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DYSPIGMENTATION

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SUMMARY

  • The classification of dyschromias is based on the location of melanin in the skin. This can be seen clinically by variation in color of the lesion, Wood’s lamp examination, as well as histopathologically.

  • The therapeutic plan primarily consists of identification and removal of causative as well as triggering factors and stringent photoprotection coupled with the use of depigmenting agents.

image Beginner Pearls

  • Sun avoidance is the most important part of the treatment of hypermelanoses, both for current improvement and future prevention of recurrence.

  • Hydroquinone (HQ) is a mainstay topical depigmenting agent in the treatment of dyschromias, particularly melasma and postinflammatory hyperpigmentation.

  • Multiple chemical peels have efficacy for dyspigmentation, including glycolic acid, Jessner’s, and TCA peels.

image Expert Pearls

  • Laser and light options include IPL, QS Nd:YAG, QS ruby, and QS alexandrite.

  • The patient should be adequately primed for around 2 to 4 weeks pre-peel with topical skin lightening agents such as HQ, GA and kojic acid, or tretinoin, coupled with regular sunscreens.

image Don’t Forget!

  • Regardless of intervention used, fundamental medical management, including religious photoprotection, is absolutely essential and even the most complex intervention will fail if the patient does not comply with the fundamentals.

  • Melasma patterns include centrofacial, malar, and mandibular patterns.

image Pitfalls and Cautions

  • Combination peels should be used cautiously in darker-skinned patients because of the risk of PIH and scarring. Patients with long-term use of HQ increase their risk for exogenous ochronosis.

image Patient Education Points

  • Rigorous sun protective behavior should be instilled in patients, including the use of broad spectrum (ideally physical blocking) sunscreens with a minimum sun protection factor of 30, along with sun protective hats and clothing.

  • Patients should understand that multiple treatments may be required and that their degree of improvement with each treatment session may be unpredictable.

  • Always err on the side of underestimating the improvement that will be seen.

INTRODUCTION

A large number of conditions may manifest with increased pigmentation of the skin. While some of them may be predominantly limited to the face, extra-facial dyspigmentation may be a major source of concern as well. These cause significant cosmetic disfigurement and therefore negatively impact the quality of life (QOL) of affected patients. This vast group of complex diagnostic and therapeutic problems includes well-defined clinical entities as well as those which have defied classification.

CLASSIFICATION OF DYSCHROMIAS

The classification of dyschromias is based on the location of melanin in the skin. This can be seen clinically by variation in color of the lesion, Wood’s lamp examination, as well as histopathologically.

Brown hypermelanosis

Lesions appear brown-black in color and there is accentuation of pigmentation on Wood’s lamp examination. The excess melanin is present in epidermis, mainly in basal and suprabasal layers. The pigmentation can be melanotic (increased ...

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