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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 122-126

A retrospective evaluation of patient profiles, investigations, and treatment modalities used within a pigmentary disorders clinic in Australia


1 The Skin Hospital, Sydney, New South Wales, Australia
2 Faculty of Medicine, University of New South Wales, Sydney, Australia

Date of Submission05-Feb-2021
Date of Decision08-Apr-2021
Date of Acceptance13-Apr-2021
Date of Web Publication12-Aug-2022

Correspondence Address:
Dr. Brent J Doolan
The Skin Hospital, Darlinghurst, 121 Crown Street, Darlinghurst, New South Wales, 2010
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pigmentinternational.pigmentinternational_

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  Abstract 


Background: Pigmentary disorders are a common presentation in dermatology practice and can be challenging to manage and require expert intervention. Currently, there are limited data on Australian patients presenting with pigmentary disorders. Aims: The aim of the study was to undertake a review of patients presenting with pigmentary disorders and to compare serology, treatment, and quality of life data to global data. Methods: A retrospective, observational study was undertaken in patients attending the pigmentary disorders clinic at The Skin Hospital, Sydney from June 2012 to March 2020. Data collection included demographics, disease duration, baseline nutritional and autoimmune serology, quality of life scores, and treatments undertaken. Results: 776 patients were identified, with 600 patients (54.3%, female) attending for management of pigmentary disorders. The mean age at time of clinic attendance was 34.5 ± 17.0 years. Vitamin D deficiency, anemia, and abnormal thyroid serology were present in 36.5%, 8.4%, and 6.6% of patients, respectively. Among vitiligo patients, a positive family history of vitiligo and autoimmune disease was present in 17.0% and 20.1% of patients, respectively. Serological testing revealed a 29.5% prevalence of thyroid autoimmunity. A mean treatment time of 1.04 ± 0.62 years was required to decrease dermatology life quality index (DLQI) scores from severe to mild (P < 0.001). Based on DLQI scores, 59% of severe and 18% of patients with moderate scores reduced their baseline scores to mild at follow-up (mean follow-up time of 1.21 ± 1.01 years). Conclusion: This study is the first to investigate the profile and management of patients with pigmentary disorders and highlights the need for such a clinic in an increasingly multiracial Australia.

Keywords: Australia, pigmentary disorders, treatment, vitiligo


How to cite this article:
Doolan BJ, Yeon J, Weaich M, Gupta M. A retrospective evaluation of patient profiles, investigations, and treatment modalities used within a pigmentary disorders clinic in Australia. Pigment Int 2022;9:122-6

How to cite this URL:
Doolan BJ, Yeon J, Weaich M, Gupta M. A retrospective evaluation of patient profiles, investigations, and treatment modalities used within a pigmentary disorders clinic in Australia. Pigment Int [serial online] 2022 [cited 2022 Sep 30];9:122-6. Available from: https://www.pigmentinternational.com/text.asp?2022/9/2/122/353679




  Introduction Top


Pigmentary disorders of the skin such as vitiligo, melasma, and post inflammatory hyperpigmentation/hypopigmentation are relatively common conditions amongst the general population, with a global prevalence of approximately 2% to- 6%.[1],[2] They are also a common presentation in dermatology practice and can be challenging to treat, requiring some expertise in management.[3] Patient concern associated with cosmesis and therapeutic difficulty can have a significant impact on quality of life, with patient’s reporting shame, reduced self-confidence, and a negative influence on psychosexual identity, interpersonal relationships, and work productivity.[4]

Currently, there is limited data on the demographics, quality of life, serological investigations, and treatment modalities of Australian patients presenting with pigmentary disorders.[5] Management and treatment of these patients is largely based on data obtained from overseas publications and international clinical trials.[2],[4],[6] Given the increasingly multicultural demographic profile of Australia, international data used for management of this cohort may not be representative. Thus, the aim of the present study was to undertake a review of patients presenting with pigmentary disorders in Australia and to assess and compare serology, treatment, and quality of life data to global data.


