Disorders of pigmentation are significantly increasing worldwide and currently
are the most frequently presented skin condition in clinical practice. The most
commonly exhibited pigmentary disorders are ephelides, solar lentigos, post-
inflammatory hyperpigmentation (PIHP), melasma, poikiloderma of civatte and
nevus of ota.
Types of Pigmentary Disorders and their Treatment
Ephelides, universally known as ‘freckles’ are flat, sharply demarcated, light brown
lesions generally detected in fair skinned and red-haired individuals. Ephelides are
mostly small in diameter and develop early in childhood. Though, it is not unusual for
them to escalate in size, number and colour after substantial sun exposure or during
adolescence, they somewhat fade throughout young adulthood. Ephelides are not
concomitant with an increase in the number of melanocytes, but rather there is a
surge in melanin of the basal layer within the epidermis, and while these
hyperpigmented lesions may be triggered by significant sun exposure, they are
Solar Lentigo, also dubbed ‘age spots,’ ‘senile lentigo,’ or ‘liver spots,’ are described
as irregularly outlined, light or dark brown macules which range from 1mm-1cm in
diameter. Solar Lentigo frequently arise after middle age and are commonly located
on the backs of hands and the face. Contrastingly to ephelides, these lesions are
associated with an increased number of melanocytes. Sun avoidance and the use of
broad spectrum sunscreen are the suggested preventative measures, though
pertaining to the treatment of existing macules, studies endorse the application of
topical products such as tretinoin cream, hydroquinone, retinoids, alpha hydroxy
acids (AHA’s) or a topical corticosteroids, as well as cryotherapy and melanin
specific high energy lasers and light therapies, such as Q-switched ruby and
alexandrite lasers, or Nd: YAG lasers.
Post-Inflammatory Hyperpigmentation (PIHP)
Post-inflammatory hyperpigmentation (PIHP) is an acquired and reactive pigmentary
disorder of the skin that ensues as a result of inflammation and trauma. There are
various causative factors associated with PIHP, such as acne, folliculitis, lichen
planus, herpes zoster and eczema, as well as medications and procedural
complications. All of these factors instigate damage to the basal layer which then
moderates the collection of melanophages within the superficial dermis. PIHP
lesions are irregularly shaped and vary in colour, from light brown to bluish grey.
Studies have suggested there to be an equal incidence between males and females,
however there is a commonality among darker skin phototypes. Currently, treatment
options include hydroquinone, kojic acid, retinoids, corticosteroids, ascorbic acid
(Vitamin C), chemical peeling preparations, dermabrasion and various laser
modalities. Though, treatment for PIHP remains challenging and research reveals
variable success rates.
Melasma (from the Greek word, meaning “black”) is the most common pigmentary
disorder largely affecting women. Melasma is a chronic, acquired, circumscribed,
symmetrical hypermelanosis located on sun exposed regions. The hyperpigmented
areas are characterised by irregular brown macules that are well defined with
scalloped edges. Melasma most commonly presents on the cheeks, upper lips, the
chin and the forehead on darker skinned phenotypes, although the condition does
affect all races. Several risk factors portray major roles in the accumulation of
melasma, such as; genetics, sun exposure, age, gender, hormones, pregnancy
(‘Mask of Pregnancy’), thyroid dysfunction, cosmetics and medications. Present
treatment and management approaches include; hydroquinone preparations, topical
steroids, retinoids, tyrosinase inhibitors (kojic acid and azelaic acid), ascorbic acid
(Vitamin C), superficial chemical peels (glycolic peeling solutions being the most
effective), and laser and light interventions, such as Intense Pulsed Light (IPL), Q-
Switched Nd: YAG, Q-Switched alexandrite and pulsed dye lasers as well as various
other fractional lasers. Melasma is renowned for its challenges when treating, owing
to the residing melanin in varying depths of the epidermis and the dermis, and even
minor sun exposure can reactivate the condition, therefore it is crucial to ensure strict
sun avoidance in accordance with the application of broad spectrum sunscreen
throughout treatment and management programs.
