Discover more from Skin Spectrum Weekly
Managing pigment reduction and loss
Hypopigmentation may be the only symptom of skin conditions in darker skin, and can have a significant quality-of-life impact (1,700 words, 8 minutes)
Decreased pigmentation can significantly impact the quality of life in patients with darker skin types and may be the only symptom of some conditions in these patients, said Dr. Andrew F. Alexis at the 8th annual Skin Spectrum Summit in September 2022.
Dr. Alexis is the Vice-Chair for Diversity and Inclusion for the Department of Dermatology and Professor of Clinical Dermatology at Weill Cornell Medical College in New York City. He is the former Chair of the Department of Dermatology at Mount Sinai Morningside and Mount Sinai West
During a broader talk on pigmentary disorders, Dr. Alexis mentioned several skin conditions that may reduce skin pigment—hypopigmentation—as one of or their only symptom in patients with dark skin types. These included:
Progressive macular hypomelanosis
Pigment loss in seborrheic dermatitis is caused by a combination of the action of Malassezia fungi and post-inflammatory effects, Dr. Alexis said. This hypopigmentation can take several months to resolve. He noted that corticosteroids are not recommended as a treatment since they can spur the growth of Malassezia. Topical calcineurin inhibitors, or topical PDE-4 inhibitors such as crisaborole, have been effective.
Dr. Alexis pointed to a promising new PDE4 inhibitor called roflumilast, currently in phase 3 trials. He said it is not yet approved for treating seborrheic dermatitis, but recent data show efficacy across all racial and ethnic populations.
The post-inflammatory hypopigmentation that may occur with atopic dermatitis or psoriasis can be managed by treating the underlying inflammatory condition, said Dr. Alexis. The colour will typically return if the clinical and subclinical inflammation can be treated.
Dr. Alexis said Tinea versicolor might present with hypopigmentation combined with a fine overlying scale, usually on the trunk. But if a patient presents with hypopigmented patches on the trunk with no scale and treatment for tinea versicolor has been unsuccessful, physicians should consider progressive macular hypomelanosis. Caused by cutibacterium acne, this condition can be treated with antibacterial or antimicrobial therapy combined with phototherapy, he said.
In addition to hypopigmentation, depigmentation—the complete loss of colour—can also occur, said Dr. Alexis. South Asian patients may find their quality of life strongly affected by vitiligo, he said.
But a better understanding of the role of interferon gamma, which modulates its effect through the JAK-STAT pathway, has permitted a better understanding of vitiligo, said Dr. Alexis. JAK inhibitors—including the recently approved topical ruxolitinib in a 1.5% cream—have successfully treated vitiligo on the face and body.
Bottom line: Hypopigmentation can be a symptom of many skin conditions in darker-skinned patients and can have a substantial impact on quality of life. Depigmentation can have an even more significant effect on patients. Effective treatments exist for many pigmentary conditions or their underlying causes, and new therapies for many are on the horizon.
From the literature on pigment disorders
Two phase 3, randomized, controlled trials of ruxolitinib cream for vitiligo
The two (Topical Ruxolitinib Evaluation in Vitiligo Study 1 [TRuE-V1] and 2 [TRuE-V2]) studies recruited patients 12 years of age or older. A total of 674 patients were enrolled; 330 in TRuE-V1 and 344 in TRuE-V2. All participants had nonsegmental vitiligo with depigmentation covering 10% or less of their total body surface area. Patients were randomly assigned in a 2:1 ratio to apply 1.5% ruxolitinib cream or vehicle control twice daily for 24 weeks to all areas of vitiligo on the face and body.
After the 24-week initial study period, every patient could apply the ruxolitinib cream through week 52.
At week 24 in TRuE-V1, 29.8% of patients in the ruxolitinib-cream group and 7.4% of those in the vehicle group had a facial Vitiligo Area Scoring Index (F-VASI)-75 response. In TRuE-V2, the percentages were 30.9% and 11.4%, respectively.
Among the patients who applied ruxolitinib cream throughout 52 weeks, 54.8% in TRuE-V1 and 62.3% in TRuE-V2 experienced adverse events. The most common adverse events were application-site acne (6.3% and 6.6%, respectively), nasopharyngitis (5.4% and 6.1%), and application-site pruritus (5.4% and 5.3%).
Treatment of facial pigmented disorders with a 785-nm picosecond Ti:sapphire laser in Asians: A report of three cases
In this pilot study, researchers investigated the efficacy and safety of a picosecond (ps)-laser with a 785-nm wavelength for treating facial pigmented lesions in Asians. Three Korean patients with facial pigmented lesions were recruited for the study. A 785-nm ps-laser with a fractionated and an unfractionated handpiece was utilized to administer the treatment. The patients' lesions included freckles, lentigines, and melasma.
All patients exhibited a significant improvement in pigmented lesions after three to four treatment sessions. The researchers observed no adverse events, including post-inflammatory hyperpigmentation or hyperpigmentation.
Quality of life impairment amongst persons living with vitiligo using disease-specific vitiligo quality of life index: A Nigerian perspective
This study assessed quality-of-life (QoL) impairment among Nigerian patients with vitiligo using the disease-specific vitiligo quality-of-life questionnaire (VitiQoL).
Researchers included 77 adults aged 18 years and older with vitiligo who attended the dermatology clinic at a tertiary health centre. As well as using the VitiQoL to assess patient QoL, the researchers measured disease severity with the Vitiligo Area Severity Index (VASI).
