Pigmentary disorders are more than just a cosmetic concern, according to Dr. Susan C. Taylor.
Studies show that disorders such as melasma and post-inflammatory hyperpigmentation (PIH) are particularly common in women with darker skin, and the conditions can have a profound effect on quality of life, Dr. Taylor said at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).
Dr. Susan C. Taylor
In one prospective cohort study, 47% of patients with pigmentation disorders said they felt self-conscious about their skin, 33% reported feeling unattractive, and 33% reported putting effort into hiding pigment changes. Nearly 24% said they thought their skin condition affected their activities, and 22% believed others focused on their skin (J. Cosmet. Dermatol. 2008;7:164-8).
"These conditions should be treated aggressively," said Dr. Taylor, founding director of the Skin of Color Center at St. Luke's–Roosevelt Hospital Center in New York. For both melasma and PIH, that means using treatments that decrease melanin formation, block the transfer of melanosomes, minimize inflammation, and nonselectively suppress melanogenesis, or increase melanin removal through desquamation, she said.
Photo credit: @2007 Elsevier Inc.
Melasma (shown above) can have a significant impact on quality of life, especially in women with darker skin.
Dr. Taylor, who also is an assistant clinical professor of dermatology at Columbia University, New York, said topical therapies are not curative, but they can be effective.
For melasma, triple combination therapy with a cream containing hydroquinone (4%), retinoic acid (0.05%), and fluocinolone acetonide (0.01%) has been shown to be quite effective in multiple studies, and is Dr. Taylor’s preferred treatment.
Data from two 8-week randomized trials showed that significantly more patients treated with the triple combination cream experienced complete clearing, compared with patients treated with dyad creams (26% vs. 5%). An extension study showed that 80% of patients treated with, or switched to the triple-combination cream, were completely cleared or nearly cleared at 12 months. Only 2.5% of patients discontinued the study because of treatment-related adverse events (J. Drugs. Dermatol. 2005;4:592-7).
Other options shown to be of benefit for the topical treatment of melasma include 0.1% tretinoin cream or 20% azelaic acid cream, Dr. Taylor said.
Oral therapy with procyanidin plus vitamins A, C, and E also shows promise. In an 8-week randomized, double-blind, placebo-controlled trial in 60 Filipino women, treatment was associated with significant improvements in the left and right malar regions, and was safe and well tolerated (Int. J. Dermatol. 2009;48:896-901). However, additional studies are needed to confirm these results, she noted.
Chemical peeling agents can serve as good adjuncts to other therapies for melasma, particularly in recalcitrant cases. In one study, Dr. Taylor said, the addition of eight glycolic acid peels to topical therapy with azelaic acid and adapalene gel improved outcomes vs. the topical treatments alone. Priming agents such as 2% hydroquinone and 0.025% retinoic acid can boost the effects of such peels (J. Dermatol. 2007;34:25-30).
Finally, an emerging treatment option for melasma appears to be fractional photothermolysis.
In a pilot study, 10 female melasma patients who failed prior treatments received four to six fractional laser treatments at 1-2 week intervals using 1,535 nm and 1,550 nm wavelengths and 6-12 mJ/microthermal zone. Most patients (60%) had 75%-100% clearing, and 30% had less than 25% improvement, Dr. Taylor said (Dermatol. Surg. 2005;31:1645-50).
The investigators used microdermabrasion to improve penetration to the target site, followed by an effective tyrosinase inhibitor to suppress melanocytes and remove melanin from the stratum corneum, she explained, adding that sunscreens and topical vitamin C were also used.
"Fractional resurfacing may hold the key to treatment of dermal melasma," she said. It also appears to be useful in PIH.
A case report of its use in a patient with PIH on the neck that had failed to respond to topical therapies for 2 years showed that after 3 treatments, the patient had near-complete clearing with no post-procedural complications or recurrence at 7-month follow-up. Treatment was with a 1,550 nm wavelength erbium-doped Fraxel SR1500 laser at a fluence of 15 mJ, level of 6, with 8-10 passes (Dermatol. Surg. 2009;35:1844-8), Dr. Taylor said.
She cautioned, however, that using lasers in patients with skin of color can potentially cause PIH.
Other treatment options for PIH include hydroquinones, which remain the gold standard, and retinoids, mequinol, and azelaic acid, she said, noting that all patients with melasma and PIH should be advised to use sunblock, protective clothing, and sunglasses and to avoid ultraviolet exposure when possible.
Dr. Taylor serves on advisory boards for Beiersdorf, Johnson & Johnson, Medicis, and GlaxoSmithKline. She has been an investigator for Johnson & Johnson, Medicis, Merz, and Palomar, and is on the speakers bureau of Medicis and Stiefel. She owns stock in T2 Skincare.