Lichen planus pigmentosus (LPP) is a condition characterized by persistent and asymptomatic slaty-gray pigmentation, predominantly in the face. Classically, the pattern is “actinic” with symmetric and diffuse pigmentation in sun-exposed areas, commonly in dark-skinned individuals. It can also rarely present as macular pigmentation of the flexures in the lighter-skinned. LPP is a disease of the middle-aged, with onset in the third to fourth decades of life and few studies show as slightly greater incidence in females. The photo-distributed or actinic pattern, which is more common, is a disease of tropics and Type IV–Type V skin types. Reports are mainly from India, the Middle East, and South America. The inversus type is relatively rare, predominantly occurring in Caucasians. LPP is thought to be a type hypersensitivity IV reaction to unknown antigen with lichenoid inflammation, leading to melanin incontinence and superficial dermal pigmentation. The natural course of the disease is not clear with some cases showing spontaneous resolution, and some cases with persistence of pigmentation for years. In addition, LPP may have marked overlap clinically and histologically with conditions such as pigmented contact dermatitis, differentiation of which may not be possible in routine practice. Because of these issues, as well as the relative rarity of the condition, there is not much evidence on the efficacy of the various treatment options. Currently, none of the available treatment options show consistent responses or a clear superiority to other modalities, the evidence on efficacy being restricted to a few case series.

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The term “acral” means the distal portions of the limbs (hand, foot) and the head (ears, nose). The term acral melanosis is loosely applied to an increase in melanin pigmentation, in a diffuse, reticulate, or focal pattern over the distal parts of the arms and legs. There are various causes of acral pigmentation varying from genetic to acquired, benign to malignant, autoimmune to infectious, drug-induced, nutritional deficiencies, postinflammatory, and even exogenous reasons. The pigmentation may be occurring in isolation or associated with various systemic features. An earlier age of the onset of pigmentation, a positive family history, and a reticulate or mottled pattern usually point to a genetic cause. The diffuse pattern of pigmentation is usually seen in racial, endocrine diseases, and nutritional deficiencies. Postinflammatory acral pigmentation may follow both infectious and autoimmune diseases and may even be drug induced. A correct diagnosis is important to decide on the management which varies from reassurance and counseling to active treatment. This review paper is an attempt to classify acral pigmentation based on its diverse etiological causes.

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Pigmentary demarcation lines (PDLs) are areas of an abrupt transition from hyperpigmented to hypopigmented or normal skin color. They are seen on limbs, face, and sometimes trunk. They are common in the black race. There are eight groups of PDL A to H. Facial PDL should be differentiated from melasma and postinflammatory pigmentation over the face. PDL are common in black women during pregnancy and are considered to be normal variants of pigmentation. Etiology of PDL continues to be an enigma and needs further research. PDL in pregnancy may regress spontaneously after delivery and do not require treatment. Facial PDL have a persistent course posing cosmetic concern for the patient and a challenge for dermatologist.

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Nevus depigmentosus is a congenital disorder of pigmentation which occurs in all sexes and races. It commonly presents in childhood and is mostly nonprogressive. It is a form of cutaneous mosaicism with functionally defective melanocytes and abnormal melanosomes. Localized solitary lesions need to be differentiated from conditions like nevus anemicus, ash leaf macule, vitiligo, etc., and generalized lesions from hypomelanosis of Ito. Treatment is usually not required although cosmetic camouflage, phototherapy, grafting, and other modalities may be tried.

