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Update on Challenging Disorders of Pigmentation in Skin of Color Heather Woolery-Lloyd, M.D

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Update on Challenging Disorders of Pigmentation in Skin of Color Heather Woolery-Lloyd, M.D Update on Challenging Disorders of Pigmentation in Skin of Color Heather Woolery-Lloyd, M.D. Director of Ethnic Skin Care Voluntary Assistant Professor Miller/University of Miami School of Medicine Department of Dermatology and Cutaneous Surgery What Determines Skin Color? What Determines Skin Color? No significant difference in the number of melanocytes between the races 2000 epidermal melanocytes/mm2 on head and forearm 1000 epidermal melanocytes/mm2 on the rest of the body differences present at birth Jimbow K, Quevedo WC, Prota G, Fitzpatrick TB (1999) Biology of melanocytes. In I. M. Freedberg, A.Z. Eisen, K. Wolff,K.F. Austen, L.A. Goldsmith, S. I. Katz, T. B. Fitzpatrick (Eds.), Dermatology in General Medicine 5th ed., pp192-220, New York, NY: McGraw Hill Melanosomes in Black and White Skin Black White Szabo G, Gerald AB, Pathak MA, Fitzpatrick TB. Nature1969;222:1081-1082 Jimbow K, Quevedo WC, Prota G, Fitzpatrick TB (1999) Biology of melanocytes. In I. M. Freedberg, A.Z. Eisen, K. Wolff, K.F. Austen, L.A. Goldsmith, S. I. Katz, T. B. Fitzpatrick (Eds.), Dermatology in General Medicine 5th ed., pp192- 220, New York, NY: McGraw Hill Role of Melanin-Advantages Melanin absorbs and scatters energy from UV and visible light to protect epidermal cells from UV damage Disadvantages Inflammation or injury to the skin is almost immediately accompanied by alteration in pigmentation Hyperpigmentation Hypopigmentation Dyschromias Post-Inflammatory hyperpigmentation Acne Melasma Lichen Planus Pigmentosus Progressive Macular Hypomelanosis Vitiligo Post Inflammatory Hyperpigmentation: Acne PIH from Acne Acne hyperpigmented macule Patients are most concerned with pigmentation Not the acne!!! Pigment and Acne in Skin of Color Common Questions Does benzoyl peroxide bleach the skin? No Rarely can cause post-inflammatory hypopigmentation Post inflammatory hyperpigmentation more common Pigment and Acne in Skin of Color Common Questions Does benzoyl peroxide cause hyperpigmentation in SOC? Yes if patient develops irritation Approximately 5% of the population is sensitive to BP Many can tolerate lower concentrations (less than 5%) Pigment and Acne in Skin of Color Common Questions Does minocycline cause hyperpigmentaion in SOC? Yes Clinically can see overall darkening of face Also reported darkening of lips, scars, legs Use other antibiotics as first line therapy in SOC Pigment and Acne in Skin of Color Common Questions Do retinoids cause hyperpigmentation in SOC? Yes if patient develops irritation More common with tretinoin and tazarotene Less common with adapalene but still possible Usually occurs within a month of use Resolves once agent is discontinued Pigment and Acne in Skin of Color Common Questions Do retinoids also treat hyperpigmentation? Yes Tretinoin Tazarotene Adapalene Tretinoin Influences melanosome transfer Tretinoin 0.1% has been demonstrated to be effective for melasma in a vehicle- controlled trial Slow results Griffiths CE. Finkel LJ. Ditre et al.British Journal of Dermatology 1993; 129(4):415-21 Tretinoin for dyschromia Blinded vehicle controlled trial 68 AA subjects with hyperpigmentation due to acne, folliculitis, eczema, shaving irritation 40 weeks Topical tretinoin 0.1% cream or vehicle applied to face and arms Investigator assessments and colorimetry La Voo EJ. New Eng J Med Nov 1993 Tretinoin for dyschromia Evaluated hyperpigmented and normal skin Hyperpigmented skin Improvement in affected skin seen clinically at 4 weeks with tretinoin vs 24 weeks with vehicle Normal skin No significant lightening observed clinically but mild skin lightening was observed via colorimetry in the tretinoin group La Voo EJ. New Eng J Med Nov 1993 Tretinoin for dyschromia Tretinoin 0.1% cream achieved more rapid clearance of hyperpigmented lesions compared to vehicle 4 weeks vs 24 weeks La Voo EJ. New Eng J Med Nov 1993 Patient with acne and hyperpigmentation treated with Tretinoin 0.1% cream La Voo EJ. New Eng J Med Nov 1993 Tazarotene for PIH Blinded vehicle controlled trial 74 patients from darker racial ethnic groups who had acne Once-daily application of tazarotene cream was shown to be effective against PIH Reductions in overall PIH severity and in the intensity and area of hyperpigmentation was observed when compared to vehicle within 18 weeks (P< or =.05). Grimes P. Callender V. Cutis. 77(1):45-50, 2006 Jan. Adapalene in Black Africans for PIH Open label trial of patents with acne N=44 Identified 5 lesions on each patient and observed color change over 4 weeks 66% of patients experienced reductions in both number of hyperpigmented macules and density of the hyperpigmentation Jacyk WK J Eur Acad Vener Dermatol Vol15 Suppl3 2001 Tazarotene vs Adapalene for PIH Blinded controlled trial n=180 Evaluated in improvement in acne and PIH Demographics (Total “nonwhite” subjects=62%) Black 29% Asian 12% Hispanic 15% Other 6% Tanghetti E et al J Drugs Dermatol. 