Poikiloderma of Civatte
Poikiloderma of civatte is a collective benign skin manifestation bestowing a triad of
signs, including; telangiectasia, atrophy and macular or reticulated hypo-
hyperpigmentation. It is not a disease, but a response to many causes including
irradiation, photo-contact reactions and connective tissue and lymphoreticular
disorders. The condition most commonly assumes lighter phototypes and is
generally observed on the lateral cheeks and the sides of the neck, with the
submental area generally spared. This anomaly can consequently result in cosmetic
disfigurement and social impairment for the sufferer, and while there is no consensus
regarding the treatment of choice, Intense Pulsed Light (IPL) is said to be the most
Naevus of Ota
Naevus of ota, also called oculodermal melanocytosis, is a form of dermal melanosis
and usually arises at birth, although in some cases it may emerge later. This
condition presents as a slate grey, blue or brownish unilateral macule along the
dissemination of the ophthalmic or maxillary branches of the trigeminal nerve.
Naevus of ota is concurrent with melasma and various other pigmentary disorders,
with 80 per-cent of cases occurring in females. Former treatments for this irregularity
have included; hydroquinone, cryotherapy, dermabrasion and skin grafting, though
presently these approaches have been substituted with the implementation of laser
and light therapies, with the Q-switched Nd: YAG being the most widely used.
The patient and the Dermal Clinician
Pigmentary disorders can be exasperating for the sufferer, and though there are
various management and treatment options available as previously outlined, they do
come with their perils and risks, one of the most common being recurrent relapse.
Owing to the Dermal Clinician’s central and in-depth knowledge concerning the
dangers, challenges and benefits associated with these present treatment approaches, they hold significant roles in the treatment, management, monitoring, collaboration and appropriate referral of patients with pigmentary disorders.
Dabas, G., Vinay, K., Parsad, D., Kumar, A., & Kumaran, M. (2019). Psychological
disturbances in patients with pigmentary disorders: a cross‐sectional
study. Journal of the European Academy of Dermatology and Venereology.
Dlova, N. C., Akintilo, L. O., & Taylor, S. C. (2019). Prevalence of pigmentary
disorders: A cross-sectional study in public hospitals in Durban, South
Africa. International Journal of Women's Dermatology.
Handel, A. C., Miot, L. D., & Miot, H. A. (2014). Melasma: a clinical and
epidemiological review. Anais Brasileiros de Dermatologia, 89(5), 771-782.
Hernando, B., Ibañez, M. V., Deserio-Cuesta, J. A., Soria-Navarro, R., Vilar-
Sastre, I., & Martinez-Cadenas, C. (2018). Genetic determinants of freckle
occurrence in the Spanish population: Towards ephelides prediction from
human DNA samples. Forensic Science International: Genetics, 33, 38-47.
Kaufman, B. P., Aman, T., & Alexis, A. F. (2017). Postinflammatory
Hyperpigmentation: Epidemiology, Clinical Presentation, Pathogenesis and
Treatment. American Journal of Clinical Dermatology, 19(4), 489-503.
Sarkar, R., Garg, V., Arya, L., & Arora, P. (2012). Lasers for treatment of melasma
and post-inflammatory hyperpigmentation. Journal of Cutaneous and
Aesthetic Surgery, 5(2), 93. doi:10.4103/0974-2077.99436
Sarma, N., Chakraborty, S., Poojary, S., Rathi, S., Kumaran, S., Nirmal, B., …
Joseph, B. (2017). Evidence-based review, grade of recommendation, and
suggested treatment recommendations for melasma. Indian Dermatology
Online Journal, 8(6), 406. doi:10.4103/idoj.idoj_187_17
Scattone, L., De Avelar Alchorne, M. M., Michalany, N., Miot, H. A., & Higashi, V. S.
(2012). Histopathologic Changes Induced by Intense Pulsed Light in the
Treatment of Poikiloderma of Civatte. Dermatologic Surgery, 38(7pt1), 1010-
Shankar, K., Godse, K., Aurangabadkar, S., Lahiri, K., Mysore, V., Ganjoo, A., …
Motlekar, S. A. (2014). Evidence-Based Treatment for Melasma: Expert
Opinion and a Review. Dermatology and Therapy, 4(2), 165-186.
Sheth, V. M., & Pandya, A. G. (2011). Melasma: A comprehensive update. Journal
of the American Academy of Dermatology, 65(4), 699-714.
Weller, R. B., Hunter, H. J., & Mann, M. W. (2015). Clinical Dermatology. Hoboken,
NJ: John Wiley & Sons.
Yan, L., Di, L., Weihua, W., Feng, L., Ruilian, L., Jun, Z., … Weihui, Z. (2017). A
study on the clinical characteristics of treating nevus of Ota by Q-switched