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Progressive macular hypomelanosis (PMH) is a common and often misdiagnosed disorder characterized by numerous nummular, coalescing hypopigmented macules on the trunk of adolescents, and young adults. It was originally described in patients with Fitzpatrick skin types V-VI from tropical countries, but is now understood to have a worldwide distribution in a variety of skin types. The pathogenesis of PMH is unknown, but is thought to involve Propionibacterium acnes, which has been found in abundance in the pilosebaceous units of lesional skin. Biopsies of lesions demonstrate normal architecture of epidermis and dermis, but exhibit decreased melanin content. It is important to note that this is different from vitiligo, which has a total absence of melanin. Many patients with PMH often times go misdiagnosed for tinea (pityriasis) versicolor, postinflammatory hypopigmentation, and other dyschromias. Topical antifungal and corticosteroid therapy have proven ineffective in PMH, but successes have been reported with topical and systemic antibacterial treatment modalities and even phototherapy. Given the increasing prevalence of patients with skin of color, it is important to better understand the nature of this condition, along with its diagnosis, management, and treatment.

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Skin color is determined by melanin and other chromophores and is influenced by physical factors (ultraviolet radiation) and other endocrine, autocrine, and paracrine factors. Being the largest organ of the body, any aberration in skin color (hyperpigmentation and hypopigmentation) can have impact on the patients’ quality of life. Hyperpigmentation may be circumscribed or diffuse. Diffuse hyperpigmentation can be multifactorial in origin; hence, a multipronged approach is needed in such cases. First, the cause (systemic or cutaneous) needs to be ascertained, and then disease-specific management needs to be performed. The biggest challenge in such cases is to treat the hyperpigmentation itself; hence, counseling and general treatment (the use of broad-spectrum sunscreen, the avoidance of sun exposure, etc.) play crucial role, and an interdisciplinary approach may be required, especially when the hyperpigmentation is due to a systemic cause.

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Background Melasma is a hypermelanotic disorder, which poses therapeutic challenge. Tranexamic acid (TA) and glutathione are novel therapies for the treatment of melasma. Aim To compare the therapeutic efficacy of localized intradermal microinjections (mesotherapy) of TA versus microinjections of glutathione for the treatment of melasma. Methods This prospective, comparative study was carried out to assess the therapeutic efficacy of TA and glutathione in 64 patients with dermal melasma after obtaining written informed consent, over a period of 12 weeks. Face of the patient was divided into two halves (split face); right cheek was injected with TA and the left with glutathione, at baseline (zero), 4th, 8th, and 12th weeks. The treatment response was assessed by using visual analog scale (VAS); photographs were taken to ascertain the improvement and its percentage was calculated. A parametric test, Student t test, and Z test were applied wherever applicable. P-value of <0.05 was considered statistically significant. Results Out of 64 enrolled, 50 patients completed the study and it was found that the reduction in VAS score from baseline to 8th week and baseline to 12th week was significant in both the groups (P < 0.05). However, the mean difference in improvement percentage between baseline and 8th week and baseline and 12th week with TA was found to be more significant than glutathione. Conclusion This study revealed that both TA and glutathione intradermal microinjections are effective in the treatment of melasma but TA is more effective.

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Tranexamic acid (TXA), an antifibrinolytic drug, is now gaining popularity as a depigmenting agent. It is a synthetic lysine amino acid derivative which mainly blocks the conversion of plasminogen to plasmin by inhibiting plasminogen activator. This results in less free arachidonic acid production, and hence a reduction in the prostaglandin (PG) levels as well. Thus, by reducing PG production, TXA reduces the melanocyte tyrosinase activity and plays an important role in the treatment of melasma, ultraviolet-induced hyperpigmentation, and other postinflammatory hyperpigmentation. It has been tried topically, orally, and intradermally in the management of melasma with minimal adverse effects. However, more randomized trials are needed to fully elucidate the exact mechanism of action, ideal route, frequency, and duration of administration of the drug, along with its potential to treat other pigmentary disorders.

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Tranexamic acid (TA), an anti-fibrinolytic agent, originally used for treating blood loss during surgery and various medical conditions, has been found to show promising results in melasma. TA has been tried as oral therapy, topical formulations and even intradermally, with or without adjuvants by various researchers in melasma but still there is no consensus on the optimum route, dose and timing of the treatment. A systematic literature search of the PubMed electronic database was performed using the keywords ‘melasma’, ‘chloasma’ and ‘tranexamic acid’ in the title. The abstracts of the articles were screened and reviewed for relevance. The selected articles were read in detail for inclusion and also the relevant references were traced. This review is an attempt to evaluate the role of TA by various routes in melasma and offer suggestions for future directions of research.

