Pigmentary disorders in black skin

Surgical Excision with Adjuvant Irradiation for Treatment of Keloid Scars: A Systematic Review

Background:

Excision followed by adjuvant irradiation is considered safe and most efficacious for treatment of keloid scars. Recently, different authors published successful treatment protocols and recommended the following: (1) the use of high-dose-rate brachytherapy instead of low-dose-rate brachytherapy or external radiation; (2) a short-time interval between operation and irradiation; (3) single fraction instead of multifraction irradiation; and (4) a minimum of 12- to 24-month follow-up post treatment.

Methods:

This study evaluates the above recommendations with a systematic review of the English-language literature, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Both PubMed and EMBASE were searched. Studies were graded according to the American Society of Plastic Surgeons Rating Levels of Evidence.

Results:

Thirty-three studies were selected. Six studies were graded as level of evidence type II studies and 27 as type III. High-dose-rate brachytherapy showed lower recurrence rates compared with low-dose-rate brachytherapy and external radiation. A short-time (<7 hours) interval between scar excision and irradiation results in a lower recurrence rate compared with long-time intervals (>24 hours). Single-fraction irradiation showed promising results in terms of recurrence rate and patient convenience. Finally, scar recurrences were seen between 2 and 36 months, with a mean of 15 months.

Conclusions:

Based on this systematic review of the literature, the evidence confirms the recommendations stated by authors in the recent years. However, due to the lack of high-quality randomized studies, the quality of this evidence is limited. More randomized studies will generate stronger recommendations.

High-dose-rate brachytherapy for the treatment of recalcitrant keloids: a unique, effective treatment protocol

BACKGROUND

Keloids cause aesthetic disfigurement and physical complaints, mainly pain and pruritus. Treatment of these scars is difficult, with high recurrence rates forming the main issue. Surgical excision with adjuvant radiotherapy is considered the most efficacious treatment. At their institution, the authors have been treating keloids with a high-dose-rate brachytherapy procedure for over 10 years, using a protocol with the lowest total radiation dosage known in the literature.

METHODS

This prospective study included 43 patients of all Fitzpatrick skin types, with 67 keloids in total. After extralesional excision, a radiation scheme of 2 × 6 Gy was administered in two fractions: the first within 4 hours after surgery and the second within 24 hours. Scars were measured and recurrence was judged. Scar appearance was evaluated using the Patient and Observer Scar Assessment Scale.

RESULTS

The recurrence rate was 3.1 percent at a mean follow-up of 33.6 months. A significant average scar surface decrease of 56.7 percent was measured (p = 0.01). Complaints of pain and pruritus decreased by 82.9 and 87.2 percent, respectively. Patients were satisfied with the treatment in 88.6 percent of the cases and with the cosmetic result in 77.1 percent. Pigmentation problems were seen in 21.4 percent of the patients, mostly in Fitzpatrick type V and VI/African American individuals.

CONCLUSIONS

The results of this prospective study show a good cosmetic outcome with a low recurrence rate. The unique radiation schedule proves the efficacy and safety of high-dose-rate brachytherapy and suggests the importance of immediate postoperative irradiation. In addition, only one outpatient treatment is required after surgery, enhancing patient convenience.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Common dermatoses in moderately pigmented skin: uncommon presentations

Several common dermatoses appear different in people of color. Most international literature, especially the reputed textbooks, are replete with photographs of skin diseases in fair-skinned patients. The orientation of Western dermatologists to common diseases in pigmented skin therefore is needed. The reverse is also true. Dermatologists who work in pigmented skin communities are known to have initial problems with fair skin. It is therefore important to have a judicious balance of entities seen in both of these skin types in major international literature, especially in textbooks. In addition, common dermatoses may appear strange and confusing particularly when they are in their advanced form. People with pigmented skin living in developing countries often present with diseases that appear greatly altered, because of various reasons. Main ones are treatment taken at home with household remedies, especially topical therapy, inappropriate treatment given by general practitioners with sparse knowledge of dermatology, and injudicious steroid use. All these factors lead to exacerbation of the disease or superimposed irritation or infection, which all contribute to a different appearance. Equally important is the delay in seeking treatment because of financial constraints.

RALGA (Diacnéal®), a Retinaldehyde and Glycolic Acid Association and Postinflammatory Hyperpigmentation in Acne – A Review

Acne vulgaris affects 3 out of 4 adolescents and usually vanishes at the end of puberty with either no sequelae or mild to moderate sequelae, such as postinflammatory hyperpigmenation (PIH), which may result in psychological and emotional damages. The poor tolerability of the actual treatments (secondary inflammation) is a hindrance to therapy. Retinaldehyde (RAL), a precursor of retinoic acid, has shown depigmenting activity. Glycolic acid (GA) decreases the excess of pigment by a wounding and re-epithelization process. Thus, a synergistic effect was expected from the combination of RAL 0.1% and GA 6% RALGA (Diacneal) in the treatment of acne vulgaris and PIH. Efficacy results of preclinical and clinical trials tend to confirm the expectations for both acne and PIH treatment. A good tolerability was observed. In conclusion, the cosmetic cream Diacneal is a well-tolerated treatment for the prevention and healing of PIH in acne patients.

