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What will the patient tell you? (History)
What will the patient tell you? (History)
Pigmentation disorders involve altered melanin production, melanocyte number, or melanin distribution, resulting in areas with too much pigment (hyperpigmentation) or too little pigment (hypopigmentation/depigmentation).
Onset & Triggers:
Sun exposure (major driver), Hormones (pregnancy, OCPs to melasma), Inflammation (acne, eczema to PIH), Infections (pityriasis versicolor), or Drugs.
Symptoms:
Dark patches that worsen with sun, heat, or injury, or light/white patches after inflammation or spontaneously. Cosmetic worry is usually the main concern.
History Specific to Skin of Colour (SOC):
Pigmentation disorders are more common, more severe, and more persistent in SOC because melanocytes are more active and easily stimulated.
Inflammation (e.g., redness from acne) is often under-recognized as it may appear brown, not red, leading to more subsequent PIH.
Patches often appear deep brown, blue-black, or charcoal, and pigment may sit deeper in the dermis, making treatment more stubborn.
Hypopigmented patches are often more noticeable against the background tone, causing higher psychological distress.
What will it look like? (Examination)
Hyperpigmentation
Description / Location: Brown, grey-brown, or black macules/patches. Common patterns include malar/centrofacial (melasma) or dark patches following injury (PIH).
SOC Features: More likely to show slate-grey or ash-brown tones. Pigment may be dermal, which is difficult to treat.
Hypopigmentation
Description / Location: Off-white or light patches (e.g., pityriasis alba, tinea versicolor).
SOC Features: Contrast is higher, making patches appear more dramatic and psychologically distressing.
Depigmentation
Description / Location: Chalk-white patches showing total absence of melanin (e.g., vitiligo, halo naevus).
SOC Features: Highest contrast and greatest distress.
Tools:
Wood’s lamp can help differentiate between epidermal (brighter under light) and dermal (no change) pigment, aiding prognosis and treatment choice.
Image of hypopigmentation
Image Sourced From Skin Sight
Image of hyperpigmented patches on the forehead
Image Sourced From cosmetic dermatology jax
How can you help? (Treatment)
Management is complex, requires strict sun avoidance, and must prioritize avoiding irritation to prevent worsening PIH.
1. General Measures (Crucial for Hyperpigmentation)
Daily broad-spectrum SPF 50+ sunscreen (must cover UVA, UVB, and visible light).
Gentle skincare; avoid harsh scrubs or irritants to reduce the risk of PIH.
Stop causative drugs where possible.
2. Treatment of HYPERPIGMENTATION
Topical Agents (First-line)
Hydroquinone (2%–4% ): Highly effective tyrosinase inhibitor.
Azelaic Acid, Niacinamide: Preferred early for SOC as they are anti-inflammatory and non-irritating, minimizing PIH risk.
Topical Retinoids: Promote skin turnover to reduce pigment.
Vitamin C, Kojic Acid: Antioxidant and natural depigmenting agents.
Advanced Treatments:
Oral Tranexamic Acid: Highly effective for melasma (reduces vascular influence on melanocytes).
Chemical Peels: Use lower concentrations and avoid aggressive peels to prevent rebound PIH.
Laser Therapy: High risk of PIH or hypopigmentation. If used, prefer picosecond or Q-switched Nd:YAG lasers with extreme caution.
Microneedling: Useful for melasma; often considered safer than many lasers in SOC.
3. Treatment of HYPOPIGMENTATION
Identify Cause: Treat underlying cause (e.g., eczema for pityriasis alba, antifungals for tinea versicolor).
Repigmentation Therapies (for Vitiligo):
Topical calcineurin inhibitors, Ruxolitinib 1.5% cream (proven repigmentation).
Phototherapy (NB-UVB): The hallmark treatment for widespread vitiligo.
SOC Considerations: Avoid long-term topical steroids on the face due to risk of atrophy or iatrogenic hypopigmentation.
Sources
Thawabteh AM et al. - Skin Pigmentation Types, Causes and Treatment—A Review: https://pmc.ncbi.nlm.nih.gov/articles/PMC10304091/
DermNet NZ – Skin pigmentation problems: https://dermnetnz.org/topics/skin-pigmentation-problems
DermNet NZ – Pigmentation disorders: https://dermnetnz.org/topics/pigmentation-disorders
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