  Methods Top


A retrospective, observational study was undertaken of patients who attended the pigmentary disorders clinic at The Skin Hospital, Sydney, Australia from June 2012 to March 2020. Data collection included demographics, treatment modalities, baseline autoimmune serology, and other relevant investigations for vitiligo patients. Quality of life was assessed at a patient’s first visit and at their subsequent visits using the dermatology life quality index (DLQI) instrument. Biochemical and serological reference ranges were based on those from The World Health Organization [Table 3].[7],[8],[9],[10],[11],[12] Ethics and governance were approved by The University of New South Wales Human Research Ethics Committee (HC200549). Summary statistics are presented as mean ± standard deviation (SD) and median (Q1, Q3). Multivariable models were used to compare treatment modalities and quality of life data.


  Results Top


Clinic presentations

A total of 776 patients were referred to the pigmentary disorders clinic, with 600 patients (54.3% female) identified with pigmentary disorders from any part of the body (those excluded included: failure to attend clinic, n = 142 and diagnosis other than a pigmentary disorder, n = 34), with demographic data presented in [Table 1]. The majority of referrals were from primary care physicians (64.8%), with 32.0% of referrals from dermatologists, requesting a second opinion or assistance with difficult-to-treat pigmentary conditions. Substantial distances were travelled by patients (median of 18 km), with 5% of patients travelling interstate (>250 km) for their appointments.
Table 1 Baseline characteristics of patients

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Vitiligo presentations

A subanalysis of vitiligo patients illustrated a family history of vitiligo (17.0%) and thyroid disease (11.3%) [Table 2]. Vitiligo patients demonstrated an association with additional autoimmune diseases, present in 20.8% (95/456) of patients. Serological testing of vitiligo patients showed thyroid autoimmunity, while also showing vitamin D deficiency, anemia, and abnormal thyroid stimulating hormone in 35.9%, 8.9%, and 6.5% of patients, respectively. For segmental vitiligo patients, a median duration of disease at the time of presentation was 1.0 year (0.5, 5.0) [Table 3].
Table 2 Subanalysis of vitiligo patients presenting to the pigmentary disorders clinic

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Table 3 World Health Organization laboratory reference ranges

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Treatment modalities and quality of life

Topical therapy was the most prescribed treatment among vitiligo, melasma, and postinflammatory dyspigmentation presentations [Figure 1]. Treatment modalities were not mutually exclusive. More than 75% of vitiligo patients were prescribed topical calcineurin inhibitors with ∼50% using narrowband UVB phototherapy and topical vitamin D analogs with corticosteroids. Among vitiligo patients, excimer light therapy was used in ∼30% of patients with ∼25% attending the nurse-led camouflage clinic. Treatment of melasma was managed with correcting creams, including topical retinoids (54.8%), hydroquinone (51.6%), and corticosteroids (48.4%). Postinflammatory hypopigmentation was treated predominantly with topical calcineurin inhibitors, though topical/systemic antifungal agents and topical corticosteroids were also used as hypopigmentation was sometimes a result of active or subsided fungal infections or eczema.
Figure 1 Bar graph outlining treatment modalities prescribed to the most common presentations within the pigmentary disorders clinic. Multiple responses in treatment were possible

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For all patients presenting to the clinic, a mean treatment time of 1.04 ± 0.62 years was required to decrease DLQI scores from severe (≥11/30) to mild (<6/30) (P < 0.001). Based on DLQI scores, 59% of severe and 18% of patients with moderate scores reduced their baseline DLQI scores to mild at follow-up (mean follow-up time of 1.21 ± 1.01 years).


