Pigmentary Disorders in Clinical Practice

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


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

genetically determined.


Solar Lentigo


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


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

clinically successful.


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.


References


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doi:10.1111/jdv.15987


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.

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Handel, A. C., Miot, L. D., & Miot, H. A. (2014). Melasma: a clinical and

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