Treating ethnic patients requires special considerations and sensitivity.
National report - Treating the pigmentation problems and volume loss that rank among ethnic patients' top concerns requires combination strategies, caution and sensitivity to cultural differences, according to various experts.
Among bleaching agents, he says, "Hydroquinone is still our gold standard." Though studies of the triple-combination cream Tri-Luma (fluocinolone acetonide, hydroquinone, tretinoin; Galderma) show it is safe for up to 12 months, Dr. Alexis says he usually prefers no more than six consecutive months' use of a hydroquinone product before switching to an alternative bleaching agent. Data regarding the use of bleaching agents in PIH remain limited, but a 792-patient study of Tri-Luma showed that 45 percent of patients were clear or almost clear in eight weeks (Baumann L, Grimes P, Pandya AG, Rendon M, Taylor SC. Triple combination cream is an effective treatment for post-inflammatory hyperpigmentation. Presented at the 65th Annual American Academy of Dermatology Meeting; Feb. 3-5, 2007; Washington, D.C.).
"We have a lot more evidence published regarding bleaching agents and melasma," Dr. Alexis says. Such agents include hydroquinone, the triple combination cream, topical retinoids, glycolic acid, azelaic acid and kojic acid. He says kojic acid is nearly as effective as hydroquinone, but carries a greater risk of irritant contact dermatitis.
"For solar lentigines, we have one product that's approved in the United States - Solagé (mequinol, tretinoin; Barrier Therapeutics/Stiefel). We can also use topical retinoids as monotherapy."
Bleaching agents are best used when combined with other strategies, particularly chemical peels, Dr. Alexis adds. To avoid peeling too aggressively in skin of color (SOC), he says, "We're limited to the superficial peels, primarily glycolic acid and salicylic acid." The typical interval between peels is two to four weeks, with hydroquinone products used concurrently, he says.
"The most important factor is to stop retinoid use one week before any peel," he says. He also advises proceeding cautiously with glycolic acid peels in darker-skinned patients. "It's important to be conservative, monitor the patient very closely, assess the skin for any evidence of erythema and neutralize earlier than four minutes if necessary."
With self-neutralizing peels such as salicylic acid, dermatologists must consider the concentration and amount applied to the skin, he says. "Salicylic acid is the main peel I would use for PIH associated with acne. Because it's very lipophilic and mildly comedolytic, it's helpful for the acne as well as the PIH." He suggests starting with a thin layer and adding more only if there is no erythema or irritation.
"When erythema occurs post-peel, I prescribe low-potency topical steroids." Regarding melasma, Dr. Alexis says one recalcitrant case he treated responded well to a combination of triple combination cream, glycolic acid peels and sunscreen.
Overall, he says, "Combining multiple modalities with different mechanisms of action is the most efficacious strategy" for treating dyschromias.