  Discussion Top


We noted a median Fitzpatrick phototype that differed from other international cohorts, indicating lighter skin types in our cohort, particularly compared to data from south-east Asian regions.[3],[13] No significant differences in gender were noted, though some studies have indicated a higher prevalence of female presentations given increased cosmetic concern due to cultural beliefs.[1],[3] The prevalence of segmental vitiligo compared to nonsegmental vitiligo was much higher than previously reported studies (∼8–16%), possibly due to segmental vitiligo being more recalcitrant to treatment and requiring additional specialist involvement.[2],[14] There was delayed access to effective treatment, which significantly impacts the quality of life of patients.[4] These delays were also observed among patients presenting with segmental vitiligo, which is of concern given that the treatment is most effective within the first 6 months of disease.[14] Delays may be due to a lack of awareness of tertiary services, the remoteness of some Australian patients, and the high wait times/out-of-pocket costs to patients when accessing specialist services.[15]

Among vitiligo patients, there was an association with a family history of autoimmune disease, particularly vitiligo and thyroid disease, consistent with previous studies.[6],[16],[17],[18] Similarly, rates of detected antibodies were comparable to the literature, especially for thyroid autoimmunity.[17],[18] Vitiligo patients were noted to have a high prevalence of vitamin D deficiency (35.9%), higher than the prevalence among the general Australian population (23.5%),[19] larger controlled studies are required to ascertain whether vitamin D has any cause/effect association with vitiligo. Despite Australia having year-round sun exposure, these patients may have been avoiding an outdoor lifestyle due to the embarrassment of their disease.

Three agents were prescribed in ∼50% of melasma patients, aligning with current best practice of combined triple therapy for melasma treatment.[4] Oral tranexamic acid was prescribed in 16.1% of melasma patients, supporting data from randomized controlled studies showing melasma improvement with the use of adjuvant oral tranexamic.[14] It was noted that a proportion of presentations were for postinflammatory hypopigmentation, with topical/systemic antifungal agents used, indicating misdiagnosis of fungal lesions as pigmentary lesions in the primary care setting.

Up to a quarter of patients accessed the camouflage clinic, highlighting the importance of adjuvant therapy, especially given the significant improvement in quality of life associated with vitiligo cosmetic camouflage.[1],[20] Given the difficulty in effective treatment and the slow response in treatment, camouflage can be an effective therapy for improving self-confidence and quality of life when physical cosmesis is not reached.[20] We noted significant improvement in DLQI scores among all patients, representing a holistic approach to treatment including dermatological consultation, nurse consultation for camouflage, and referral for psychological assessment for cognitive behavioural therapy. Comparing the baseline and final follow-up DLQI questionnaires, there was significant translatable improvement in quality of life, though vitiligo-specific quality of life instruments may have provided more specific information for this subgroup.[2] We were unable to ascertain treatments that were used in the primary care setting before clinic attendance, which may under-represent treatment modalities. We recommend this holistic model of care as it provides a range of phototherapy options, access to camouflage, and referrals for psychological support in addition to surgical therapies for stable disease. This has been associated with a high satisfaction in a survey of our patients.[21] This study is the first to investigate the profile and management of Australian pigmentary disorders patients and highlights the need for such a clinic in an increasingly multiracial country.

Acknowledgments

We would like to acknowledge Dr Nancy Briggs, senior statistical consultant at The University of New South Wales, for her technical assistance in providing the analysis of the quality of life data.

Ethics approval statement

Ethics and governance were approved by The University of New South Wales Human Research Ethics Committee (HC200549).

Patient consent for publication statement

Please note that all patients included in this research have signed a consent for their data to be used for research and publication.