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Postinflammatory hyperpigmentation (PIH) is a common pigmentary disorder that is distressing to patients, particularly those with skin of color, and can be very difficult to treat. Part of this difficulty arises from the dermal melanosis in addition to the epidermal hyperpigmentation. This article reviews the mechanisms that induce the hyperpigmentation including inflammatory mediators such as metabolites of arachidonic acid and reactive oxygen species (ROS) and how these may influence prevention and treatment strategies. Treating the inflammatory cause and sun protecting are crucial to effective therapy. Although common, few studies have been done focusing on prevention and treatment of this disease. Topical therapies are the mainstay of treatment for PIH, but have shown poor efficacy for the dermal hyperpigmentation component. Hydroquinone in combination with topical steroids, retinoids, glycolic acid, and lactic acid have been augmented with numerous emerging natural therapies such as kojic acid, arbutin, ascorbic acid, soy, and niacinamide. Although efficacious for hyperpigmentation, most of the natural therapies have not been studied specifically for PIH. Salicylic acid and glycolic acid chemical peels, as well as the quality-switched (QS) neodymium-doped yttrium aluminum garnet (Nd: YAG), QS Ruby, 1550 nm erbium fiber fractional thermolysis, and 1927 nm fractional thulium fiber lasers have shown good efficacy for the treatment of facial hyperpigmentation.

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Melasma is one of the most common pigmentary disorders worldwide with a still unresolved pathogenesis and treatment continues to be challenging. Increased sun exposure and genetic factors are considered the two most important etiological factors. Estrogens, progesterones and increased melanocyte stimulating hormone are also involved. Melasma treatment can be very frustrating as many modalities can turn out to be ineffective. Dermal and mixed variants are quite resistant to therapy. Most patients seek medical help much after the onset of the condition, making treatment even more difficult. Sunscreens and topical depigmenting agents remain mainstay of therapy. Chemical peels and light sources are beneficial as adjuncts. There have been numerous advances in the understanding and management of melasma. This review attempts to look at these newer vistas in melasma. Literature search for the review was done from PubMed, the Cochrane Library, MEDLINE and Embase using the key word "melisma," "melasma pathogenesis" and "melasma treatment."

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We report a case of lichen planus pigmentosus (LPP) that developed in a linear pattern, that too over nonsun-exposed areas. The patient presented with linear dark brown macules and patches on the back in the midline. Skin biopsy showed features consistent with a diagnosis of LPP. LPP should be considered in the clinical differentials of linear hyperpigmented skin lesions.

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Idiopathic guttate hypomelanosis is a commonly acquired, benign leukoderma characterized by multiple, discrete round or oval, porcelain-white macules on sun-exposed areas, especially the extensor aspect of forearms and shins, sparing the face, neck, and trunk. It usually affects the geriatric population (>50 years); chronic exposure to ultraviolet rays and senile degeneration being the important pathogenic factors. The diagnosis remains essentially clinical, whereas newer confirmatory investigations are emerging. Despite the benign course of progression, many patients seek medical attention owing to cosmetic concerns. Several treatment modalities have been tried over time including topical, physical, and surgical measures, although there is lack of a standard treatment regime. In this article, we have reviewed the different aspects of this condition including treatment, along with the recent updates to create awareness about this dermatological entity.

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Vitiligo is the most common depigmentary disorder that has been affecting human lives across centuries. Despite its high prevalence, not much can be said precisely about its pathogenesis. Over the years, several theories based on a lot of research have been put forward and many more are coming up each day. This article aims to summarise the various theories put forward so far and highlight the Recent updates in each of them.

