Dr Taylor on Treating Hyperpigmentation in Skin of Color

In this podcast, Susan Taylor, MD, discusses common causes of pigmentary disorders and effective procedural and medical options for improving hyperpigmentation among patients with skin of color.

Dr Taylor is the Sandra J. Lazarus Professor of Dermatology, vice chair for Diversity, Equity, and Inclusion, associate professor of Dermatology at the University of Pennsylvania Perelman School of Medicine, as well as the vice president of the American Academy of Dermatology and founder of Skin of Color Society.

Transcript

Melissa: Hello. Welcome to another podcast with The Dermatologist. Today, we will be speaking with Dr Susan Taylor on the treatment of pigmentary disorders among patients with skin of color. Dr Taylor presented on this topic at the Skin of Color Update.

She is the Sandra J. Lazarus Professor of Dermatology, Vice Chair for Diversity, Equity, and Inclusion, and Associate Professor of Dermatology at the University of Pennsylvania Perelman School of Medicine. Dr Taylor is also the Vice President of the American Academy of Dermatology and founder of Skin of Color Society. Thank you so much for joining us today, Dr Taylor.

What are some of the common causes of hyperpigmentation in patients with skin of color?

Dr Susan Taylor: The majority of patients with skin of color who present with pigmentation disorders have post-inflammatory hyperpigmentation, most often as the result of acne. There’s also melasma that we see commonly in a variety of age groups.

Then there is hyperpigmentation associated with aging, where women and men, when they’re in their 50s and 60s and beyond, will notice an overall darkening of their facial skin hue, as well as a darkening of other areas of sun exposure. Those are the three that I see most often. Let me add that any types of inflammation or injury can produce pigmentary disorders.

Melissa: Which topical treatment options are effective for improving primary pigmentary disorders?

Dr Taylor: The foundation for our treatment of pigmentary disorders in patients with skin of color is photoprotection, and I cannot emphasize the importance of photoprotection with a myriad of agents.

Let’s talk about sunscreens. The previous paradigm is that sunscreens have been used to prevent worsening of pigmentary disorders, but now there’s a new paradigm. That is based upon more recent studies that have been published, that have determined that sunscreen use is really therapeutic for the treatment of pigmentary disorders.

For example, there are studies that show that regular application of broad-spectrum sunscreens that block UVA and UVB can improve hyperpigmentation. There are more recent studies that have demonstrated the role of visible light and blocking visible light with iron oxide or antioxidants can improve melasma specifically. The foundation for treatment of pigmentary disorders rely on sunscreens and then other methods of photoprotection, such as clothing, hats, and sunglasses.

The next level of treatment then revolves around our gold standards, and our gold standards include 4% hydroquinone, although it is often compounded to 6, 8, and 10%.

There are also products that contain hydroquinone in addition to a retinoid or a topical steroid, for example. The bottom line is that hydroquinone remains the gold standard for most pigmentary disorders.

There is a triple combination cream that contains hydroquinone as well as a retinoid and a topical steroid. That is the gold standard for treatment of melasma. Now, whereas both of these medications are usually well-tolerated in skin of color, they can produce redness, irritation, and rarely, a contact allergic dermatitis.

Now, for irritation and redness, as well as drying and peeling, these side effects can be managed by decreasing the number of times of application, as well as increasing moisturization of the skin.

There are a host of cosmeceutical agents with a variety of ingredients that can also be safe and effectively used for the treatment of pigmentary disorders. Of the cosmeceuticals of note are some new formulations. For example, cysteamine hydrochloride has been recently released, and that has been demonstrated in clinical trials, at a 5% concentration, to have significant reduction in melasma, for example.

We are all well-aware of the new data on oral tranexamic acid, but there are some topical cosmeceutical agents that contain tranexamic acid in a 3% concentration. They are combined with other ingredients such as kojic acid, which is a tyrosinase inhibitor, as well as niacinamide, which is an agent that decreases the transfer of melanosomes from melanocytes into keratinocytes.

Finally, there’s a very new agent, a resorcinol agent, that has been released in Africa, Latin America, and Europe. It is called isobutylamido thiazolyl resorcinol, and that will be coming to the United States shortly. Those are some of the new over-the-counter cosmeceutical agents that we rely on for the treatment of pigmentary disorders.

Melissa: For pigmentary disorders caused by inflammatory conditions, such as atopic dermatitis or psoriasis, are those still the mainstay of treatment, or are there better options for more sensitive skin?