Financial support and sponsorship

There was funding supplied from a research grant from The Vitiligo Association of Australia.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Taylor A, Pawaskar M, Taylor SL, Balkrishnan R, Feldman SR. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol 2008;7:164-8.  Back to cited text no. 3
    
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Anderson L, Rodrigues M. Quality of life in a cohort of melasma patients in Australia. Australas J Dermatol 2019;60:160-2.  Back to cited text no. 5
    
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Plensdorf S, Livieratos M, Dada N. Pigmentation disorders: diagnosis and management. Am Fam Physician 2017;96:797-804.  Back to cited text no. 6
    
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World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva: WHO. 2011. Available from https://www.who.int/vmnis/indicators/haemoglobin.pdf. [Accessed 2021 January 05].  Back to cited text no. 7
    
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World Health Organization. Serum and red blood cell folate concentrations for assessing folate status in populations. Geneva: WHO. 2012. Available from https://www.who.int/vmnis/indicators/serum_RBC_folate.pdf. [Accessed 2021 January 05].  Back to cited text no. 8
    
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World Health Organization. Conclusions of a WHO Technical Consultation on folate and vitamin B12 deficiencies. Food Nutr Bull 2008;29:S238-44.  Back to cited text no. 9
    
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De-Regil LM, Palacios C, Lombardo LK, Peña-Rosas JP. Vitamin D supplementation for women during pregnancy. Cochrane Data Sys Rev 2016;1:CD008873.  Back to cited text no. 10
    
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World Health Organization. Evaluating the public health significance of micronutrient malnutrition. Geneva: WHO. 2006. Available from https://www.who.int/nutrition/publications/micronutrients/GFF_Part_2_en.pdf. [Accessed 2021 January 05].  Back to cited text no. 11
    
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World Health Organization. Diagnosis and monitoring of diseases of the thyroid. Geneva: WHO. 2000. Available from https://apps.who.int/iris/bitstream/handle/10665/66342/WHO_DIL_00.4_eng.pdf?sequence=1&isAllowed=y. [Accessed 2021 January 15].  Back to cited text no. 12
    
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Nouveau S, Agrawal D, Kohli M, Bernerd F, Misra N, Nayak CS. Skin hyperpigmentation in Indian population: insights and best practice. Indian J Dermatol 2016;61:487-95.  Back to cited text no. 13
[PUBMED]  [Full text]  
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Majid I, Imran S. Excimer light therapy in childhood segmental vitiligo: Early treatment gives better results. Dermatol Ther 2020;33:e13408.  Back to cited text no. 14
    
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McIntyre D, Chow CK. Waiting time as an indicator for health services under strain: a narrative review. Inquiry 2020;57:46958020910305.  Back to cited text no. 15
    
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Minni K, Poojary S. Efficacy and safety of oral tranexamic acid as an adjuvant in Indian patients with melasma: a prospective, interventional, single-centre, triple-blind, randomized, placebo-control, parallel group study. J Eur Acad Dermatol Venereol 2020;34:2636-44.  Back to cited text no. 16
    
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Berti S, Bellandi S, Bertelli A, Colucci R, Lotti T, Moretti S. Vitiligo in an Italian outpatient center: a clinical and serologic study of 204 patients in Tuscany. Am J Clin Dermatol 2011;12:43-49.  Back to cited text no. 17
    
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van Geel N, Speeckaert M, Brochez L, Lambert J, Speeckaert R. Clinical profile of generalized vitiligo patients with associated autoimmune/autoinflammatory diseases. J Eur Acad Dermatol Venereol 2014;28:741-6.  Back to cited text no. 18
    
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Australian Bureau of Statistics. Australian health survey: biomedical results for nutrients [Cited 2020 December 20]. Available from: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/australian-health-survey-biomedical-results-nutrients/latest-release#data-download  Back to cited text no. 19
    
20.
Kornhaber R, Visentin D, Thapa DK et al. Cosmetic camouflage improves quality of life among patients with skin disfigurement: a systematic review. Body Image 2018;27:98-108.  Back to cited text no. 20
    
21.
Doolan BJ, Weaich M, Gupta M. An analysis of patient satisfaction in a pigmentary disorders clinic from a quaternary referral service. Australas J Dermatol 2021;62:e109-10. Epub ahead of print. PMID: 32632963  Back to cited text no. 21
    


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