HYPER & HYPO- PIGMENTATION DISORDERS

KENNETH M. CARANGUIAN MD

SUBTOPICS

•Melasma • Lentigo • Freckles • Juvenile lentigens • Solar lentigens• PIH

•Nevus of ota • Idiopatic gutate

hypomelanosis• pytiriasis alba• vitiligo

MELASMA• Acquired in genetically predisposed women.• light-brown to gray-brown macules and

patches on sun-exposed areas.•Chloasma- synonymous term, aka “mask of

pregnancy”• 2nd or 3rd trimester, OCP or exogenous

estrogens• Fades slowly after pregnancy or

discontinuation of OCP

DISTRIBUTION:• sides of the face, forehead, upper lip, chin, malar

eminences and sides of the neck.PATHOPHYSIOLOGY:• Unknown or uncertain• Study - high expression of MSH in keratinocytes

that plays a key role in hyperpigmentation • Most common in women during reproductive

years, 90%• Family history of >30%

PHYSICAL FINDINGS:symmetric, intensity of pigmentation variescolor- uniform but may be blotchy,edges- irregular, well defined,(-) inflammation

DIFFERENTIAL DIAGNOSIS:1. Exogenous ochronosis• associated with bleaching agent hydroquinone. It is caused by

the deposition of polymerised homogentisic acid in the skin.2. PIH• dx is clinical• Skin that was previously inflamed due to dermatitis.• Hx: erythema, pruritus, and dermatitis 3. Phototoxic reaction• Dx is clinical• exposed to systemic or topical medicines or cosmetics, and

UV radiation.• Begins abruptly, in contrast to melasma, which develops

gradually.

TREATMENTNOTE:• The patient should not be promised great

therapeutic results.

1. Topical Bleaching AgentsA. HYDROQUINONE

• 2%- 5% cream or lotion b.i.d. for 2 months.• Compete with tyrosine oxidation by acting as an

alternate substrate for tyrosinase, the enzyme that converts tyrosine to melanin and selective damage to melanosomes and melanocytes

• m/c side effects: irritation and contact dermatitis - treated with topical steroids

• Common side effect among abusers is exogenous ochronosis- extended use of HQ

• Alternating HQ in 4-month cycles with other depigmenting agents can prevent or reduce side effects.

B.MONOBENZYL ETHER OF HYDROQUINONE (MBEH/Benoquin)

melanocidalSelectively taken up by melanocytes and

metabolized into free radicals that can destroy melanocytes permanently, leading to irreversible depigmentation

Reserved for generalized depigmentation with extensive vitiligo

Requires 9-12 months of continuous daily application to achieve complete depigmentation effect

C. KLIGMAN’S formula 5% HQ , 0.1% TRETINOIN, and 0.1% DEXAMETHASONE - in hydrophilic ointment

D. AZELAIC ACID• a naturally occurring dicarboxylic acid

derived from Pityrosporum ovale• 15- 20%• Applied BID x 3-12 months, well

tolerated• tx of acne- decreases comedo formation•Unlike HQ, it targets only hyperactive

melanocytes and thus will not lighten skin with normally functioning melanocytes

F. OTHER TREATMENTS – kojic acid glycolic acid (topical or peels 30-70%) Jessner's solution microdermabrasion•Alternative agents with potential therapeutic effects include aloesin (aloe vera), arbutin (bearberry fruits), licorice extract (Glabridin), soy, and vitamin C.

2. SUNSCREENS/ SUNBLOCKS• Because the ability of the sun to darken

lesions is much greater than HQ to bleach the pigment, strict avoidance of sunlight is imperative.

• Broad-spectrum with SPF 30 or > • Preferably containing, mexoryl,

avobenzone or physical blockers- titanium dioxide or zinc oxide that blocks both UVA and UVB

• IPL and Fractional CO2 laser may have additional benefits but results are variable

LENTIGO• Common, benign, circumscribed, 1-3 cm light yellow

or light brown macules from a localized proliferation of melanocytes due to acute or chronic sun exposure• Histologically - increased number of melanocytes in

the basal layer of the epidermis• affects 30 yrs old and above• May arise after sunburn or after PUVA overdosage• It is a localized hyperpigmentation in 3 patterns :

