Am J Clin Dermatol 2000 Sep-Oct; 1 (5): 261-268 DISEASE MANAGEMENT 1175-0561/00/0009-0261/$20.00/0 © Adis International Limited. All rights reserved. Management of Facial Hyperpigmentation Ana Pérez-Bernal, Miguel A. Muñoz-Pérez and Francisco Camacho Department of Dermatology, Faculty of Medicine, Virgen Macarena Hospital, Seville, Spain Contents Abstract . 261 1. Management of Facial Hyperpigmentation . 262 2. Riehl’s Melanosis and Related Conditions . 262 2.1 Poikiloderma of Civatte . 262 2.2 Erythromelanosis Follicularis of the Face and Neck . 262 2.3 Erythrose Peribuccale Pigmentaire of Brocq . 263 2.4 Linea Fusca . 263 3. Facial Hyperpigmentation Associated with Use of Cosmetics and Drugs . 264 4. Melasma (Chloasma) . 264 5. Treatment of Facial Hyperpigmentation . 265 5.1 General Instructions . 265 5.2 Hypopigmentation Agents . 265 5.2.1 Hydroquinone . 265 5.2.2 Hydroquinone and Tretinoin Combinations . 266 5.2.3. Other Phenolic Compounds . 266 5.2.4 Azelaic Acid . 266 5.2.5 Tretinoin . 266 5.2.6 Kojic Acid . 266 5.2.7 Ascorbic Acid (Vitamin C) and Tocopherol (Vitamin E) . 266 5.3 Chemical Peels . 266 5.4 Laser Therapy . 267 6. Conclusion . 268 Abstract Facial and neck pigmentations are the most cosmetically important. They are common in middle-aged women, and are related to endogenous (hormones) and exogenous factors (such as use of cosmetics and per- fumes, and exposure to sun radiation). Melasma (chloasma) is the most common cause of facial pigmentation, but there are many other forms such as Riehl’s melanosis, poikiloderma of Civatte, erythrose peribuccale pigmentaire of Brocq, erythromelanosis follicularis of the face and neck, linea fusca, and cosmetic hyperpigmentations. Treatment of melasma and other facial pigmentations has always been challenging and discouraging. It is important to avoid exposure to the sun or to ultraviolet lamps, and to use broad-spectrum sunscreens. Several hypopigmenting agents have been used with differing results. Topical hydroquinone 2 to 4% alone or in com- bination with tretinoin 0.05 to 0.1% is an established treatment. Topical azelaic acid 15 to 20% can be as efficacious as hydroquinone, but is less of an irritant. Tretinoin is especially useful in treating hyperpigmentation of photoaged skin. Kojic acid, alone or in combination with glycolic acid or hydroquinone, has shown good results, due to its inhibitory action on tyrosinase. Chemical peels are useful to treat melasma: trichloroacetic acid, Jessner’s solution, Unna’s paste, α-hydroxy acid preparations, kojic acid, and salicylic acid, alone or in various combinations have shown good results. In contrast, laser therapies have not produced completely satisfactory results, because they can induce hyperpigmentation and recurrences can occur. New laser ap- proaches could be successful at clearing facial hyperpigmentation in the future. 262 Pérez-Bernal et al. 1. Management of Facial Hyperpigmentation mainly affects perimenopausal women. There is an irregular dark pigmentation with a reticulate distribution over a slight erythem- Normal skin color is dependent on the quantity and type of atous field, located on the lateral and low neck. melanin pigment in the melanocytes and keratinocytes. The thick- Histologically, there is hyperkeratosis and epidermal atro- ness of the stratum corneum, the dermal vasoconstriction or vaso- phy, liquefaction degeneration of the basal layer, numerous der- dilatation and the occasional presence of endogenous or exoge- mal melanophages, and a perivascular or band-like lymphocytic nous pigments, may also modify the skin color. infiltrate. Exposure to light, photodynamic substances in cosmet- Several factors may be responsible for the numerous hyper- ics, and an unknown endocrine factor are important factors. It is chromatic processes affecting the epidermis and/or dermis: he- necessary to use sunscreens and avoid precipitating factors.[5] reditary, endocrine, nutritional, neoplastic, inflammatory, drugs, physical and chemical.[1] Due to their visibility, facial and neck pigmentations (cervico- facial pigmentations) are the most cosmetically important. They 2.2 Erythromelanosis Follicularis of the Face and Neck are more common in middle-aged women and are related to endo- Erythromelanosis follicularis of the face and neck is an ery- genous and exogenous factors, such as use of cosmetics and per- thematous and pigmentation disorder affecting the follicles. His- fumes, and exposure to sun radiation.[2] tologically, there is follicular dilatation with infundibular keratotic Among the most common cervicofacial hyperpigmentations are Riehl’s melanosis, which is difficult to conceptually differen- tiate from other disorders such as poikiloderma of Civatte, ery- throse peribuccale pigmentaire of Brocq, erythromelanosis follicularis of the face and neck, because they share clinical and etiologic factors. Currently, all of them are considered variants of Riehl’s melanosis.