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To effectively treat pigmentary disorders in skin of color patients, dermatologists need to understand important nuances in treating the darker skin types, in order to avoid making pigmentary issues worse, says an expert. Learn more
The pigmentation disorders melasma and postinflammatory hyperpigmentation (PIH) occur more often in African Americans, Hispanics/Latinos and Asian Pacific Islanders than in Caucasians, according to Susan Taylor, M.D., who presented “Disorders of Pigmentation” at the 2015 Skin of Color Seminar in New York City. To effectively treat pigmentary disorders in skin of color patients, dermatologists need to understand important nuances in treating the darker skin types, in order to avoid making pigmentary issues worse, says Dr. Taylor.
Treatment of common pigmentary disorders is important to many skin of color patients. Why? Because of their psychological toll.
“Pigmentary disorders occur commonly in skin of color patients, they are cosmetically unacceptable to patients and negatively affect the patients’ quality of life,” says Dr. Taylor, who practices in Philadelphia, Penn., is founding director of the Skin of Color Center at St. Luke’s-Roosevelt Hospital Center, and is emeritus professor of dermatology at the Icahn School of Medicine at Mt. Sinai, New York, N.Y.
In fact, researchers have found that melasma, PIH and other pigmentary disorders affect quality of life regardless of skin type. In one study1, they found 80% of 140 patients undergoing skin exams at a private dermatology practice had one or more pigmentary disorders.
“About 47.3% of patients admitted of feeling self-conscious about their skin to some degree, 21.8% felt others focused on their skin, 32.7% felt unattractive because of their skin, 32.7% put effort into hiding pigment changes and 23.6% felt their skin affected their activities,” according to the study.1
Dr. Taylor cited an evidence-based review2 which included 40 studies and 2.912 participants with melisma, a chronic, relapsing disorder for which there is no cure. Key findings are that it negatively impacts quality of life and should be treated. Available treatments are only somewhat effective-sometimes putting especially skin of color patients at risk for treatment-related hyperpigmentation.
Chemical peels and laser and light therapies are among the treatments that have mixed results for melasma while increasing risk of irritation and subsequent hyperpigmentation, particularly in darker-skinned individuals, according to the study.
The authors concluded that topical combination therapies were more effective than monotherapy. However, even with triple combination treatment, 40% of patients develop erythema and peeling.
The gold-standard treatment for melasma is triple combination therapy tretinoin/ hydroquinone/ fluocinolone acetonide, (Galderma Tri-Luma), according to Dr. Taylor. Dr. Taylor was lead author on a study3 on 641 melasma patients comparing treatment with a hydrophilic cream formulation containing tretinoin 0.05%, hydroquinone 4.0%, and fluocinolone acetonide 0.01% to dual-combination agents tretinoin plus hydroquinone, tretinoin plus fluocinolone acetonide, and hydroquinone plus fluocinolone acetonide. The researchers found 26.1% of those on the triple combination therapy experienced complete clearing, compared with 4.6% in the other treatment groups. And while 75% of patients in the triple combination therapy group saw a more than 75% reduction in melasma and pigmentation, only 30% of those receiving dual combination agents saw as good results.
Dr. Taylor also coauthored a study4 looking at triple combination treatment for melasma patients previously treated with a triple combination cream or one of its dyads. They found 80% of lesions completely or nearly cleared at month 12.
Researchers have also looked at using triple combination cream as a maintenance therapy for melasma. In a recent study5, researchers found “After resolution of melasma with [triple combination therapy], maintenance therapy over 6 months was successful in preventing relapse in over half of the patients who entered maintenance phase. Prescribing medicines should be adapted to patients based on melasma severity.”
PIH is the result of an antecedent rash or injury to the skin (inflammation) that stimulates the melanocytes to produce more melanin pigmentation, according to Dr. Taylor.
“These conditions likely occur more commonly in skin of color patients because they have melanocytes that have the ability to produce large amounts of melanin, and their skin cells contain more melanin than Caucasian skin,” she says.
Unfortunately, some treatments that dermatologists perform can cause PIH in skin of color. “PIH can result from procedures such as laser and peels. Performing a patch test prior to the full procedure can be helpful,” Dr. Taylor says.
