Challenging Cases in Skin of Color Patients

In this first part of our coverage of “The Skin of Color Update Pre-Conference Virtual Symposium” held August 3, we review challenging cases of melasma, vitiligo, and post-inflammatory hyperpigmentation in skin of color patients.

On August 3, the Skin of Color Update held their “Skin of Color Pre-Conference Virtual Symposium,” with challenging skin of color (SOC) cases that physicians have encountered in their practice. Moderators Andrew Alexis, MD, MPH, vice-chair for diversity and inclusion and assistant professor of dermatology at Weill Cornell Medicine in New York City, New York, and Eliot Battle, MD, CEO and co-founder of Cultura Dermatology & Plastic Surgery, Washington, D.C., opened the symposium with Battle leading the first hour of discussion. 

Melasma

The first case was presented by Heather Woolery-Lloyd, MD, board certified dermatologist, director of the skin of color division in the Frost Department of Dermatology at the University of Miami Miller School of Medicine, Miami, Florida, on a long-term case of melasma.1 In 2013, Woolery-Lloyd met a 66-year-old patient with melasma and a history of stable lichen planopilaris and migraines. 

This patient has used natural oils on the scalp and lived in a tropical climate while taking walks often. Woolery-Lloyd emphasized sun avoidance and sun protection while starting the patient on a topical treatment of a compounding pharmacy of hydroquinone 8%, which she does use for the entire treatment phase, tretinoin 0.025%, and dexamethasone 0.1%. Woolery-Lloyd then treated the patient with a hydroquinone-free skin brightener to help maintain progress, and she does prescribe a topical anti-inflammatory (hydrocortisone or pimecrolimus) at night if there is skin irritation.

The alternatives that the patient used were licorice extract, vitamin C, niacinamide, azelaic acid, and cysteamine. After a regimen of cleanser, antioxidant with skin brightener, broad-spectrum sun protection with an oral antioxidant in the morning and a cleanser, hydroquinone free skin brightener, topical anti-inflammatory as needed, and a moisturizer also as needed, for 3 years, the patient had not made progress. Woolery-Lloyd then added glycolic peels every 4 weeks for a series of 5 to 6 peels, after emphasizing to the patient that a series of peels, going to lowest concentration to highest, is needed to achieve results. The retinoids were stopped 7 days before a peel treatment and placing the patient on hydroquinone prior to a peel to decrease the risk of hyperpigmentation was considered. 

By June of 2019, there still was little progress and in April of that same year the patient had visited the tropical climate of southeast Asia where the melasma worsened. Tranexamic acid was considered, but the patient was not a good candidate, as she was now 74 and had an increased risk of stroke and it was decided the risks outweigh the benefits. The patient left in April of 2021 to visit family in the northeast US and came back in June of 2021 with vastly improved skin because she was not in the sun and stayed mostly indoors. In July of 2021, after 1 month back in the Miami outdoors, the melasma is beginning to return.

Wooley-Lloyd concluded that sun protection and avoidance is essential for treatment and avoiding triggers like oral hormonal therapies, photosensitizing medications, topical estrogen, and topical phytoestrogens is important. 

“So, one thing I want you to just keep in mind that many essential oils have very strong estrogenic effects. Lavender and tea tree oils are linked to gynecomastia,” said Wooley-Lloyd. “I do think in her case, because she's postmenopausal, her use of these essential oils with the estrogenic effects may be driving her melasma.”

Seemal Desai, MD, FAAD, board of directors for the American Academy of Dermatology, past president of the Skin of Color Society, clinical assistant professor in the department of dermatology at the University of Texas Southwestern Medical Center, and founder and medical director of Innovative Dermatology, Plano, Texas, agreed with Wooley-Lloyd’s approach and concurred with the comment that tranexamic acid does not work for every patient.

Naeelam Vashi, MD, associate professor of dermatology at the Boston University School of Medicine, founder and director of the Center for Ethnic Skin, and director of Cosmetic and Laser Center, Boston, Massachusetts, also uses the same approach, but she also uses more microneedling to help the hydrocodone treatment.

After an audience question asked about what to ask patients before treatment, Wooley-Lloyd talked about how most patients with melasma are younger females. So, when suggesting tranexamic acid, she make sure that patients are aware of the risk as it has a similar risk of a thromboembolic event as birth control. She mentioned that it was not her first choice, but there is a tropical tranexamic acid if there are worries about side effects.

Vitiligo

Next, Desai present his case on vitiligo.2 He states that in the first moments of the exam, the physician must decide whether the vitiligo is stable or not. This can be determined by looking for physical clues, including if new patches are appearing and how often, and by asking the patient details about their experience. 

“If the patient says, ‘I have a patch on my face,’ yeah, that's new. ‘I've got 1 on my chest,’ oh, that's new as well. ‘I've got a small area on my leg, 1 on my arm, 1 on my genitals,’ and you can kind of estimate and quantify all those patches. And that adds up to 1 or 2 palms of their hands. Remember 1 problem of course, 1% of their own [body surface area] BSA, if you can quantify all those patches in a 1% to 2% BSA, within a 4-to-6-week period, 6 weeks on average, that patient is unstable,” said Desai.

