1. hyper & hypo- pigmentation DISORDERS
Kenneth M. caranguian md

2. subtopics Melasma Lentigo Freckles Juvenile lentigens Solar lentigens
PIH
Nevus of ota
Idiopatic gutate hypomelanosis
pytiriasis alba
vitiligo

3. 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

4. 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%

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

7. 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.

8. TREATMENT
NOTE:
The patient should not be promised great therapeutic results.

9. Topical Bleaching Agents
A. 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

10. 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.

11. B.MONOBENZYL ETHER OF HYDROQUINONE (MBEH/Benoquin) melanocidal Selectively 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

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

13. 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

14. glycolic acid (topical or peels 30-70%) Jessner's solution
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.

15. 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

16. 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 Lentigo
3. Solar lentigo

17. 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

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

19. 2. JUVENILE LENTIGENS
HISTORY:
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

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

21. Common in sun exposed skin
3. SOLAR LENTIGENS
HISTORY:
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

22. PHYSICAL FINDINGS: Tend to be larger (2- 20mm) Oval to geometric macules uniform in color, appear as fine grains, blotchy, with borders that are sharply defined

23. 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

24. 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

26. 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

28. IDIOPATHIC GUTATE HYPOMELANOSIS
DESCRIPTION:
Common assymptomatic dermatosis of unknown etiology
Consists of white small macules in sun exposed upper and lower extremities
HISTORY:
middle aged and older people
% 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

29. PHYSNICAL FINDINGS:
Macules are white and hypopigmented, 2 to 5 mm, Borders regular and smooth to slight xerotic scaling

30. Encourage sun protection with clothing Sunscreens are less effective
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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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

37. VITILIGO
Sex – equally affected but has a predominance to female- reflects greater concern about cosmetic appearance
Age – begin at any age
50% (10-35y/o)
old age – unusual
Incidence – common worldwide
Race - all races
Inheritance - >30%, family history, thyroid disease and DM

38. 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

39. 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.

40. 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

41. PHYSICAL FINDINGS:
Consists of white depigmented 0.5 to 5 cm macules and patches with well defined borders

43. DIFFERENTIAL DIAGNOSIS:
Idiopathic guttate hypomelanosis
Small, circular macules, slowly progressive accumulation of isolated lesions.
Pityriasis alba
Asymptomatic, ill-defined small patches with fine scaling in children and adolescents
Discoid Lupus Erythematuses

44. 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.

45. TREATMENT: General guide: Psoralen plus ultraviolet A (PUVA)
a combination treatment using Psoralen (P) and exposing the skin to Ultraviolet A (UVA)= PUVA
General 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

46. 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.

47. Successful therapy requires 9-18 months. 2
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

48. 5. Broad spectrum sunscreens - at least spf 30 6
5. Broad spectrum sunscreens - at least spf 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.

49. 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

50. Thank you!