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Postinflammatory hyperpigmentation (PIH) is an acquired hypermelanosis arising after inflammation or injury to the skin and can develop in all skin types especially in Fitzpatrick skin phototypes III to VI. In higher skin phototypes, chances of PIH following procedures using laser and other light sources are high. Therefore, it is becoming increasingly important to manage this unforeseen condition. Wide variety of treatment options are available for PIH, but there is limited literature regarding efficacy and safety of chemical peels in PIH. Hence, a thorough systematic review was performed by searching Pubmed, Scopus, Medline, and Cochrane databases in English language involving studies on PIH. Thus, this article is an attempt to bring together all the possible ways of using chemical peels (alone, in combination with other peels or topical agents) for the management of PIH.

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Skin is an easily accessible source of various sub population of stem cells including epidermal stem cells, hair follicle stem cells (HFSCs) and dermal mesenchymal stem cells. The outer root sheath (ORS) of the hair follicle is a rich source of a type of HFSCs called the melanocytes stem cells (MelSCs). These HFSCs have a vast, unexplored potential in the treatment of vitiligo as initial re-pigmentation often occurs around the hair follicles. Common therapeutic modalities such as tacrolimus, phototherapy and dermabrasion acts through MelSCs. Newer cellular techniques have explored the use of ORS hair follicle suspension in surgical treatment of vitiligo. Advancement in melanocyte and stem cell research has identified various cytokines, growth factors and regulators involved in proliferation and differentiation of melanoblasts, which can be used for autologous in situ melanocyte regeneration. In this review, we briefly discuss the current position and future prospects of stem cells in vitiligo.

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Lichen planus pigmentosus, erythema dyschromicum perstans and idiopathic eruptive macular pigmentation are the three most commonly accepted subtypes of acquired dermal hyperpigmentary disorders. While some patients fit easily into one of these subtypes, others do not. Overlapping features of several subtypes may also be seen in the one patient. This paper covers these three entities in detail and highlights the diagnostic and classification challenges.

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Dyschromia is one of the leading diagnoses in skin of color of populations. Inclusive within this broad realm of diagnoses includes physiologic pigmentation, which refers to normal biologic variations in skin coloration. In order to properly diagnose and manage disorders of pigmentation, one must be aware of the normal variations in skin pigmentation. Our review summarizes molecular mechanisms and the diverse patterns of physiologic pigmentation that may be encountered in the clinic and that are especially common in richly pigmented individuals.

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Intralesional steroids are commonly used in dermatological practice. This route of administration has the advantage of minimal side effects. However, other adverse reactions namely local atrophy, ulceration, infections, etc. have been noted. One peculiar side effect following this route of administration “steroid-induced perilymphatic hypopigmentation and atrophy” has been described below. Although this condition repigments spontaneously, the use of tacrolimus to fasten the response has been highlighted in the case report.

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A 45-year-old female patient presented with two black plaques over her toes for the past 3 months that were persistent without any changes in the color, size or surface. Histopathology showed epidermal hyperplasia with corneal collection of fibrinous proteinaceous material and hemosiderin-laden macrophages and fibrinous exudate. We report this case to highlight the importance of proper diagnosis by means of dermoscopy and paring, of any black patch over acral regions in order to exclude the more concerning acral lentiginous melanoma.

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Reticulate pigmentary disorders include presentations with “net-like,” “sieve-like,” or “chicken wire” configuration of the skin lesions. Various congenital and acquired dermatoses, as well as few systemic diseases, are present with this pattern of skin lesions. However, there is a lack of consensus on the exact scope of the term “reticulate” pigmentary disorders. True reticulate disorders include mostly genetic disorders including dyskeratosis congenita, Dowling Degos, acropigmentation of Kitamura, Naegeli Franceschetti Jadassohn (NFJ) syndrome, X-linked reticulate pigmentary disorder, dyschromatosis symmetrica hereditaria (DSH), and dyschromatosis universalis hereditaria (DUH). We review the “true” genetic reticulate pigmentary disorders here.

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