As we age, brown spots and splotchy skin are all too often a fact of life. But for people with darker skin, changes in pigmentation can occur without warning at any age and can be very difficult to treat. Fortunately, dermatologists can help people with skin of color diagnose and treat bothersome pigmentation problems.
At the American Academy of Dermatology’s Summer Academy Meeting 2009 in Boston, dermatologist Jonith Y. Breadon, M.D., FAAD, co-chair of Dermasurgery at John H. Stroger, Jr. Hospital of Cook County in Chicago, discussed pigmentation problems that occur more frequently in darker-skinned patients and how early diagnosis is key to stopping the progression of these skin conditions.
“Even though people with skin of color have less moles and experience less premature aging from the sun than lighter-skinned individuals, in some ways their darker pigmentation makes their skin more vulnerable to other skin problems,” said Dr. Breadon. “While these skin discolorations can be stubborn, there are treatments that offer noticeable improvement.”
One of the most common pigmentation problems in darker-skinned individuals is hyperpigmentation (or the darkening of the skin). Usually the result of some type of inflammation or injury to the skin, such as a cut, burn or scrape, hyperpigmentation produces darkened areas of the skin that can last months or years. Even healed acne lesions can leave permanent dark spots in darker-skinned people that, in some cases, can be more distressing than the original acne.
Dr. Breadon noted that treatments for hyperpigmentation are based on whether or not the dark areas are confined to the surface of the skin or if they have penetrated to the deeper layers of the skin. For superficial dark spots, a prescription topical medication consisting of hydroquinone, retinoic acid and mild hydrocortisone can be effective in fading skin discoloration. Deeper dark areas require an in-office surgical procedure, such as dermabrasion, chemical peels, or microdermabrasion with an infusion of hydroquinone solution. In patients with lighter skin, intense pulsed light (IPL) or one of the pigmented lasers could be considered.
“Patients with any type of hyperpigmentation problem need to use a sunscreen with a high sun protection factor (SPF) regularly - the higher SPF the better,” said Dr. Breadon. “There is no cure for this condition, so even when patients experience clearing, it can come back. For most patients, I usually recommend a three-month topical regimen then long-term maintenance with a sunscreen.”
Often referred to as the “mask of pregnancy,” melasma is a skin condition marked by brown patches on areas such as the face, neck and arms that most often affects dark-skinned people and women in particular. Many dermatologists have long believed that there may be a hormonal component to melasma, and a recently published study found that there were an increased number of estrogen receptors in areas where patients developed melasma.
For this reason, Dr. Breadon advises patients with melasma to consider stopping oral contraceptives and hormone replacement therapy due to the large amount of estrogens in these medications. Regular sunscreen use is vital to protect the skin from further hyperpigmentation.
With melasma, the skin can be affected in three different ways: on the epidermis (superficial layer), in the dermis (deep layer) or a mixture of both the epidermis and dermis. Dermatologists use a light device known as the Woods lamp, which shows skin diseases as specific colors, to determine how deep melasma has penetrated the skin.
For superficial melasma, the triple cream combination of hydroquinone, retinoic acid and mild hydrocortisone with regular sunscreen use can be effective, with clearance occurring in about three months for most patients. Dr. Breadon noted that cases where melasma has penetrated the dermis are very difficult to treat and the combination triple cream medication will not be effective in these patients. However, some patients may experience improvement with microdermabrasion, dermabrasion, chemical peels or lasers. In cases where both the epidermis and the dermis are involved, the triple cream medication may offer some improvement for some patients.
“Melasma is hard to define, as it can occur in women during or after pregnancy or in women who have never been pregnant or used oral contraceptives,” said Dr. Breadon. “While lasers can be effective, there are risks of further hyperpigmentation and results vary greatly from person to person. Dermatologists can help patients decide the best course of treatment, depending on the severity of the condition.”
Lichen planus is a common inflammatory disease of the skin and the mouth that is characterized by a rash of round, or oval, violet-colored lesions. While lichen planus can affect people of all races and genders, it is more pronounced in people with darker skin since, as the lesions heal, the affected skin can develop very dark, leopard-looking spots.
When caught early, steroid injections are used to reduce the inflammation thereby minimizing hyperpigmentation. However, if the condition progresses before it can be treated and dark spots appear, Dr. Breadon explained that the triple cream topical medication, mild or systemic steroids, or lasers can be used with varying degrees of success to try to lighten the darkened areas of the skin.
“Detecting lichen planus early can make all the difference between spots that heal without hyperpigmentation and spots that are extremely pronounced and do not fade on their own,” said Dr. Breadon. “That’s why it is critical that people who experience an unexplained rash see their dermatologist immediately for proper diagnosis and treatment.
Another skin condition that affects people of color, and especially African-Americans, is ashy dermatosis. While the cause of ashy dermatosis is unknown, it usually starts as a flat, dark grayish-brown rash that appears bi-laterally (or on both sides of body, such as both arms or both legs).
Ashy dermatosis closely resembles a condition known as fixed drug eruption, which causes the same type of pigmentation problem and is the result of an allergy to a food, medication or workplace trigger. For example, one of Dr. Breadon’s patients with this type of rash noticed a flare when she would consume a particular sugar substitute - which was eventually identified as the trigger.
“Based on my evaluation of numerous cases of ashy dermatosis and fixed drug eruption, my theory is that these two conditions are actually one in the same,” said Dr. Breadon. “That’s why I think it is so important to identify the trigger, as this can help alleviate the rash and prevent its spread. I encourage my patients to keep a food diary or a list of any medications or items with which they come into contact to see if we can identify the source of the problem.”
Dr. Breadon noted that ashy dermatosis and fixed drug eruption can be very difficult to treat. A compound lotion of salicylic acid, a mid-potency steroid and hydroquinone can offer gradual clearing. Regular use of sunscreen with a high SPF also is highly recommended to avoid further hyperpigmentation.
“It is important for people with darker skin to be aware of any changes in their skin and to see a dermatologist at the first sign of anything unusual,” said Dr. Breadon. “Dermatologists not only can diagnose and provide the best treatment options for a particular pigmentation problem, but also can rule out a serious condition, such as skin cancer.”
Headquartered in Schaumburg, Ill., the American Academy of Dermatology (Academy), founded in 1938, is the largest, most influential, and most representative of all dermatologic associations. With a membership of more than 16,000 physicians worldwide, the Academy is committed to: advancing the diagnosis and medical, surgical and cosmetic treatment of the skin, hair and nails; advocating high standards in clinical practice, education, and research in dermatology; and supporting and enhancing patient care for a lifetime of healthier skin, hair and nails.