotene 0.045% polymeric emulsion lotion, the reviewers say in studies it has demonstrated good efficacy, safety, and tolerability over 24 weeks in adult female patients with moderate-to-severe melasma or PIH.
The effect of melasma on the quality of life in people with darker skin types living in Durban, South Africa
This study aimed to assess the severity of melasma on people with darker skin types, evaluate the effects of melasma on the quality of life (QoL), and establish QoL predictors in affected individuals.
Researchers enrolled 150 patients from three private dermatology clinics in Durban, South Africa who were diagnosed with melasma.
Investigators measured melasma severity alongside QoL using a melasma area and severity index (MASI) score and melasma quality of life scale (MELASQoL), respectively. The enrolled patients were predominantly females (95%), of which 76% were of Black African ethnicity, 9% were of Indian ethnicity, and 15% had mixed ancestry, with an average age of 47.30 years. Family history revealed that 61% had no prior melasma cases, while 39% had affected relatives, most commonly mothers (41%).
The authors found the most common site for melasma was the cheeks. They noted MASI score (β=0.209, t=2.628, p<0.001), the involvement of cheeks (β=-0.268, t=-3.405, p<0.001), level of education (β=-0.159, t=-2.029, p=0.044), and being menopausal (β=-0.161, t=-2.027, p=0.045) were predictors of QoL. The researchers created a regression model to forecast MELASQoL using these four predictors. They write the equation's significance lies in its ability to enable the remote assessment of MELASQoL based on these four variables. It offers a valuable tool for researchers and medical professionals to quantitatively and objectively evaluate the impact of melasma on an individual's quality of life.
Targeting the dermis for melasma maintenance treatment
Noting that recent studies suggest that photoaging in the dermis is the main pathologic mechanism of melasma, researchers investigated the maintenance effect of microneedling radiofrequency (RF) for melasma treatment.
In this study, subjects with melasma were administered oral tranexamic acid and triple combination cream for two months and had a randomly assigned half of their face treated with RF.
The investigators continued RF treatment monthly for six months after discontinuation of conventional therapy. They also collected modified Melasma Area Severity Index (mMASI) score and L* value monthly.
Of 15 subjects initially enrolled, 11 completed the eight-month study. At the second month of conventional therapy, all subjects showed improvement with a 64% reduction in mMASI scores. With continuous RF treatment, the improvement was well maintained. In the untreated sides, the Δ L* gradually decreased, returning to baseline after the conventional therapy ended.
The authors conclude continuous microneedling RF therapy is beneficial in maintaining the conventional therapy of melasma, which suggests there is value in exploring the protective effect of dermal targeting therapy in melasma.
The role of 755-nm alexandrite picosecond laser in melasma management
Noting that melasma disproportionately affects women, particularly those of Latino, Black, and Asian ethnicities, the authors of this review assessed the efficacy and safety of the 755 nm alexandrite picosecond laser both as a stand-alone treatment for melasma and in combination with topical agents.
Conducting a Pubmed search, the researchers included English-written studies examining this laser as monotherapy or in combination with the topical agent.
In one study, monotherapy with the 755 nm picosecond laser led to a 50 to 75% improvement in melasma appearance in 40% of participants and a significant reduction in the average Melasma Area and Severity Index (MASI) score (p<0.001) in all patients. Notably, the use of topical tranexamic acid (TTA) in conjunction with the picosecond laser exhibited the most significant degree of improvement in hemi-MASI scores compared to the laser monotherapy group at one- and three-months post-treatment (p<0.05). Patient satisfaction was also significantly higher for the combination group (p<0.05). In contrast, combining hydroquinone (HQ) with the picosecond laser demonstrated no significant difference in outcomes compared to HQ alone, both of which were less effective than TTA with picosecond laser. The combination of the 755 nm picosecond laser with TTA proves promising, outperforming both laser monotherapy and laser with HQ. The authors note that while monotherapy with the picosecond laser or topical agents is effective, the literature favours combination therapy, especially the 755 nm picosecond laser with TTA, for superior benefits and minimal side effects. Ultimately, they say, individualized regimens, considering factors like skin type, should be prioritized, given the heightened risk of postinflammatory hyperpigmentation, especially in skin of colour patients.
VIDEO: Hair dye and facial pigmentation
Dr. Paul Devakar Yesudian, Consultant Dermatologist at the Betsi Cadwaladr University Health Board in Chester, U.K., discusses the potential for ingredients of hair dye to cause pigmented contact dermatitis. His talk covers the mechanism of pigmentation, clinical manifestations, and management.
At the intersection of skin and society
Kamal Khera, Canada’s Minister of Diversity, Inclusion and Persons with Disabilities announced the theme for Black History Month 2024, which begins on Feb. 1.
This year’s theme is “Black History Month: Black Excellence: A Heritage to Celebrate; a Future to Build,” according to a press release.
The theme reveal occurred during an announcement of an award of nearly $370,000 granted to support 14 equity-deserving Black-led, Black-focused organizations in British Columbia. The funding is being provided under the Events component of the Multiculturalism and Anti-Racism Program and the Supporting Black Canadian Communities Initiative.
"As we approach Lincoln Alexander Day and the beginning of Black History Month on February 1, I look forward to celebrating the rich contributions and accomplishments of Black people in Canada not only next month but throughout the year,” said Khera. “Our government is dedicated to actively building capacity within Black communities. Today's investment will support Black-led, Black-focused organizations in British Columbia in amplifying Black voices throughout Black History Month and beyond, fight anti-Black racism, and help increase capacity to better serve Black communities in the province. Together, we forge a more just, empowered and celebrated Canada year-round."
This week
January is World Health Esteem Month
Jan. 24 is International Day of Education
Jan. 27 is International Day of Commemoration in memory of the victims of the Holocaust
Something to think about in the week ahead. . .
—Henry Drummond, Scottish writer (1851 to 1897)
Next week
Dermatologist Dr. Maritza I. Perez, professor of dermatology at the University of Connecticut, speaks about the way basal cell carcinomas and cutaneous squamous cell carcinomas often present in patients with darker skin.
If you like Skin Spectrum Weekly, why not check out 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. Lauren Lam (Calgary), Sam Hanna (Toronto), Benjamin Barankin (Toronto), and Renée A. Beach, (Toronto) discuss many of the new therapeutic options that arrived in 2023.
Dr. Andrew F. Alexis (New York) details pigmentary disorders in patients with skin of colour.
An essay from Dr. Sheila Wang (Montreal) submitted to the 2022 Dermatology Industry Taskforce on Inclusion, Diversity and Equity (DiTiDE) short essay contest. Dr. Wang wrote about the development of new imaging technology to detect and assess ‘beneath-the-skin’ inflammation, perfusion, and tissue oxygenation in any skin phototype.
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Read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary* subscription or to receive a sample copy, please email health@chronicle.org with your contact information.
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
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 or not vitamin D has any impact on psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
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