Solar-induced postinflammatory hyperpigmentation after laser hair removal

BACKGROUND

Postinflammatory hyperpigmentation (PIHP) is a frequently encountered problem in many cosmetic procedures. The treatment of PIHP is difficult and remains a challenge.

OBJECTIVE

To treat a patient who developed multiple hyperpigmented macules on her thighs due to sun exposure after treatment of unwanted hair using a normal-mode ruby pulse laser.

METHODS

The patient was treated daily with tretinoin (Retin A) 0.1% cream, triamcinolone 0.1% cream, and hydroquinone 4% cream with sunscreen (Solaquin forte), and was to avoid sun exposure. Several sites received monthly treatment of 40% trichloroacetic acid (TCA). The degree of clinical improvement of the hyperpigmentation was assessed by both the physician and the patient.

RESULTS

Cosmetic results were fair. The amount of hair in her thighs was reduced but the PIHP responded only slightly to therapy.

CONCLUSION

To our knowledge this is the first case of solar-induced PIHP following laser hair removal. The treatment of PIHP is difficult because there are few therapeutic options that are consistently successful. Avoidance of exposure to ultraviolet light should be emphasized to all patients prior to laser therapy. We demonstrated that serial TCA peels provided an additional benefit compared to medical treatment.

Glycolic acid peels for postinflammatory hyperpigmentation in black patients. A comparative study

BACKGROUND

Treatment of postinflammatory hyperpigmentation in patients of Fitzpatrick skin types IV, V, and VI is difficult. Glycolic acid peels are useful for pigment dyschromias in caucasians; however, there are no controlled studies examining their safety and efficacy in dark-complexioned individuals.

OBJECTIVE

To determine if serial glycolic acid peels provide additional improvement when compared with a topical regimen of hydroquinone and tretinoin.

METHODS

Nineteen patients with Fitzpatrick skin type IV, V, or VI were randomized to a control or peel group. The control group applied 2% hydroquinone/10% glycolic acid gel twice daily and 0.05% tretinoin cream at night. The peel patients used the same topical regimen and, in addition, received six serial glycolic acid peels (68% maximum concentration). Patients were evaluated with photography, colorimetry, and subjectively.

RESULTS

Sixteen patients completed the study. Both treatment groups demonstrated improvement, but the patients receiving the glycolic acid peels showed a trend toward more rapid and greater improvement. The peel group also experienced increased lightening of the normal skin.

CONCLUSIONS

This pilot study demonstrates that serial glycolic acid peels provide an additional benefit, with minimal adverse effects, for the treatment of postinflammatory hyperpigmentation in dark-complexioned individuals.

Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients

BACKGROUND AND METHODS

Irregular disfiguring skin hyperpigmentation due to inflammation may develop in black persons. We investigated the treatment of this hyperpigmentation with topical tretinoin (0.1 percent retinoic acid cream). Fifty-four subjects completed a 40-week randomized, double-blind, vehicle-controlled study. Twenty-four subjects applied tretinoin daily to the face, arms, or both areas, and 30 subjects applied vehicle cream. At base line and after 40 weeks of treatment, each subject's post-inflammatory hyperpigmented lesions and normal skin were assessed by clinical and colorimetric evaluations and by analysis of biopsy specimens.

RESULTS

The facial post-inflammatory hyperpigmented lesions of the tretinoin-treated subjects were significantly lighter after the 40 weeks of therapy than those of the vehicle-treated subjects (P < 0.001); overall improvement was first noted after four weeks of tretinoin treatment. At the end of treatment, colorimetry demonstrated a 40 percent lightening of the lesions toward normal skin color in the tretinoin-treated lesions, as compared with an 18 percent lightening in vehicle-treated lesions (P = 0.05). The epidermal melanin content in the lesions decreased by 23 percent with tretinoin and by 3 percent with vehicle (P = 0.24). Normal skin was minimally lightened by tretinoin as compared with vehicle, according to both clinical evaluation (0.1 vs. -0.1 unit change on an 8-point scale; P = 0.055) and colorimetry (P < 0.001). Retinoid dermatitis developed in 12 of the 24 tretinoin-treated subjects who completed the study (50 percent) and in 1 tretinoin-treated subject who withdrew from the study, but diminished as the study progressed.

CONCLUSIONS

Topical application of tretinoin significantly lightens post-inflammatory hyperpigmentation and, to a clinically minimal but statistically significant degree, lightens normal skin in black persons.