[3] In addition to these forms of hyperpigmen- tations, the management of cosmetic hyperpigmentations, linea fusca, and melasma (chloasma) will also be discussed. 2. Riehl’s Melanosis and Related Conditions Riehl’s melanosis occurs in middle-aged women. Brownish gray reticulate pigmentation develops over the face and neck, on the temples, cheeks, chin, supraciliary, dorsum of nose, lateral surfaces of neck, and low neck (fig. 1). It was first described in the First World War, and endogenous factors may be involved, such as digestive disorders, neurovegetative lability, vitamin de- ficiency, and toxic factors. However, in most currently observed cases the condition has been induced by use of cosmetics contain- ing coal tar derivatives, which have a high propensity to cause photosensitivity.[4] Histologically, there is a pigmentary overload in the dermal melanophages, occasional epidermic edema and hyperfunction of melanocytes. Riehl’s melanosis shows a long evolution over time and the recognition and removal of causal agents will lead to a gradual improvement in the condition. The use of sunscreens, and creams containing hydroquinone 2 to 5% plus tretinoin or glycolic acid, also produce a slow improvement. 2.1 Poikiloderma of Civatte Poikiloderma of Civatte is a very common disorder that Fig. 1. Riehl’s melanosis: brownish reticulate pigmentation on neck. © Adis International Limited. All rights reserved. Am J Clin Dermatol 2000 Sep-Oct; 1 (5) Management of Facial Hyperpigmentation 263 Therapy with tretinoin cream, ammonium lactate 12% lotion, metronidazole gel, or hydroquinone cream is ineffective. No effec- tive therapy is currently available. 2.3 Erythrose Peribuccale Pigmentaire of Brocq Erythrose peribuccale pigmentaire of Brocq typically appears as a reddish brown pigmentation around the mouth as far as the nasolabialis sulcus, and sometimes presents as a narrow perioral ring. It may be the result from the use of topical corticosteroids of the treatment of rosacea,[7] and from photodynamic substances present in cosmetics. The pigmentation persists for a long time, even after the cause is eliminated. Elimination of the cause, camouflage, sunscreens, and depigmentation using the different techniques that will be described for melasma (see section 3), have been used to treat this condition. 2.4 Linea Fusca In linea fusca, brownish yellow pigmentation develops near the hair implantation line in an arch disposition, affecting the forehead (fig. 3) and temporal areas. Similar dark plaques can be observed all over the face. Histologically, there is liquefaction degeneration of the basal layer, perivascular chronic inflammatory infiltrate, follicular hy- perkeratosis and melanin deposition in dermis and melano- phages.[7] It is necessary to rule out the possibility of exogenous factors as a cause for the condition (e.g. use of cosmetics, hat ribbons, Fig. 2. Erythromelanosis follicularis of the face and neck: reddish brown pigmen- tation on face and neck. plugging, the sebaceous glands are enlarged, and a periadnexial lymphocytic infiltrate and vasodilatation may be observed. Clinically, there is a symmetric, well defined, reddish brown pigmentation affecting preauricular and maxillary areas, with fol- licular papules and erythema (fig.2). Using the pressure of a glass the reddish brown area becomes pale, and then it is possible to see brown pigmentation and some telangiectasia. First described in Japan, cases in Caucasians have been re- ported.[6] This condition can be differentiated from ulerythema ophryogenes, erythromelanosis peribuccale pigmentaire of Brocq and poikiloderma, due to its typical location, the presence of pigment and telangiectasia. Of unknown etiology, some cases are inherited as an autosomal recessive disorder. No photosensi- tivity relationship has been found. Fig. 3. Linea fusca: brownish pigmentation affecting forehead. © Adis International Limited. All rights reserved. Am J Clin Dermatol 2000 Sep-Oct; 1 (5) 264 Pérez-Bernal et al. etc), because typical linea fusca can be associated to central nerv- ous system disorders such as encephalitis, tumors, and syphilis. 3. Facial Hyperpigmentation Associated with Use of Cosmetics and Drugs Photosensitizers can act by a phototoxic, or by a photoal- lergic mechanism. Some photodynamic substances that induce phototoxic contact dermatitis can produce severe hyperpigmenta- tion. This is the case of berloque dermatitis occurring after the application of eau de cologne or perfumes containing bergamot oil, an ultraviolet sensitizer. Some plants containing furocou- marines may induce