Patient guidance on hyperpigmentation
A resource for educating patients with dark skin on causes and self-care of unwanted dark spots (1,450 words, 7 minutes)
The American Academy of Dermatology (AAD) has updated its guide for patients on how to fade hyperpigmented spots in darker skin tones.
This lay-language guide discusses the causes of unwanted dark spots, keys to successful treatment, managing expectations, and includes some recommendations for steps patients can take themselves.
In talking about causes, the AAD discusses the importance of controlling or clearing inflammatory skin conditions as a first step before addressing pigment changes. Similarly, they emphasize that if a patient suspects a medication is causing hyperpigmented spots as a side-effect, they should consult with their physician regarding a medication change rather than discontinuing treatment.
The document lists some topical treatments that patients may have access to without a prescription, including azelaic, glycolic, kojic acids, over-the-counter retinoids and vitamin C. However, it emphasizes the importance of sunscreen use to prevent new dark spots and assist in fading existing ones.
Patients are cautioned to be careful in their choice of lightening products, though, citing cases where products have been found to contain unlabelled steroids or mercury.
The guide also warns against the use of liquid bleach on the skin.
Overall, the recommendations from the AAD include:
Patients should apply sunscreen every two hours and after swimming or sweating.
When outdoors, they should wear a wide-brimmed hat.
Patients should avoid being outdoors when the sun is strongest, between 10 a.m. and 2 p.m.
Skincare products should be chosen that are gentle on the skin. Products that burn or sting when applied should be discontinued.
Individuals should work to address the root cause of the dark spots. For example, treating inflammatory skin conditions.
If self-care is not effective, individuals should seek assistance from a dermatologist.
Bottom line: This is a helpful guide that dermatologists can use to help their patients with skin of colour understand hyperpigmentation. It provides tips for what patients can do independently and emphasizes dermatologists’ vital role in clearing hyperpigmentation. The guide also links to three other related pages: 10 tips for clearing acne in skin of colour, treatment of melasma, and skin cancer in people with skin of colour.
From the literature on hyperpigmentation in skin of colour
Comparative study on depigmenting agents in skin of colour
This single-centre prospective study was performed in two phases. The first phase compared five commercially available depigmenting products. A second phase compared five single active ingredients in a lipophilic base.
In phase 1, 28 healthy female volunteers were recruited to test Eldopaque, Aziderm, Garnier Dark Spot Corrector, Ban a Tan Cream and Neostrata Pigment Lightening Gel.
Twenty-six other volunteers were recruited to compare hydroquinone 4%, ascorbyl palmitate 1%, resveratrol 1% arbutin 5% and azelaic acid 20%.
Each test agent was applied twice a day for five days per week and continued for six weeks.
All the applications containing active ingredients showed significant skin lightening. However, only arbutin demonstrated significant diminution of pigmentation when compared to an inactive control.
A single-blinded, randomized, controlled trial comparing efficacy between low-fluence alexandrite 755-nm picosecond laser and low-fluence neodymium-doped yttrium aluminum garnet (Nd:YAG) 1064-nm picosecond laser for the treatment of ultraviolet B-induced hyperpigmentation
In this study, 20 Asian patients with Fitzpatrick skin types III and IV and ultraviolet-B (UVB)-induced hyperpigmentation each had three pigmented spots treated with one of two laser treatments or left as a control site.
The patients received weekly laser treatments for five sessions. Follow-ups were scheduled one and two months after the last session.
Compared to the control site, a significant improvement was seen with both 755-nm and 1,064-nm picosecond lasers. Improvement with the 755-nm laser began at day 49, and at day 77 with the 1,064-nm laser. At day 105, the average lightness of spots treated with the 755-nm laser was higher than with the 1,064-nm laser. Spots treated with the 1,064-nm laser initially had higher lightness and patient satisfaction, though both measurements changed to favour the 755-nm laser over time. Also, the average improvement in lightness in skin type IV was not significantly different between the 1,064-nm laser and the control.
