Presentation on theme: "hyper & hypo- pigmentation DISORDERS"— Presentation transcript:
1 hyper & hypo- pigmentation DISORDERS Kenneth M. caranguian md
2 subtopics Melasma Lentigo Freckles Juvenile lentigens Solar lentigens PIHNevus of otaIdiopatic gutate hypomelanosispytiriasis albavitiligo
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 estrogensFades 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 uncertainStudy - high expression of MSH in keratinocytes that plays a key role in hyperpigmentationMost 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 ochronosisassociated with bleaching agent hydroquinone. It is caused by the deposition of polymerised homogentisic acid in the skin.2. PIHdx is clinicalSkin that was previously inflamed due to dermatitis.Hx: erythema, pruritus, and dermatitis3. Phototoxic reactionDx is clinicalexposed to systemic or topical medicines or cosmetics, and UV radiation.Begins abruptly, in contrast to melasma, which develops gradually.
8 TREATMENTNOTE:The patient should not be promised great therapeutic results.
9 Topical Bleaching Agents A. HYDROQUINONE2%- 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 HQAlternating 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 formula5% HQ , 0.1% TRETINOIN, and 0.1% DEXAMETHASONE - in hydrophilic ointment
13 D. AZELAIC ACIDa naturally occurring dicarboxylic acid derived from Pityrosporum ovale15- 20%Applied BID x 3-12 months, well toleratedtx of acne- decreases comedo formationUnlike 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 acidglycolic acid (topical or peels 30-70%)Jessner's solutionmicrodermabrasionAlternative 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 UVBIPL and Fractional CO2 laser may have additional benefits but results are variable
16 LENTIGOCommon, benign, circumscribed, 1-3 cm light yellow or light brown macules from a localized proliferation of melanocytes due to acute or chronic sun exposureHistologically - increased number of melanocytes in the basal layer of the epidermisaffects 30 yrs old and aboveMay arise after sunburn or after PUVA overdosageIt is a localized hyperpigmentation in 3 patterns :1. Freckles (Ephelides)2. Juvenile Lentigo3. Solar lentigo
17 FRECKLESHISTORY:childhood, 5-7 yrs oldADM/c in redheads, blondes and fair skinnedParadoxically, 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 usualDarkens during summertime and fade almost completely during winterUsually 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 LENTIGENSHISTORY:childhoodLesions do not increase in number or size, or darken in response to sunlightcharacteristic feature of certain hereditary conditionsMay persist year round or may spontaneously resolve
20 PHYSICAL FINDINGS:appears as round to oval macules, 2 to 10 mm in diameterDarker than frecklesUniformly tan, or brown or black
21 Common in sun exposed skin 3. SOLAR LENTIGENSHISTORY:Common in sun exposed skinIncreased in number and size in advancing years75% of white people over 60 yrs have one or more lesionsAka- liver age spotsUsually 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 TREATMENTMonitor existing lesions for interval changeStable lesions do not require txHQ 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 injuryexcessive irritation from cosmetic products and procedures, pimples, scratching or any kind of traumaGradual darkening several weeks after the original injuryMore common in darker skin and sun exposedSome are more prone to PIH than othersresolve after several months or years
26 NEVUS OF OTAbluish 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 brownMore common in Asians in 1- 2 % of the populationcan cause facial disfigurement - emotional and psychologic distressFemales > males (4x)Both dermal and epidermal components may co existCreams- ineffectiveCan 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 etiologyConsists of white small macules in sun exposed upper and lower extremitiesHISTORY:middle aged and older people% over the age of 50F>MGenetic predispositionAlthough asymptomatic, it is cosmetically distressingLesions 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 clothingSunscreens are less effectiveCan be camouflaged with tinted make upSelf tanning creams that contains dihydroacetone darkens the lesions, but the appearance is not pleasingA light spray with liquid nitrogen may partially fade the lesions although there is a potential to worsen the dyspigmentationReassurance is all that is required
31 PITYRIASIS ALBAhypopigmented, slightly elevated, fine scaling patches with indistinct borders typically on the lateral cheeks, lateral upper arms and thighsyoung children, resolves in early adulthoodAsymptomaticNo history of prior rash, trauma or inflammationLoss 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 melanosomesOften seen in children between the ages 3 and 16 yearsmales > femalesOccurs 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 inspectionLesions more common in lateral cheeks, lateral upper arms and thighsCondition 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 mycologyNummular 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 timeIf 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 scaringHowever 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 VITILIGOSex – equally affected but has a predominance to female- reflects greater concern about cosmetic appearanceAge – begin at any age50% (10-35y/o)old age – unusualIncidence – common worldwideRace - all racesInheritance - >30%, family history, thyroid disease and DM
38 THREE SUBTYPES OF VITILIGO: Localized or focal- <20% body surface areaOne 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 hypomelanosisSmall, circular macules, slowly progressive accumulation of isolated lesions.Pityriasis albaAsymptomatic, ill-defined small patches with fine scaling in children and adolescentsDiscoid Lupus Erythematuses
44 4. Pityriasis versicolor Polycyclic, well-demarcated, typical upper trunk and shoulder distribution.5. Seborrheic DermatitisDistribution 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)= PUVAGeneral guide:if vitiliginous skin is <6 cm2 (the size of a quarter or half- dollar)- topical psoralenslarge portion - systemic psoralens and sunlightextremely 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