Abstract
Alterations in skin pigmentation may often have a dramatic expression in individuals with a dark skin complexion and can be a source of significant emotional distress in these individuals. Hyperpigmented disorders such as melanosis (melasma), post-inflammatory hyperpigmentation, drug-induced hyperpigmentation, and erythema dyschromicum perstans tend to have a prolonged course and, in many cases, are refractory to treatment, further contributing to the psychological impairment of the affected patients. Melanosis, is a common form of facial pigmentation attributable to sunlight and hormonal factors. A range of treatment modalities, such as depigmenting agents, topical retinoids, and chemical peels in conjunction with rigorous sun protection, can improve the melanosis but the condition usually recurs. Combination regimens, including frequent applications of superficial- and medium-depth chemical peels, appear to be particularly effective and well tolerated in dark-skinned patients with melanosis. Post-inflammatory hyperpigmentation is the result of excess pigment deposition following an inflammatory skin disorder. Topical tretinoin, hydroquinone, azelaic acid, kojic acid, and glycolic acid peels have been employed with variable degrees of success. Drug-induced pigmentation is a frequent cause of acquired hypermelanosis, its clinical expression depending on the triggering molecule and the underlying pathogenetic mechanism. Identifying and discontinuing the offending agent is the main approach in this condition, although, recent reports have demonstrated the efficacy of Q-switched lasers in accelerating the pigment removal. Erythema dischromicum perstans is a characteristic dermal pigmentation occurring mainly in dark-skinned individuals. Immunomodulating agents, such as clofazimine and dapsone have been shown to lighten this disorder, although, the exact mode of action is not clear.
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References
Taylor SC. Skin of color: biology, structure, function, and implications for dermatologic disease. J Am Acad Dermatol 2002; 46 (Suppl.2): S41–62
O’Brien TJ, Dyall-Smith D, Hall AP. Melasma of the forearms. Austral J Dermatol 1997; 38: 35–7
Grimes PE. Melasma: etiologic and therapeutic considerations. Arch Dermatol 1995; 131: 1453–7
Sanchez NP, Pathak MA, Sato S, et al. Melasma: a clinical, light microscopic, ultrastructural, and immunofluorescence study. J Am Acad Dermatol 1981; 4: 698–710
Taylor SC. Epidemiology of skin diseases in ethnic populations. Dermatol Clin 2003; 21 (4): 601–7
Kimbrough-Green CK, Griffiths CEM, Finkel LJ, et al. Topical retinoic acid (tretinoin) for melasma in Black patients: a vehicle-controlled clinical trial. Arch Dermatol 1994; 130: 727–33
Resnik S. Melasma induced by oral contraceptive drugs. JAMA 1967; 199: 95–9
Johnston GA, Sviland L, McLelland J. Melasma of the arms associated with hormone replacement therapy [letter]. Br J Dermatol 1998; 139: 932
Hassan I, Kaur I, Sialy R, et al. Hormonal milieu in the maintenance of melasma in fertile women. J Dermatol 1998; 25: 510–2
Katsambas AD, Stratigos AJ. Depigmenting and bleaching agents: coping with hyperpigmentation. Clin Dermatol 2001; 19: 483–8
Kramer KE, Lopez A, Stefanato CM, et al. Exogenous ochronosis. J Am Acad Dermatol 2000; 42: 869–71
Levin CY, Maibach H. Exogenous ochronosis: an update on clinical features, causative agents and treatment options. Am J Clin Dermatol 2001; 2: 213–7
Perez-Bernal A, Munoz-Perez MA, Camacho F. Management of facial hyperpigmentation. Am J Clin Dermatol 2000; 1 (5): 261–8
Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol 1975; 111: 40–8
Kang WH, Chun SC, Lee S. Intermittent therapy for melasma in Asian patients with combined topical agents (retinoin acid, hydroquinone and hydrocortisone): clinical and histological studies. J Dermatol 1998; 25: 587–96
Yoshimura K, Harii K, Aoyama T, et al. A new bleaching protocol for hyperpigmented skin lesions with a high concentration of all-trans-retinoic acid aqueous gel. Aesthetic Plast Surg 1999; 23: 285–91
Tadaki T, Watanabe M, Kumasaka K, et al. The effect of topical tretinoin on the photodamaged skin of Japanese. Tohoku J Exp Med 1993; 169: 131–9
Griffiths CEM, Finkel LJ, Ditre CM, et al. Topical tretinoin (retinoic acid) improves melasma: a vehicle-controlled, clinical trial. Br J Dermatol 1993; 129: 415–21
Balina LM, Graupe K. The treatment of melasma: 20% azelaic acid versus 4% hydroquinone cream. Int J Dermatol 1991; 30: 893–5
Verallo-Rowell VM, Verallo V, Graupe K, et al. Double-blind comparison of azelaic acid and hydroquinone in the treatment of melasma. Acta Derm Venereol Suppl. (Stockh) 1989; 143: 58–61
Garcia A, Fulton JE. The combination of glycolic acid and hydroquinone or kojic acid for the treatment of melasma and related conditions. Dermatol Surg 1999; 22: 443–7