If a patient has confetti-like depigmentation, BSA spread, and trichrome spread of vitiligo, these can be signs of instability. Desai says the patient can be stabilized using oral mini-pulse (OMP) systemic steroids. For example, dexamethasone 4 mg daily on 2 consecutive days per week, for 8 weeks if the patient is 16 years or younger. He has had patients on for much longer or for as short as 4 weeks and the decision is based both on lab monitoring and patient feedback.

Another way to stabilize is intramuscular triamcinolone acetonide injections 60 mg once a month for 3 months, but Desai does not like it as much for long-term patients.

 Antioxidants like polypodium leucotomos, when combined with phototherapy, have higher rates of re-pigmentation and are an option, but the newest therapies use topical Janus kinase (JAK) inhibitors. There are adverse events (AEs) to consider like erythema, hyperpigmented rims at the edge of treatment area, and papular eruption.

An audience member asked where to get some of the topical treatments, such as ruxolitinib, for their patients, and Desai answered with finding a compounding pharmacy and finding the best pricing. He also said that, as these are off label uses, it is not FDA approved for the treatment of vitiligo. 

Hyperpigmentation

Lastly, Vashi gave her presentation of post-inflammatory hyperpigmentation (PIH).3 The patient was a 25-year-old woman with Fitzpatrick type V skin that had dark spots for a week following intense pulsed light (IPL) laser therapy, where her skin had burned and crusted over.

Treatment for this includes photoprotection and eliminating exacerbating factors. There must be a balance between procedures, so they are not too harsh or too irritating. The first treatment Vashi prescribed was a topical lightening agent that disrupted the melanogenesis and removed melanin. After, chemical peels, microdermabrasion, microneedling, and lasers are all considered. 

“So, in regard to topical treatments, we have a handful of prescription agents in comparison to a very large plethora of over-the-counter lightening formulations. Hydroquinone remains our gold standard,” said Vashi. While it is the gold standard, it has limited use because of its side effects. Other topicals include, retinoids, triple combination creams (TCC), azelaic acid, and alternative options.

For her patient, Vashi treated her with a full face of mandelic acid 40% for 2 minutes, then a daily ointment of triamcinolone .01%, and then after that hydroquinone 8% compound with triamcinolone treatment for 2 weeks. This is repeated every 3 weeks, each time increasing the length of time with the mandelic acid 40%, up to 5 minutes, and slowly waning off the steroids.

The audience asked if this skin type a candidate IPL treatment. All the doctors agreed that this patient is not a good candidate for IPL. Vashi said that she does not perform IPL on patients darker than skin type III. 

“…I always talk about there is a delay inside affecting skin color. That's why this entire face was done because the practitioner probably didn't see the erythema, the redness immediately while she was treating and it all came afterwards,” said Battle when referring to IPL treatments and SOC patients.

Using lasers on SOC patients was also discussed. Vashi said very few patients are treated with a laser, as it is costly, and most other treatment options work just as well if not better than a laser. Desai agreed, saying lasers are a third line option, particularly in melasma. For him, the risk of rebound, relapse, and PIH are the main challenges. Wooley-Lloyd mentioned that where a practice is located also determines what lasers can be used. As she practiced in a high ultraviolet (UV) ray location, many times the risks outweigh the potential benefit. 

Lastly, the doctors discussed a question Alexis posed on whether any of the doctors are treating patients with melasma with tranexamic acid. 

Desai stated that he had, but it is off label, because of the help to block the productions of prostaglandins and leukotrienes and it reduces the pigment. He has also used it to treat PIH, but it is not as successful. Wooley-Lloyd also uses it for melasma and asked if anyone was using it before and right after a laser treatment to prevent PIH as there are studies on the effects. Desai has not and that there was not enough data to do so. 

The Skin of Color Update will be held virtually on September 10-12. To sign up visit: https://skinofcolorupdate.com.

Disclosures:

Woolery-Llyod is the speaker for Ortho Dermatologics and EPI, researcher at Galderma, Allergan, and Pfizer, and shareholder at Somabella Laboratories, LLC. 

Desai serves as a member of the FDA and PCAC. 

Vashi has no relevant disclosures.

References:

1. Wooley-Lloyd H. A Challenging Case of Melasma. Presented at the: The Skin of Color Update Pre-Conference Virtual Symposium; August 3, 2021; virtual. Accessed August 4, 2021.

2. Desai S. Vitiligo Treated with Pulsed Corticosteroids & JAK-Inhibitors. Presented at the: The Skin of Color Update Pre-Conference Virtual Symposium; August 3, 2021; virtual. Accessed August 4, 2021.

3. Vashi N. Post-Inflammatory Hyperpigmentation (PIH) Topical & Procedural Treatment. Presented at the: The Skin of Color Update Pre-Conference Virtual Symposium; August 3, 2021; virtual. Accessed August 4, 2021.