Dr Taylor: The inflammatory disorders such as atopic dermatitis and psoriasis can be very difficult to treat the resulting post-inflammatory hyperpigmentation. That is because in atopic dermatitis in particular, there is a derangement of the barrier. Some of our agents that I just talked about can cause further irritation of the skin and can be poorly tolerated in these inflammatory disorders.

I think what is critically important for these particular disorders is to bring the inflammatory component completely under control, to use good moisturization, and particularly moisturizers that are going to provide a good occlusive barrier. Then once that barrier has been repaired, then we can use, let us say, more gentle agents.

For example, kojic acid and azelaic acid are often better tolerated, although I must point out they don’t have the same efficacy as our gold standard hydroquinone or triple combination therapy. With those particular inflammatory disorders, we have to utilize or exert more caution.

For our acne-induced post-inflammatory hyperpigmentation, generally the barrier is intact, and those patients can indeed tolerate 4% hydroquinone. They can tolerate and also benefit from topical retinoids.

We have not talked about procedural treatments like chemical peels. Patients with acne and PIH from acne can specifically benefit with salicylic acid peels, which can assist in the improvement of their acne, as well as their PIH.

Melissa: Going off of that, what procedures are effective for pigmentary disorders?

Dr Taylor: There are several procedures that can be used safely and can be effective for the treatment of pigmentary disorders in skin of color. Chemical peeling agents, particularly superficial chemical peeling agents, can significantly improve post-inflammatory hyperpigmentation.

We rely on glycolic acid, as well as salicylic acid-containing peels, as well as combination peels that contain low concentrations of, let’s say, trichloroacetic acid. We rely on Jessner solution or modified Jessner solution, and those chemical peeling agents can be utilized every three to four weeks in a series of four to six peels.

There have been studies that have demonstrated an improvement with microneedling as an adjuvant treatment for melasma, for post-inflammatory hyperpigmentation and in some cases, certain specific lasers. For example the 650-microsecond Nd:YAG 1064 laser is appropriate for the treatment of melasma, post-inflammatory hyperpigmentation, and acne in individuals with skin of color.

My word of caution is that you need to go slowly when you are using procedures to treat post-inflammatory hyperpigmentation in our skin of color patients, and you can really benefit and our patients can benefit if we perform test spots, test areas, with these therapeutic modalities to assess how skin of color is responding to that specific therapeutic modality.

Melissa: Kind of going off of that, what pitfalls should dermatologists keep in mind and things they should avoid when treating pigmentary disorders in skin of color patients, especially ones with darker phototypes?

Dr Taylor: The primary pitfall that a dermatologist can run into when treating individuals for pigmentary disorders is inducing further post-inflammatory hyperpigmentation from irritation or being far too aggressive. Here’s a patient who comes to you to decrease their hyperpigmentation, and you’ve actually increased it. You’re not going to have a very happy patient.

The most important pearl is to know that patient’s skin, to proceed very carefully, to instruct the patient that if he or she experiences redness, burning, tingling to discontinue the topical agent immediately and give you a call. Often, we can rely on our topical steroids to calm everything down before further post-inflammatory hyperpigmentation is induced.

Likewise with procedures, be it chemical peels or microneedling or laser, if we start off cautiously doing a test spot first and then assessing what the skin looks like, you can’t go wrong, and then you can do larger areas and be a little bit more aggressive depending upon the response to your treatment.

Melissa: What additional research is needed to improve the treatment of pigmentary disorders?

Dr Taylor: Of course, there is a need for additional research for even more effective therapeutic agents. Although we do have our gold standards, very few new agents have come out in the last 5 to 10 years. I did highlight some of the new ones, but there is additional room for even more therapeutic modalities, be it topical agents or procedural agents. I think we are still in our infancy of finding solutions for pigmentary disorders.

Melissa: What final takeaways would you like to leave our audience with?

Dr Taylor: In summary, for treatment of our pigmentary disorders, first we’re going to try to prevent the disorder or treat very aggressively the disorder that has caused the pigmentary disorder if it’s post-inflammatory hyperpigmentation. We want to use a very aggressive photoprotection and then rely on our gold standards of topical treatment, as well as newer cosmeceutical agents, and finally the myriad of procedural treatments that are now in our therapeutic armamentarium.

Melissa: Thanks again for joining us today, Dr Taylor. If you have any questions or comments, please submit them in the feedback box below, and thank you for listening.