Erythema Dyschromicum Perstans: Response to Topical Tacrolimus

[Treatment of pigmentation disorders in association with systemic diseases]

Pigmentation disorders are a frequent skin problem and incorporate a broad spectrum of diseases, caused by an abnormal melanin pigmentation or also non-melanin pigmentation of the skin. Both hypermelanosis and hypomelanosis can be hereditary or acquired. This article summarizes the treatment approaches that are used in the majority of acquired pigmentation disorders of the skin. The following forms of hypermelanosis are addressed: lentiginosis, hyperpigmentation due to endocrine disorders or other systemic diseases, drug-induced hyperpigmentation. Acquired hypomelanoses include postinflammatory hypomelanosis, chemical depigmentation, idiopathic guttate hypomelanosis and punctate leucoderma. With reference to non-melanin pigmentation, the exogenous pigmentation due to chemicals, metals and drug exposure are discussed. The treatment is primarily based on finding the cause of the alterations to the pigment. The affected area, age and ethnic origin are also important factors. The spectrum of therapeutic options is broad: topical agents, chemical peeling, systemic agents, laser and light-based treatment. As some of these treatment procedures can have side effects, the availability of a protocol that contains information on the drug concentration, dose, parameters for laser treatment and the number of sessions is important. For every disorder the specific dermatological treatment is presented even when some pigmentation alterations that occur in association with systemic diseases, are cured by the treatment of the primary disease. Most diseases are exacerbated by exposure to UV light. Therefore, sun protection is recommended and a cosmetic coverage is indicated.

The color of skin: blue diseases of the skin, nails, and mucosa

Diseases of the skin, hair, nails and mucosa can appear as flesh-colored lesions or may present as any of the colors of the visual spectrum. Diseases associated with blue (or shades of blue) discoloration represent a unique group of conditions that occur de novo or as a reaction to either a topical or a systemic agent to which the individual has been exposed. Blue diseases can affect the skin, the nails or the mucosal membranes of the mouth (buccal mucosa, gingiva, lips, palate or tongue) or eyes (sclera). In addition to appearing blue, they can also appear as blue-black, blue-brown, blue-gray, blue-green, blue-purple, blue-red, and blue-silver. The conditions range from those secondary to exogenous agents (systemic or tattoo or topical) to syndromes to systemic diseases to tumors (adnexal, melanocytic, vascular, or miscellaneous). A comprehensive attempt to include all conditions that have been described as blue (or a shade of blue) has been performed by evaluating the following terms using the medical search engine PubMed: blue and either gingiva, lips, lunula, mucosa, nails, oral, palate, sclera, skin, or tongue. Subsequently, the conditions were organized by color (blue and shades of blue) and within each color by location (skin, nails, oral mucosa and sclera). The results are presented in organized tables; in addition, there is discussion of some of the conditions that are unique to one or more specific locations. In conclusion, 'preserve and cherish the pale blue dot' and remember that a big red rock eater with chrysiasis is the answer to the riddle, "What is big and blue and eats rocks?"

Erythema dyschromicum perstans: A case report and systematic review of histologic presentation and treatment

Objective

Erythema dyschromicum perstans (EDP) can be difficult to diagnose and treat; therefore, we reviewed the literature to assess whether histology can be used to differentiate lichen planus pigmentosus (LPP) from EDP and determine which treatments are the most effective for EDP. We also present a case of a patient who was treated successfully with narrow-band ultraviolet B (NB-UVB).

Methods

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted up to July 2017 using four databases.

Results

Histologic analyses from the literature reveal a significant percentage of melanophages, lymphocytic infiltrates, and basal vacuolar degeneration in EDP, and a significant histologic overlap with LPP. The review of the literature on treatment outcomes showed that NB-UVB and tacrolimus were effective with minimal side effects. Clofazimine was effective, but demonstrated significant-to-intolerable side effects. Griseofulvin, isotretinoin, and dapsone provided unsatisfactory results as lesions recurred after discontinuation. Lasers were largely ineffective and may cause postinflammatory hyperpigmentation and fibrosis.

Conclusion

A diagnosis of EDP should not be based on histologic findings alone. Clinical history, morphology, and distribution should be used to differentiate EDP and LPP. NB-UVB and tacrolimus are promising treatments for EDP with minimal side effects. This is the first report to our knowledge of sustained resolution of EDP after treatment with NB-UVB at long-term follow-up of 4 years. Larger studies are needed to confirm these findings.

A global consensus statement on ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus, idiopathic eruptive macular pigmentation, and Riehl's melanosis

Ashy dermatosis (AD), lichen planus pigmentosus (LPP), erythema dyschromicum perstans (EDP), and idiopathic eruptive macular pigmentation are several acquired macular hyperpigmentation disorders of uncertain etiology described in literature. Most of the published studies on these disorders are not exactly comparable, as there are no clear definitions and different regions in the world describe similar conditions under different names. A consensus on the terminology of various morphologies of acquired macular pigmentation of uncertain etiology was a long-felt need. Several meetings of pigmentary disorders experts were held to address this problem. A consensus was reached after several meetings and collation of e-mailed questionnaire responses and e-mail communications among the authors of publications on the above conditions. This was achieved by a global consensus forum on AD, LPP, and EDP, established after the 22nd International Pigment Cell Conference held in Singapore in 2014. Thirty-nine experts representing 18 countries participated in the deliberations. The main focus of the deliberations was terminology of the conditions; as such, we present here the consensus statement of the forum and briefly review the available literature on the subject. We have not attempted to discuss treatment modalities in detail.