Jimbow K. N-acetyl-4–5cysteaminylphenol as a new type of depigmenting agent for the melanoderma of patients with melasma. Arch Dermatol 1991; 127: 1528–34
Lim JTE, Tham SN. Glycolic acid peels in the treatment of melasma among Asian women. Dermatol Surg 1997; 23: 177–9
Sarkar R, Kaur C, Bhalla M, et al. The combination of glycolic acid peels with a topical regimen in the treatment of melasma in dark-skinned patients: a comparative study. Dermatol Surg 2002; 28: 828–32
Hurley ME, Guevara IL, Gonzales RM, et al. Efficacy of glycolic acid peels in the treatment of melasma. Arch Dermatol 2002; 138: 1578–82
Grimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups. Dermatol Surg 1999; 25: 18–22
Taylor CR, Anderson RR. Ineffective treatment of refractory melasma and post-inflammatory hyperpigmentation by Q-switched laser. J Dermatol Surg Oncol 1994; 20: 592–7
Manaloto RM, Alster T. Erbium:YAG laser resurfacing for refractory melasma. Dermatol Surg 1999; 25: 121–3
Nouri K, Bowes L, Chartier T, et al. Combination treatment of melasma with pulsed CO2 laser followed by Q-switched alexandrite laser: a pilot study. Dermatol Surg 1999; 25: 494–7
Nordlund JJ. Postinflammatory hyperpigmentation. Dermatol Clin 1988; 6: 185–92
Ruiz-Maldonado R, Orozco-Covarrubias ML. Postinflammatory hypopigmentation and hyperpigmentation. Semin Cutan Med Surg 1997 Mar; 16 (1): 36–43
Bulengo-Ransby SM, Griffiths CEM, Kimbrough-Green CK, et al. Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in Black patients. N Engl J Med 1993; 328: 1438–43
Burns RL, Prevost-Blank PL, Lawry MA, et al. Glycolic acid peels for postinflammatory hyperpigmentation in Black patients. Dermatol Surg 1997; 23: 171–5
Watanabe S, Brorson S, Dalickas G, et al. Comparative studies of femtosecond to microsecond laser pulses on selective pigmented cell injury in skin. Photochem Photobiol 1991; 53: 757–62
Dereure O. Drug-induced skin pigmentation: epidemiology, diagnosis and treatment. Am J Clin Dermatol 2001; 2: 253–63
Basler R. Minocycline-related hyperpigmentation. Arch Dermatol 1985; 121: 606–8
Argenyi ZB, Finelli L, Bergfeld WF, et al. Minocycline-related cutaneous hyperpigmentation as demonstrated by light microscopy, electron microscopy and X-Ray energy spectroscopy. J Cutan Pathol 1987; 14: 176–80
Odom RB, James WD, Berger TG. Contact dermatitis and drug eruptions. In: Odom RB, James WD, Berger TG, et al., editors. Andrew’s diseases of the skin: clinical dermatology. 9th ed. Philadephia (PA): WB Saunders Co., 2000: 133–4
Sokol RJ, Lichtenstein PK, Farrell MK. Quinacrine hydrochloride-induced yellow discoloration of the skin in children. Pediatrics 1982; 69 (2): 232–3
Waitzer S, Butany J, From L, et al. Cutaneous ultrastructural changes and photosensitivity associated with amiodarone therapy. J Am Acad Dermatol 1987; 16 (4): 779–87
Job CK, Yoder L, Jacobson RR, et al. Skin pigmentation from clofazimine therapy in leprosy patients: a reappraisal. J Am Acad Dermatol 1990; 23 (2): 236–41
Collins P, Cotterill JA. Minocycline-induced pigmentation resolves after treatment with the Q-switched ruby laser. Br J Dermatol 1996; 135: 317–9
Tsao H, Busam K, Barnhill RL, et al. Treatment of minocycline-induced hyperpigmentation with the Q-switched ruby laser. Arch Dermatol 1996; 132: 1250–1
Becker-Wegerich PM, Kuhn A, Malek L, et al. Treatment of nonmelanotic hyperpigmentation with the Q-switched ruby laser. J Am Acad Dermatol 2000; 43: 272–4
Karrer S, Hohenleutner U, Szeimies RM, et al. Amiodarone-induced pigmentation resolves after treatment with the Q-switched ruby laser. Arch Dermatol 1999; 135: 251–3
Ramirez CO. The ashy dermatosis (erythema dyschromicum perstan: epidemiological study and report of 139 cases. Cutis 1967; 3: 244–7
Ing EB, Buncic JR, Weiser BA, et al. Periorbital hyperpigmentation and erythema dischromicum perstans. Can J Ophthalmol 1992; 27: 353–5
Baranda L, Torres-Alvarez B, Cortes-Franco R, et al. Involvement of cell adhesions and activation molecules in the pathogenesis of erythema dischromicum perstans (ashy dermatitis): the effect of clofazimine therapy. Arch Dermatol 1997; 133: 325–9
Kontochristopoulos G, Stavropoulos P, Panteleos D, et al. Erythema dischromicum perstans: response to dapsone therapy. Int J Dermatol 1998; 37: 790–9
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No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.
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Stratigos, A.J., Katsambas, A.D. Optimal Management of Recalcitrant Disorders of Hyperpigmentation in Dark-Skinned Patients. Am J Clin Dermatol 5, 161–168 (2004). https://doi.org/10.2165/00128071-200405030-00004
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DOI: https://doi.org/10.2165/00128071-200405030-00004