Pigmentary Disorders

WEDNESDAY, July 19, 2023 (HealthDay News) -- Among skin of color (SOC) individuals, use of skin lightening (SL), involving the use of chemicals to lighten the skin, is prevalent, and those using SL agents rarely consult a medical provider before using the products, according to a study published in the October issue of the International Journal of Women's Dermatology.Karishma Daftary, M.D., from the Northwestern University Feinberg School of Medicine in Chicago, and colleagues examined SL habits among SOC individuals in the United States. A cross-sectional survey was administered to SOC individuals and data were collected on demographics, rates of SL, SL habits, and perceived colorism among SL users and nonusers.Four hundred fifty-five participants completed the survey. The researchers found that 21.3 percent of participants reported using SL agents: 73.2 and 26.8 percent for treatment of a skin condition and for general SL. Before using the products, only 22.6 percent of SL users consulted a medical provider. Overall, 45.4 percent were unaware of their SL product ingredients and 35.1 percent reported use of hydroquinone-based products. Compared with nonusers, SL users had significantly higher composite colorism scores (20.03 versus 18.20 percent)."These findings underscore the important role of dermatologists in addressing skin tone and pigmentary concerns with their SOC patients, as patients may be using SL agents for a variety of reasons: most commonly for self-treatment of a skin condition but also for general SL," the authors write.

Skin lightening agent users have significantly higher composite colorism scores than nonusers

Skin Lightening Prevalent Among 'Skin of Color' Individuals

For patients with melasma, tranexamic acid (TXA) and platelet-rich plasma (PRP) are an effective and safe treatment, according to a study published online April 22 in
 
 Dermatologic Therapy
 
 .




 Nitin Krishna Patil, M.D., and Aditya Kumar Bubna, M.B.B.S., from Katihar Medical College in India, compared the therapeutic efficacy and safety of TXA and PRP microinjections for patients with melasma. Forty patients were enrolled and randomly assigned to one of two groups who received either intradermal microinjections of TXA (4 mg/mL) or intradermal microinjections of PRP, once every four weeks for a total of five sessions (Groups A and B, respectively). Improvement in melasma was evaluated using the melasma area severity index (MASI) and modified MASI (mMASI) scoring systems at each visit.




 Eighteen patients in group A and 15 in Group B completed the study. The researchers found that both MASI and mMASI scores were significantly reduced from baseline to end point in Group A (16.6 ± 9.227 to 10.028 ± 8.07 and 8.885 ± 5.418 to 4.639 ± 3.863, respectively). In Group B, similar significant reductions were seen in both scores at the end of treatment (20.42 ± 7.979 to 12.253 ± 7.37 for MASI and 10.673 ± 4.642 to 5.613 ± 3.98 for mMASI). During the entire duration of the study, there were no significant adverse effects reported in either treatment arm.




 "Although the improvement witnessed was slightly higher in the PRP group, based on our findings we cannot vehemently state that it is a far more superior form of treatment when compared to intralesional TXA," the authors write.




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Both melasma area severity index, modified MASI significantly reduced with TXA, PRP treatment

Is Tranexamic Acid, Platelet Rich Plasma Effective for Melasma?

Seminar-in-Depth: Save the Mushrooms for the Pizza: Clinical Superiority of Human Tyrosinase Inhibition For Hyperpigmentation

In this highly engaging seminar-in-depth, Cheri Frey, MD, reviewed the pathogenesis of hyperpigmentation and discussed a novel ingredient for the treatment of hyperpigmentation. Disorders of hyperpigmentation are common and can negatively affect patients’ quality of life. For clinicians, it is often difficult to determine the etiology of the hyperpigmentation and determine whether that pigment exists in the epidermis, dermis, or both. Dr Frey discussed two of the most common types of hyperpigmentation, postinflammatory hyperpigmentation (PIH) and melasma. Current treatment options include photoprotection, chemical peels, lasers, and topical bleaching or lightening agents such as hydroquinone, tretinoin, kojic acid, azelaic acid, and arbutin, among others. Dr Frey reviewed the process of melanogenesis and how this contributes to pigmentary disorders. Tyrosine is converted into levodopa (L-DOPA) and then either pheomelanin or eumelanin by tyrosinase inside of melanosomes. The conversion of tyrosine to L-DOPA is a key rate-limiting step in the melanogenesis pathway and is the most targeted mechanism of action to reduce hyperpigmentation. Dr Frey introduced a novel ingredient, thiamidol, currently being developed as a topical tyrosinase inhibitor. During a screening of 50,000 compounds, thiamidol was found to be the strongest inhibitor of human tyrosinase, stronger than hydroquinone, arbutin, and kojic acid. Topical thiamidol led to significantly higher melasma severity score reduction compared to hydroquinone 2% in a 12-week split-face, double-blind clinical study. Longer-term studies out to 24 weeks demonstrated continued improvements in melasma with once daily thiamidol use. Dr Frey discussed that thiamidol has also shown efficacy for treating postinflammatory hyperpigmentation in small clinical studies. Importantly, melanin-index scores were not shown to be reduced in perilesional skin, only in lesional skin. Thiamidol also shows promise for the prevention of laser-induced postinflammatory hyperpigmentation. &nbsp;

