Marta I. Rendon
Dermatology and Aesthetic Center and University of Miami, Miami, and Florida Atlantic University, Boca Raton, Florida, U. S.A.
Jorge I. Gaviria
Medical Hair Research Group, Inc. and Clinical Research, Skin Care Research, Inc., Boca Raton, Florida, U. S.A.
When approaching a patient with a pigmentary disorder, four issues must be taken into consideration: the patient’s skin type and ethnic background, type of disorder, history of reaction to prior surgical treatments, and post-inflammatory hyperpigmentation (PIH). This information is necessary to determine the most appropriate treatment option. Hyperpigmentation is caused by a wide variety of conditions, diseases, and entities, most of which are acquired. Pigmentary disorders have a tremendous impact on patients’ self-esteem and social interactions; therefore, improving patients’ quality of life is essential.
Treatments for these disorders can be difficult and lengthy, often resulting in a high degree of patient dissatisfaction and causing some patients to seek care from another dermatologist. Therefore, educating patients to have realistic expectations is an important aspect of the therapeutic process. This chapter will discuss the factors essential to choosing the optimal therapeutic approach, and includes a discussion of first-line therapies, when botanicals should be incorporated, and at what point surgical or other procedures should be used.
The treatment of pigmentary disorders is one of the greatest challenges in dermatology (Table 1). The therapeutic armamentarium has been reduced due to the lack of efficacy of most depigmenting agents available on the market. Relapses, as well as lack of permanent remissions, are the norm rather than the exception.
Hyperpigmentation is caused by a wide variety of factors (Tables 1 and 2). The mechanisms inducing hyperpigmentation have not been completely elucidated. Pigmentation is a complex metabolic process that includes tyrosinase activity, melanosome formation, and a cascade of intermediate metabolites that result in the formation of melanin. A rational therapeutic approach should be medications or
Table 1 Causes of Hyperpigmentation
Acanthosis nigricans Addison’s disease Argyria Becker’s nevus Cafe; au lait macules
Drug-induced hyperpigmentation (Table 2)
Dyschromatosis symetrica hereditaria Dyschromia of photoaging Ephelides
Erythema dyschromicum persistans
Erythromelanosis follicularis
Exogenous ochronosis
Familial periorbital hyperpigmention
Hemochromatosis
Hyperthyroidism
Lentigines
Linea fusca
Liver disease
McCun-Albright syndrome
Melasma
Nevi
Nevus de ota
Photoallergic reaction
Pituitary tumors
Poikiloderma of civatte
Post-inflammatory hyperpigmentation
Polycistic ovarian syndrome
Pregnancy
Scleroderma
Riehl’s melanosis
Solar lentigines
Sun exposure
Tinea versicolor
Causes of acquired hyperpigmentation Skin diseases and conditions Erythromelanosis follicularis Linea fusca Melasma
Poikiloderma of civatte Postinflammatory hyperpigmentation Riehl’s melanosis
Exogenous causes of acquired hyperpigmentation
Cosmetics
Drugs (Table 2)
Photosensitizing agents (e. g., berloque dermatitis due to bergamot oil, furocoumarins) Ultraviolet exposure (e. g., melasma, solar lentigines, ephelides)
Ultraviolet tanning beds
compounds acting at different levels of the melanogenesis cascade to produce better aesthetic and clinical results.
Treatment of hyperpigmentation induced by medications should be individualized. In some cases, discontinuation of the drug is impossible, and treatment must be delayed
Table 2 Drugs Known to Induce Hyperpigmentation
Amiodarone
Amitriptyline
Arsenic
Bismuth
Bleomycin
Busulfan
Clofazimine
Cyclophosphamide
Daunorubicin
Dibromomannitol
Doxorubicin
Gold
Mercury
Minocycline
Nitrogen mustard
Phenothiazines
Phenytoin
Silver
Sulfonamides
Tetracyclines
Zodovudine until that medication is no longer in use. In other cases, progressive discontinuation of the medication is the answer. Use of an alternative medication can solve the pigmentation phenomenon in other patients (1).
No standard therapeutic guidelines exist for treating the most common hyperpigmentation disorders, including lentigines, melasma, pigmentation of aging, and PIH. Due to variations in therapeutic regimes, the different population groups studied, and the limited number of comprehensive studies performed to date, comparison of results is very difficult. This chapter is an overview of topical depigmenting agents and a discussion of physical and combination therapies currently available to treat hyperpigmentation (2).