1. Freckles (Ephelides)2. Juvenile Lentigo3. Solar lentigo

1. FRECKLES HISTORY:• childhood, 5-7 yrs old• AD• M/c in redheads, blondes and fair skinned • Paradoxically, there are fewer melanocytes in a

freckle than in normal surrounding skin, but those that are present are large and able to form more melanin than usual

• Darkens during summertime and fade almost completely during winter

• Usually confined to face, arms, upper trunk

PHYSICAL FINDINGS:Appears as 1-2 cm, sharply defined, red or tan to light brown macules with uniform color

2. JUVENILE LENTIGENSHISTORY:• childhood• Lesions do not increase in number or size,

or darken in response to sunlight• characteristic feature of certain hereditary

conditions•May persist year round or may

spontaneously resolve

PHYSICAL FINDINGS:• appears as round to oval macules, 2 to 10 mm in diameter• Darker than freckles• Uniformly tan, or brown or black

3. SOLAR LENTIGENSHISTORY:

•Common in sun exposed skin• Increased in number and size in advancing

years• 75% of white people over 60 yrs have one or

more lesions• Aka- liver age spots •Usually in association with other changes

from sun damage, including wrinkling, dryness, and actinic keratoses

PHYSICAL FINDINGS:TEND TO BE LARGER (2- 20MM)OVAL TO GEOMETRIC MACULESUNIFORM IN COLOR, APPEAR AS FINE GRAINS, BLOTCHY, WITH BORDERS THAT ARE SHARPLY DEFINED

TREATMENT• Monitor existing lesions for interval change• Stable lesions do not require tx • HQ solutions, tretinoin, azelaic acid cream, glycolic

acid peels and creams are all valuable in reducing hyperpigmenation over weeks to months

POST INFAMMATORY HYPERPIGMENTATION (PIH)• Results from any skin injury• excessive irritation from cosmetic products

and procedures, pimples, scratching or any kind of trauma•Gradual darkening several weeks after the

original injury•More common in darker skin and sun exposed• Some are more prone to PIH than others• resolve after several months or years

NEVUS OF OTA• bluish gray spots (forehead, temples, upper cheeks,

around the eye, and eyebrow and nose, mucosa, conjunctivae, and tympanic membranes)• With shades of blue, black, purple or brown• More common in Asians in 1- 2 % of the population• can cause facial disfigurement - emotional and psychologic

distress• Females > males (4x)• Both dermal and epidermal components may co exist• Creams- ineffective• Can be effectively lightened with pigment lasers (ND-YAG,

Q switched) but multiple treatment sessions (about 7 to 10) are required

IDIOPATHIC GUTATE HYPOMELANOSISDESCRIPTION:• Common assymptomatic dermatosis of unknown etiology• Consists of white small macules in sun exposed upper and

lower extremitiesHISTORY:•middle aged and older people• 50- 70 % over the age of 50• F>M• Genetic predisposition • Although asymptomatic, it is cosmetically distressing• Lesions are stable in size but the number increases with

age

PHYSNICAL FINDINGS:

• Macules are white and hypopigmented, 2 to 5 mm, Borders regular and smooth to slight xerotic scaling

TREATMENT:

• Encourage sun protection with clothing• Sunscreens are less effective •Can be camouflaged with tinted make up• Self tanning creams that contains

dihydroacetone darkens the lesions, but the appearance is not pleasing• A light spray with liquid nitrogen may partially

fade the lesions although there is a potential to worsen the dyspigmentation•Reassurance is all that is required

PITYRIASIS ALBA• hypopigmented, slightly elevated, fine scaling patches

with indistinct borders typically on the lateral cheeks, lateral upper arms and thighs• young children, resolves in early adulthood• Asymptomatic• No history of prior rash, trauma or inflammation• Loss of pigment is often more noticeable and

distressing in darkly pigmented people

• Specific cause is unknown• Hypopigmentation due to both reduced activity of

melanocytes with fewer and smaller melanosomes• Often seen in children between the ages 3 and 16

years• males > females• Occurs more frequently in those of light skinned,

but is more apparent in those with darker complexion

• White macules are round to oval, varies in size, usually 2-4 cm in diameter• A fine surface scale often seen on close inspection• Lesions more common in lateral cheeks, lateral upper arms and thighs• Condition more obvious in summer and in darker skin types