Managing Facial Hyperpigmentation in All Skin Types and Colors 

Andrew Alexis, MD, MPH, provides an overview of hyperpigmentation and available treatments for patients. Melasma is subcategorized into centrofacial, malar, and mandibular based on primary facial location as well as into dermal, epidermal, or mixed presentations based on depth of hyperpigmentation. Other types of hyperpigmentation are frequently mistaken for melasma, particularly in individuals with skin of color, as it may also be indicative of conditions such as lichen planus pigmentosus or drug-associated photodistributed hyperpigmentation.&nbsp;The presentation emphasized prevention of hyperpigmentation through reducing visible light exposure and early treatment of acne in skin of color. A study presented showed that darker skin exposed to visible light was more hyperpigemented compared to UVA exposure. Therefore, prevention of visible light penetration using iron oxide rather than titanium or zinc oxide becomes increasingly important with increasing darkness of skin.&nbsp;There are several treatments that affect various steps in the pigment production pathway, including retinoids, glucosamine, azelaic acid, ellagic acid, and nicotinamide. Despite the numerous available treatments, there are several challenges to treating hyperpigmentation, including limitations and side effects from known treatments. Hydroquinone, often a first-line treatment for hyperpigmentation, can have adverse effects such as halo hypopigmentation and ochronosis. There are several treatments that are currently being explored as alternatives to hydroquinone, which include topical cysteamine, 2-mercaptonicotinoyl, oral tranexamic acid, chemical peels, lasers, and microneedling.&nbsp;Dr Alexis concludes by recommending a treatment progression that begins with hydroquinone 4% triple combination therapy, followed by the addition of procedural treatments and oral agents with a transition to or incorporation of nonhydroquinone therapies. Visible light photoprotection should be incorporated into all regimens as preventive protection.

What You Need To Know NOW About Hyperpigmentation

So my talk at fault clinical was what you need to know now about hyperpigmentation. I covered the differential diagnosis of hyperpigmentation, really pointing out that not everything is post inflammatory hyperpigmentation. I then went on to discuss prevention of hyperpigmentation, primarily sunscreens, and then finally treatment of hyperpigmentation, all the way from cosmeaceuticals to prescription to procedures. So we covered the whole gamut in what you need to know now about hyperpigmentation.

Hyperpigmentation has many different etiologies and can be a diagnostic and therapeutic challenge for dermatologists. In this session, Susan C. Taylor, MD, discussed tips for differentiating between the different types of hyperpigmentation and best strategies for treatment. Melasma and postinflammatory hyperpigmentation (PIH) are 2 common causes of facial hyperpigmentation. Melasma is usually found in sun-exposed areas on women of reproductive age, while patients with PIH should have a history of acne or another inflammatory facial dermatosis. Dr Taylor reviewed mimickers of melasma and PIH on the face, including exogenous ochronosis, lichen planus pigmentosus, maturational hyperpigmentation, drug-induced hyperpigmentation, and adrenal insufficiency. Nasal hyperpigmentation can be seen in a postviral state and has been reported following Chikungunya infection and COVID-19 infection.&nbsp;Moving on, Dr Taylor discussed strategies for preventing hyperpigmentation, which starts with sun protection. Multiple studies have shown improved resolution of both PIH and melasma with the use of sunscreen. Visible light is now understood to contribute to the pathogenesis of hyperpigmentation and is not blocked by traditional UV filters. Tinted sunscreens containing iron oxides as well as a new formulation of sunscreen containing 5 antioxidants have all been shown to reduce hyperpigmentation from visible light.&nbsp;Wrapping up with a review of treatment, Dr Taylor reviewed efficacy data for tretinoin for acne and acne-induced PIH as well as topical cysteamine 5% for PIH. Traditional triple therapy with combination tretinoin, fluocinolone, and hydroquinone has well-known efficacy for the treatment of melasma, although long-term use is limited by the risk of exogenous ochronosis. Dr Taylor introduced a novel triple-combination therapy for melasma containing isobutylamido thiazolyl resorcinol, tretinoin, and a corticosteroid. A 24-week randomized, double-blind, prospective clinical trial comparing the novel triple therapy with traditional triple therapy found a 63% reduction in melasma severity score for the novel combination versus 39% reduction with the traditional combination. Both oral and topical tranexamic acid as well as use of polypodium leucotomos extract has also shown benefit in the treatment of melasma.