2010 May;9(5):549-58 Tazarotene vs Adapalene Both tazarotene 0.1% cream and adapalene 0.3% gel were effective for acne The percentage of non-white patients with compete resolution of their PIH at week 16 20 % (5/25) in the tazarotene 0.1% cream group 7% (2/29) in the adapalene 0.3% gel group Tazarotene 0.1% cream was more effective than adapalene 0.3% gel in reducing PIH Subjects experienced more erythema, peeling, dryness and burning with tazarotene compared to adapalene Tanghetti E et al J Drugs Dermatol. 2010 May;9(5):549-58 Isotretinoin reduces hyperpigmentation in acne Ten black patients, ranging in age from 17 to 34 years, were treated for nodulocystic acne with 1 mg/kg/d of isotretinoin for 20 weeks The authors concluded “isotretinoin is as safe and effective in the black patient with acne as it is in the white patient with acne” An additional benefit in black patients was the prevention of new, and repression of old, post- inflammatory hyperpigmentation. Kelly, A. Paul, and Darlene D. Sampson. "Recalcitrant nodulocystic acne in black Americans: treatment with isotretinoin." Journal of the National Medical Association 79.12 (1987): 1266. Before and after 20 weeks Isotretinoin 1mg/kg Kelly, A. Paul, and Darlene D. Sampson. "Recalcitrant nodulocystic acne in black Americans: treatment with isotretinoin." Journal of the National Medical Association 79.12 (1987): 1266. Retinoids work for PIH in acne Don’t hesitate to use them in skin of color Choose the one that best suits your patients needs! Acne and Post-Inflammatory Hyperpigmentation - Treatment Acne and dyschromia (<16yo) Retinoids not only improve acne but also pigmentation Azelaic acid 20% cream or 15% gel Works on hyperpigmentation and acne Moisturizer with sunscreen Consider natural therapies (soy, licorice or emblica) Acne and Post-Inflammatory Hyperpigmentation Acne and dyschromia (>16yo) Add hydroquinone 2% available OTC 4% available with a prescription 6-8% can be compounded Apply only to the affected area as needed Avoid continued long term use Less than 2 months Maintain with alternate therapies Hydroquinone Sensitivity A subset of patients are sensitive to and irritated by HQ Irritation from HQ is frequently due to HQ sodium metabisulfite (a common preservative in HQ preparations) Continuing HQ despite irritation can lead to post- inflammatory hyperpigmentation Pei-Ying Huang, Chia-Yu Chu (2007) Allergic contact dermatitis due to sodium metabisulfite in a bleaching cream Contact Dermatitis 56 (2) , 123–124 Before treatment After 8 weeks of HQ8%/Tret0.025%/Dex0.1% Hydroquinone Halo Occurs when hydroquinone is applied with the fingertips To avoid the hydroquinone halo Advise patient not to rub HQ in with fingertips Utilize cotton tipped applicator to spot treat Apply HQ to dark spots first and then apply retinoid to full face Post-Inflammatory Hyperpigmentation- Summary Prevention is the best therapy Remember post inflammatory hyperpigmentation can take an average of 4 months to clear Melasma Clinical Pearls in Hyperpigmentation -Focus on Melasma Melasma Dialogue Treatment Plan Maintenance Plan Melasma Dialogue • Just as important as the treatment plan • Patient must understand the natural course of melasma • Take time with new patients • Ask about meds (specifically- hormones) Melasma- Manage Expectations *What I tell every patient* “Melasma is a chronic condition” “Disease of women in their 30’s, 40’s, and 50’s” “Tends to resolve in later decades. You won’t have this forever” “There is no one simple “cream or peel” that you use once to make it go away” BUT “There are many great treatments to keep your melasma under control” *Our Goal* Decrease Pigment Size and Intensity and Prevent Flares NO TREATMENT WITH TREATMENT/MANAGEMENT Treatment Plan Sun avoidance and sun protection Treatment Phase Maintenance Phase Sun Avoidance and Sun Protection Sun Avoidance and Sun Protection Spend time to emphasize the importance of sun block and sun avoidance In some ways this is more important than the treatment itself “10 minutes of unprotected sun exposure and the melasma will come right back” Sun Avoidance and Sun Protection Broad Spectrum UVA/UVB Blocker Add Visible light coverage if possible Look for sunscreens that contain Iron Oxide Iron oxide is a pigment so color matching different skin types can be challenging Add an oral agent UV-Visible Light Sunscreen vs UV only Sunscreen in Melasma 68 patients with melasma were randomized in two groups to receive HQ 4 % plus either UV-VL sunscreen SPF ≥ 50 UV-only sunscreen SPF ≥ 50 8 weeks Assessed by Melasma Activity and Severity Index Colorimetry (L*) Histological analysis of melanin Castanedo‐Cazares, Juan Pablo, et al. "Near‐visible light and UV photoprotection in the treatment of melasma: a double‐blind randomized trial." Photodermatology, photoimmunology & photomedicine 30.1 (2014): 35-42. UV-Visible Light Sunscreen vs UV only Sunscreen in Melasma Improvement in UV-Visible light group showed 15% greater improvement over UV only sunscreen for MASI 28% greater improvement over UV only sunscreen for colorimetry (L*) 4% greater improvement over UV only sunscreen for melanin Castanedo‐Cazares, Juan Pablo, et al.
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