DIFFERENTIAL DIAGNOSIS:• PIH history of another inflammatory skin disorder;• Atopic dermatitis, very itchy symmetrical plaques

that respond to topical steroids;• Psoriasis- symmetrical scaly plaques in typical sites

including scalp;• Pityriasis versicolor- affects upper trunk of

adolescents and adults and has positive microscopy;• Tinea corporis - has positive mycology• Nummular dermatitis - dry or crusted itchy round

patches;• Vitiligo - progressive macules with complete pigment

loss and no scale

TREATMENT:• Treatment is not necessary since it will resolve on

its own. • Reassurance- loss of pigment is not permanent

and fades with time• If the patches are red or itchy, mild topical steroid

can be applied. Sometimes these will help make the skin disorder disappear faster, but other times it may have absolutely no effect at all.

PROGNOSIS:• very good. • no scaring• However if forcefully remove with constant

washing with skin products it could remain longer than usual. But if the correct treatment is applied it can disappear more quickly

VITILIGOSex – equally affected but has a predominance to female- reflects

greater concern about cosmetic appearanceAge – begin at any age

50% (10-35y/o) old age – unusual

Incidence – common worldwideRace - all racesInheritance - >30%, family history, thyroid disease and DM

THREE SUBTYPES OF VITILIGO:• Localized or focal-• <20% body surface area• One or more macules in two single area. • limited to one or may only a few body areas.

• Generalized, aka vitiligo vulgaris; and universalis • -complete or near complete depigmentation.• most common pattern

• Segmental vitiligo- • much more common in children than adults • tends to spread rapidly within the segment of skin.

One or more macules in dermatomal or quasidermatomal pattern.• It corresponds to one or more dermatomes unilaterally

and may meet or slightly pass the midline.

•Common sites includes dorsal hands and fingers, face, body folds, axillae, genitalia•There is also predilection for orifices including eyes, nostrils, mouth, nipples, umbilicus, anus

PHYSICAL FINDINGS:• Consists of white depigmented 0.5 to 5 cm macules and

patches with well defined borders

DIFFERENTIAL DIAGNOSIS:1. Idiopathic guttate hypomelanosis• Small, circular macules, slowly

progressive accumulation of isolated lesions.

2. Pityriasis alba• Asymptomatic, ill-defined small patches

with fine scaling in children and adolescents

3. Discoid Lupus Erythematuses

4. Pityriasis versicolor• Polycyclic, well-demarcated, typical upper trunk

and shoulder distribution. 5. Seborrheic Dermatitis• Distribution pattern- (e.g., scalp, forehead,

eyebrow, nasolabial fold, periauricular, central chest, and back), greasy scales, dandruff.

TREATMENT:1.Psoralen plus ultraviolet A (PUVA) a combination treatment using Psoralen (P) and

exposing the skin to Ultraviolet A (UVA)= PUVAGeneral guide:

• if vitiliginous skin is <6 cm2 (the size of a quarter or half-dollar)- topical psoralens • large portion - systemic psoralens and

sunlight • extremely widespread (>50%),-

depigmentation with MBEH may be considered

• They radically increase the erythema response of skin to long-wave ultraviolet light (UVA) after either topical application or systemic administration.• 75% will have partial repigmentation

when treated twice a week for > 1 year.• Thus therapy be initiated gradually and

monitored carefully.

Successful therapy requires 9-18 months. 2. Narrowband UVB (NB-UVB)- also use as

monotherapy 3. Depigmenting the surrounding skin to blur

the margins or removing all remaining pigmentation in extensive cases may lead to cosmetic improvement.

Blurring of the margins may be attempted with HQ compounds.

4. Oil of Bergamot- contains psoralen as photosensitizer making skin sensitive to the tanning effect of sunlight

5. Broad spectrum sunscreens - at least spf 30

6. Concealing and Camouflaging agents 7. Topical immunomodulators- induce

repigmentation up to 90%. 0.1% tacrolimus ointment BIDx2

months, nearly as effective as superpotent topical corticosteroids and does not carry risk of adverse effects.

8. Surgical techniques- transplant of autologous melanocytes or cultured epidermal autografts to nonpigmenting areas

has promising effect with stable vitiligo that fails to respond to topical or phototherapies

The surgical technique include tissue and cellular grafting

Thank you!