Are stronger retinoids more effective for Post-Inflammatory Hyperpigmentation compared to weaker retinoids?

You retinoids in PIH is a story than a plot that continues to thicken. In my opinion. There have been some studies that have shown, for example, that tazaratine zero one cream was more effective than adaptoline .3 gel in treating PIH. So the question is, are all retinoids created equal for post inflammatory hyperpigmentation? And in my opinion they're not. And I think you have to use the strongest retinoid vehicle you can with minimizing irritation because you don't want to get a retinoid dermatitis, especially in a skin of color patient, and then subsequently get PIH from the retinoid dermatitis. So make sure you're selecting based on vehicle and skin type and having that discussion with your patient.

Is there any evidence for the use of oral or systemic glutathione?

So glutathione skin pigmentation? Is there any evidence the answer is intravenous and oral? Glutathione has never been studied in randomized, double blinded, placebo controlled trials for lightning the skin. It has been thought to be an antioxidant due to its effect on pheo and umelanin low oral bioavailability, which is why in some countries, even parts of the US, you can get it. Iv in my opinion, we should not be advocating for this until we have better studies and better safety outcomes.

How long do you allow patients to use hydroquinone 4% since melasma is a chronic disease that can last for years? Do you use "drug holidays"?

You. Hydroquinone and hydroquinone holidays, as I like to call them, are important. Hydroquinone is not something you should ever tell your patient. Hey, go use it for six months to a year and come see me in a year. No, doesn't work like that. You need to use the hydroquinone in a systematic fashion with an on off regimen when needed. Twelve to 16 weeks initially. I'll have a new patient come in. They get no refills. They get pictures at baseline, pictures at follow up. They're counseled on side effects, and then we go into second line topicals after that. So hydroquinone holidays are critical, in my opinion, especially at preventing irritation and okranosis.

How do you have your patients take oral tranexamic acid? Is there any benefit to splitting the 650 mg tablet?

You tranxemic acid orally. We've talked about in length in many of my talks. It's in the US, available as a 650 milligram dose, and I usually have patients split it bi d 325 in the morning or 325 at night. I like to split the dosing. I feel that that can be more compliant. And also I can monitor for those early side effects of headache, nausea and vomiting early on. Based on the dose and the frequency. Some people say you don't really have to split it, but that's what I do. And if you look at the asian studies, the doses were divided by D in most of the large papers, particularly from the Singapore group that published in the Blue Journal.

Do you ever use triple therapy cream for Post-Inflammatory Hyperpigmentation?

You. I do get asked a lot. Do I ever use triple combination therapy for PIH? And the answer is I do. However, it's not something that I use for every patient with post inflammatory hyperpigmentation. You have to be careful because remember, if it's pih from acne, you don't want to just put spots everywhere and then get a halo effect from the hydroquinone. You want to be able to use something that's more uniform on the space. So retin, azalic acid, chemical peels, antioxidants, really like those for ph and yes, hydroquinone based triple combination for the stubborn areas. But I don't use it exclusively all the time as much as I do in melasma, for example. And.

Pigmentary Disorders Condition Center

Featured in Pigmentary Disorders

Seminar-in-Depth: Save the Mushrooms for the Pizza: Clinical Superiority of Human Tyrosinase Inhibition For Hyperpigmentation

Latest Pigmentary Disorders Videos

Managing Facial Hyperpigmentation in All Skin Types and Colors

Are stronger retinoids more effective for Post-Inflammatory Hyperpigmentation compared to weaker retinoids?

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