Erythema Dyschromicum Perstans in an 8-Year-Old Indian Child

We report an 8-year-old East Indian boy with erythema dyschromicum perstans. The condition has very rarely been reported in prepubertal Indian children. A perusal of the literature revealed but two cases, to which we add another one. Recognition of erythema dyschromicum perstans in prepubertal Indian children is important for proper diagnosis and to prevent unnecessary investigations.

Treatment of burn scars in Fitzpatrick phototype III patients with a combination of pulsed dye laser and non-ablative fractional resurfacing 1550 nm erbium:glass/1927 nm thulium laser devices

Introduction:

Burn scars cause cosmetic disfigurement and psychosocial distress. We present two Fitzpatrick phototype (FP) III patients with burn scars successfully treated with combination pulsed dye laser (PDL) and non-ablative fractional lasers (NAFL).

Case 1:

A 30-year-old, FP III woman with a history of a second-degree burn injury to the bilateral arms and legs affecting 30% body surface area (BSA) presented for cosmetic treatment. The patient received three treatments with 595 nm PDL (7 mm, 8 J, 6 ms), six with the 1550 nm erbium:glass laser (30 mJ, 14% density, 4–8 passes) and five with the 1927 nm thulium laser (10 mJ, 30% density, 4–8 passes). Treated burn scars improved significantly in thickness, texture and colour.

Case 2:

A 33-year-old, FP III man with a history of a second-degree burn injury of the left neck and arm affecting 7% BSA presented for cosmetic treatment. The patient received two treatments with 595 nm PDL (5 mm, 7.5 J, 6 ms), four with the 1550 nm erbium:glass laser (30 mJ, 14% density, 4–8 passes) and two with the 1927 nm thulium laser (10 mJ, 30% density, 4–8 passes). The burn scars became thinner, smoother and more normal in pigmentation and appearance.

Discussion:

Our patients’ burn scars were treated with a combination of PDL and NAFL (two wavelengths). The PDL targets scar hypervascularity, the 1550 nm erbium:glass stimulates collagen remodelling and the 1927 nm thulium targets epidermal processes, particularly hyperpigmentation. This combination addresses scar thickness, texture and colour with a low side effect profile and is particularly advantageous in patients at higher risk of post-procedure hyperpigmentation.

Conclusion:

Our cases suggest the combination of 595nm PDL plus NAFL 1550 nm erbium:glass/1927 nm thulium device is effective and well-tolerated for burn scar treatment in skin of colour.

While all scars can be bothersome, burn scars can be particularly troubling. They can be large, itchy, painful and limit range of motion. Patients with medium and darker skin tones may be more likely to develop dark and discoloured scars due to burns and other scarring injuries. In our case series, we used two types of lasers to treat thick, darkly pigmented burn scars in two patients with medium and darker skin tones. While the pulsed dye laser targets the redness and thickened aspects of scars to restore a more normal appearance, the non-ablative fractional resurfacing laser creates microscopic zones of controlled injury to resurface scars, stimulate new collagen growth, improve texture and lighten excess pigmentation. Treatments were performed once a month for 6–12 months. Using these lasers in combination, our treatment method made our patients’ scars thinner, smoother and more evenly coloured over time, resulting in a more natural appearance. This multi-modal approach was a safe and effective no-downtime method for the improvement of scars in skin of colour patients.

Postinflammatory hyperpigmentation: A comprehensive overview: Epidemiology, pathogenesis, clinical presentation, and noninvasive assessment technique

Postinflammatory hyperpigmentation (PIH) commonly occurs after various endogenous and exogenous stimuli, especially in dark-skinned individuals. PIH is one of the most common complications of procedures performed using laser and other light sources. The severity of PIH is determined by the inherent skin color, degree and depth of inflammation, degree of dermoepidermal junction disruption, inflammatory conditions, and the stability of melanocytes, leading to epidermal and dermal melanin pigment deposition. The depth of melanin pigment is the key factor to predict prognosis and treatment outcome. Epidermal hyperpigmentation fades more rapidly than dermal hyperpigmentation. Various inflammatory disorders can eventually result in PIH. The evaluation of pigmentation using noninvasive tools helps define the level of pigmentation in the skin, pigmentation intensity, and guides therapeutic approaches. This first article in this 2-part series discusses the epidemiology, pathogenesis, etiology, clinical presentation, differential diagnoses, and investigation using noninvasive assessment techniques that objectively determine the details of pigmentation.

Facial Hyperpigmentation in Skin of Color: Special Considerations and Treatment

Differences in cutaneous diseases in people of color call for nuanced evaluation and management. One of the most common dermatological complaints from patients with skin of color is dyspigmentation, particularly hyperpigmentation. The challenge for clinicians is to establish correct diagnoses along with consistently successful treatments to meet the needs of the increasingly diverse population served. This review focuses on facial hyperpigmentation and outlines the most common skin disorders and treatment options.