There were 32 males and 45 females, with a mean age of 38.97±13.2 years. Almost half (37 (48.1%)) of the vitiligo patients belong to a lower socioeconomic class. The mean age of the first onset of vitiligo was 33.5±14.84 years; 32 (41.6%) of the participants had an age of first onset between 24 and 42 years.
The mean VitiQoL score was 30.51±15.74 (range 3-64). Researchers found a significant relationship between the VASI score and VitiQoL (p=0.036, r=0.517). Other factors such as age, gender, socioeconomic status, disease activity, family history of vitiligo, duration of the disease, and educational attainment were significantly associated with the VitiQoL score (p<0.05).
Treatment of Nevus of Ota in Black patients with the 1,064 nm QS or picosecond laser and non-ablative fractional photothermolysis
This retrospective review included 10 Black patients with Fitzpatrick skin types V or VI presenting with Nevus of Ota. Patient ages ranged from nine months to 45 years.
Each patient was treated with a 1,064 nm Q-switched neodymium-doped yttrium aluminum garnet (QS Nd:YAG) laser, with an average of 4.7 treatments at two to 10-month intervals. Fluences ranged from 1.8 to 2.3 J/cm2. Total pulse counts ranged from 510.9 to 776.6.
Two patients were also treated with 1,550 nm non-ablative fractional resurfacing (NAFR), and one patient underwent combination therapy with both NAFR and 1,064 nm picosecond laser therapy.
The three independent dermatologists evaluated improvement using before and after photographs on a five-point visual analogue scale.
Overall, patients saw a mean improvement of 51%-75% at five to 254 weeks of follow-up (mean 51.5 weeks) after treatment. Three patients experienced mild guttate hypopigmentation in treated areas. No other long-term adverse events were encountered.
VIDEO: Light spots & patches on Brown or dark skin? Causes & Treatment—Dr.Nischal K | Doctors’ Circle
At the intersection of skin and society
A recent ruling by the Quebec Superior Court said that police motor vehicle stops without cause violate the Canadian Charter of Rights and Freedoms, reports CBC News.
The court allows a six-month delay until the rules allow random stops are officially invalid.
“Racial profiling does exist. It is not a laboratory-constructed abstraction. It is not a view of the mind. It is a reality that weighs heavily on Black communities. It manifests itself in particular among Black drivers of motor vehicles,” the news report quoted Judge Michel Yergeau saying.
“Charter rights can no longer be left in thrall to an unlikely moment of epiphany by the police. Ethics and justice must go hand in hand to turn this page.”
The ruling comes in a lawsuit filed by Montreal resident Joseph-Christopher Luamba, a 22-year-old Black man. In his testimony, Luamba said he gets ready to pull over whenever he sees a police cruiser, according to the CBC.
Luamba said in the 18 months after he received his driver’s license in March 2018, he was stopped by police approximately ten times for no specific reason. He was the driver in half of the stops, and a passenger in the other stops. None of the stops resulted in a ticket, and Luamba testified that he felt he had been racially profiled.
The news outlet notes that Common law has allowed Canadian police to stop people for no reason. However, Luamba has been working to have the practice declared unconstitutional.
“I was frustrated,” he told the court. “Why was I stopped? I followed the rules. I didn’t commit any infractions.”
Lawyers for Luamba and the Canadian Civil Liberties Association, which has intervener status in the case, told the court that the power of police to stop drivers, other than at drunk driving checkpoints randomly, is unconstitutional and enables racial profiling.
The court ruled on Tuesday, Oct. 25, 2022, that this practice violates the rights guaranteed by Sections 7 and 9 and paragraph 15 of the Canadian Charter of Rights and Freedoms.
“The preponderant evidence shows that over time, the arbitrary power granted to the police to carry out roadside stops without cause has become for some of them a vector, even a safe conduit for racial profiling against the Black community,” wrote Yergeau in his ruling.
November is National Diabetes Month in the U.S.
Nov. 7-13 is National Nurse Practitioner Week in the U.S.
Something to think about in the week ahead…
Annette Funicello, American actress, 1942—2013
There are several barriers to adherence to treatment of pediatric atopic dermatitis (AD) in marginalized and ethnic communities, Dr. Danielle Marcoux reported during her presentation at the 2022 Skin Spectrum Summit. In addition to discussing these barriers and how a physician can work with patients to overcome them, Dr. Marcoux also discussed some comorbidities of AD that are more common in patients with darker skin types.
If you like Skin Spectrum Weekly, why not check out our 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:
Dr. Lyn Guenther (London, Ont.) discusses the benefit a fixed-dose combination calcipotriol/betamethasone dipropionate (Cal/BD) foam can have at alleviating psoriasis-related impairment of work productivity and activity
A review of recent literature on acne treatments, featuring interviews with Dr. Michelle Pratt (St. John’s, NL), Dr. Ben Barankin (Toronto), Dr. Maha Dutil (Toronto) and Dr. Yuka Asai (Kingston, Ont.)
Plus regular features, including the popular column “Vender on Psoriasis” by Hamilton, Ont. dermatologist Dr. Ron Vender
To apply for a complimentary* subscription or to receive a sample copy, please email firstname.lastname@example.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 Vendor on Psoriasis Podcast featuring Canadian dermatologist Dr. Ronald B. Vender is coming soon. Watch this space for updates.
And if you’re looking for a web destination for all things derm, please visit derm. city, “Where Dermatology Lives.” Please like it, rate it and share it with your colleagues.