Melasma: The need for tailored photoprotection to improve clinical outcomes
The authors of this paper write that the literature shows that melasma arises from a complex interaction between genetics, sex hormones, and sun exposure. They note that melasma disproportionally impacts dark-skinned individuals. These populations take fewer steps to protect themselves from the sun, even though both visible light and long-wave ultraviolet-A (UVA) light play a key role in melasma development. Intensive use of a broad-spectrum sunscreen can prevent melasma in high-risk individuals, lessen melasma severity, and reduce relapses.
They conclude that because of how light drives melasma, sunscreens should be broad-spectrum with a high sun protection factor and provide high protection against both high-energy UVA and visible light. Tinted sunscreens are an excellent choice for this kind of sun protection, as pigments can protect from both visible and UVA light, but they should be available in colours that match each patient's skin tone to increase compliance.
Adverse events of nonablative lasers and energy-based therapies in subjects with Fitzpatrick skin phototypes IV to VI: A systematic review and meta-analysis
This review article looked at papers that evaluated the adverse events of nonablative laser and energy-based therapies for skin rejuvenation and acne scarring in patients with skin types IV to VI.
They found that postinflammatory hyperpigmentation (PIH) and prolonged reddening were the most common adverse events. PIH rate was significantly higher for diode and erbium-doped lasers than with intense pulsed light and radiofrequency. Darker skin types, higher laser density, and more total energy delivered were all associated with a higher risk of PIH.
VIDEO: Doctor V - Is tranexamic acid suitable for skin of colour
At the intersection of skin and society
Indigenous delegates are to meet with Pope Francis at the Vatican at the end of March, a meeting the Catholic Church has said is to discuss reconciliation and healing. However, Indigenous artists and curators say that healing cannot be achieved if important Indigenous objects remain unseen, reports CTV News.
The article quotes First Nations artist and curator Gerald McMaster questioning what mysteries and cultural objects are kept within the Vatican’s collection of Indigenous artifacts.
McMaster said the artifacts are important to Indigenous identity, but access to the vaults has been limited.
“What is being hidden? Why is it being hidden?” McMaster asked in an interview with The Canadian Press.
“Why [do] Indigenous people remain shut out whereas the vault will be open to other curators that are non-Indigenous, other European curators?”
McMaster, who is from the Siksika Nation in Alberta, is a 2022 winner of the Governor General’s Awards in visual and media arts, a research chair in Indigenous curatorial practice and director of the Centre for Indigenous Visual Knowledge at the Ontario College of Art and Design in Toronto. He also has more than 40 years of experience in art, museology and Indigenous esthetics.
Many objects were taken after the Canadian government, through the Indian Act in 1876, outlawed cultural practices, including wearing traditional clothing, McMaster said in the interview. Ceremonial items and other important objects were seized, then sold, given to museums or destroyed.
Many other items were gifts to popes and the Catholic Church, according to the Vatican.
Even if items were given willingly, how they are treated and displayed must be done in consultation with Indigenous people, McMaster said.
CTV News notes the collection is known to contain masks, wampum belts, pipes and rugs, and other items from Indigenous communities in North America.
This week
March 30 is National Doctors’ Day in the U.S.
April is National Donate Life Month in the U.S.
April is Stress Awareness Month in the U.S.
Something to think about in the week ahead…
Next week
Many Indigenous Canadians live in communities far from major medical centres. At the 7th annual Skin Spectrum Summit on November 6, Dr. Rachel Netahe Asiniwasis discussed skincare in remote communities, including the value and application of virtual care.
Coming soon
Registration is still open for the 2022 Summit on Atopic Dermatitis. This one-day virtual medical educational event will be held on April 23, 2022.
The Summit was developed to address an unmet need for education on the incidence of and latest therapies for atopic dermatitis (AD) among dermatologists and general practitioners.
Co-chairs Drs. Neil Shear and Marissa Joseph will lead a discussion of the most current treatments for all disease severities. The conference will also emphasize AD diagnosis in skin of colour and will provide resources for patient and caregiver support.
Registration for the Summit on Atopic Dermatitis is open and available. As a Skin Spectrum Weekly subscriber, you will not be charged for registration, if you use this link.