Many of the same treatments used to treat melasma are effective for patients with PIH. However, the gold standard treatment for PIH is topical 4% hydroquinone, according to Dr. Taylor.
While some botanical therapies might play roles in hyperpigmentation treatment, research is lacking on their use with standard therapies. Moreover, according to Dr. Taylor, botanicals can worsen hyperpigmentation.
Disclosure: Dr. Taylor is on the advisory board, speaker’s board or is an investigator with Aclaris Therapeutics, Allergan, Alphaeon, Beiersdorf, Evolus, Galderma, T2 Skincare and Valeant.
1. Taylor A, Pawaskar M, Taylor SL, Balkrishnan R, Feldman SR. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol. 2008 Sep;7(3):164-8. http://www.ncbi.nlm.nih.gov/pubmed/?term=Taylor+M.+Prevalence+of+pigmentary+disorders+and+their+impact+on+quality+of+life%3A+A+prospective+cohort+study.+J+Cosmet+Dermatol+2008%3B7%3A164%E2%80%93168
2. Rivas S, Pandya AG. Treatment of melasma with topical agents, peels and lasers: an evidence-based review. Am J Clin Dermatol. 2013 Oct;14(5):359-76. http://www.ncbi.nlm.nih.gov/pubmed/?term=2.%09Rivas+S%2C+Pandya+AG.+Treatment+of+melasma+with+topical+agents%2C+peels+and+lasers%3A+an+evidence-based+review.+Am+J+Clin+Dermatol.+2013+Oct%3B14(5)%3A359-76
3. Taylor SC, Torok H, Jones T, Lowe N, Rich P, Tschen E, Menter A, Baumann L,Wieder JJ, Jarratt MM, Pariser D, Martin D, Weiss J, Shavin J, Ramirez N. Efficacy and safety of a new triple-combination agent for the treatment of facial melasma. Cutis. 2003 Jul;72(1):67-72. http://www.ncbi.nlm.nih.gov/pubmed/12889718
4. Torok H, Taylor S, Baumann L, Jones T, Wieder J, Lowe N, Jarret M, Rich P, Pariser D, Tschen E, Martin D, Menter A, Weiss J. A large 12-month extension study of an 8-week trial to evaluate the safety and efficacy of triple combination (TC) cream in melasma patients previously treated with TC cream or one of its dyads. J Drugs Dermatol. 2005 Sep-Oct;4(5):592-7. http://www.ncbi.nlm.nih.gov/pubmed/?term=4.+Torok+H%2C+Taylor+S%2C+Baumann+L%2C+Jones+T%2C+Wieder+J%2C+Lowe+N%2C+Jarret+M%2C+Rich+P%2C+Pariser+D%2C+Tschen+E%2C+Martin+D%2C+Menter+A%2C+Weiss+J.+A+large+12-month+extension+study+of+an+8-week+trial+to+evaluate+the+safety+and+efficacy+of+triple
5. Arellano I, Cestari T, Ocampo-Candiani J, Azulay-Abulafia L, Bezerra Trindade Neto P, Hexsel D, Machado-Pinto J, Muñoz H, Rivitti-Machado MC, Sittart JA,Trindade de Almeida AR, Rego V, Paliargues F, Marques-Hassun K. Preventing melasma recurrence: prescribing a maintenance regimen with an effective triple combination cream based on long-standing clinical severity. J Eur Acad Dermatol Venereol. 2012 May;26(5):611-8. http://www.ncbi.nlm.nih.gov/pubmed/?term=%5BArellano+I%2C+Cestari+T%2C+Ocampo-Candiani+J%2C+Azulay-Abulafia+L%2C+Bezerra+Trindade+Neto+P%2C+Hexsel+D%2C+Machado-Pinto+J%2C+Mu%C3%B1oz+H%2C+Rivitti-Machado+MC%2C+Sittart+JA%2CTrindade+de+Almeida+AR%2C+Rego+V%2C+Paliargues+F%2C+Marques-Hassun+K.+Preventing+melasma+recurrence%3A+prescribing+a+maintenance+regimen+with+an+effective+triple+combination+cream+based+on+long-standing+clinical+severity