Comorbid psychiatric disease significantly mediates increased rates of alcohol use disorder among patients with inflammatory and pigmentary skin disorders: a case-control study in the All of Us Research Program.

Dermatologic diseases have a well-documented association with depression and anxiety, which are in turn often comorbid with alcohol use disorder (AUD). Nonethleess, the relationship between dermatologic disease and AUD, and the relative contribution of depression and anxiety, are poorly understood. Here, we utilize the National Insittutes of Health All of Us Research Program to investigate the association between inflammatory and pigmentary dermatologic diseases with AUD. Furthermore, we investigate whether comorbid depression and anxiety mediates this relationship. We employed a matched case-control model with multivariable logistic regression. We also employed a mediation analysis. We found an increased odds of AUD among patients with atopic dermatitis, acne/rosacea, hidradenitis suppurativa, psoriasis, and pigmentary disorders (vitiligo, melasma, and post-inflammatory hyperpigmentation). This was partially mediated by anxiety and depression, especially for diseases with a significant cosmetic component. Overall, these findings highlight the profound psychological and physical health effects that inflammatory and pigmentary disease can have on patients, both independently and in combination with comorbid psychiatric disease.

Seasonal Patterns in Tetracycline-Associated Hyperpigmentation Among Patients With Acne Vulgaris.

BACKGROUND: Oral tetracyclines (TCNs) are commonly prescribed for acne, but they have been shown to increase the risk of hyperpigmentation, particularly in the setting of sun exposure. OBJECTIVE: We evaluated seasonal trends in TCN-associated hyperpigmentation incidence in addition to Google search trends for hyperpigmentation-related terms. METHODS: We performed a retrospective review of acne patients seen at Massachusetts General Brigham and Women’s Hospital between 1992 and 2022. We calculated the incidence of new hyperpigmentation diagnoses for each drug cohort. We also analyzed search volume of hyperpigmentation-related terms extracted from Google Trends. RESULTS: Seasonal differences in new hyperpigmentation diagnoses were identified among acne patients prescribed doxycycline (P=0.016), with peak incidence in April. In the control group of patients who had never received a TCN, diagnoses peaked in May. There were no significant seasonal differences among patients prescribed minocycline (P=0.885). There was greater search volume for hyperpigmentation-related terms in spring and summer compared to fall and winter (P<0.001). Limitations of this study include its retrospective nature and reliance on prescription and diagnosis coding data. CONCLUSIONS: Our findings support the seasonal periodicity of acne-related hyperpigmentation, underscoring the importance of photoprotection counseling for patients with acne. Additionally, doxycycline may be associated with an earlier onset of hyperpigmentation, suggesting a potential benefit of considering minocycline or other alternatives to doxycycline. J Drugs Dermatol. 2023;22(11):e9-e11    doi:10.36849/JDD.7409e.

Inflammatory response: The target for treating hyperpigmentation during the repair of a burn wound.

Hyperpigmentation is a common complication in patients with burn injuries during wound healing; however, the mechanisms underlying its occurrence and development remain unclear. Recently, postinflammatory hyperpigmentation (PIH) was found to result from overproduction of melanin. Local or systemic inflammatory responses are often observed in patients who develop hyperpigmentation. However, we lack studies on the relationship between PIH and burn injury. Therefore, we comprehensively reviewed the existing literature on the melanogenesis of the skin, inflammatory mechanisms in pigmentation, and local or systemic alteration in inflammatory cytokines in patients suffering from burn trauma to elucidate the relationship between PIH and burn injury. We believe that this review will guide further research on regulating melanin production in the burn management process.

[Inflammatory dermatoses in skin of color]. / Entzündliche Dermatosen auf pigmentierter Haut.

Acne, rosacea, atopic dermatitis, and psoriasis vulgaris are common inflammatory dermatoses. Of note, the epidemiology and clinical presentation of these common dermatologic diseases varies considerably between people with different colors of skin. Yet, most dermatology textbooks present and describe the clinical pictures of White people. To provide excellent dermatological care for all patients, it is of central importance to know the epidemiology and recognize key clinical characteristics of these diseases in patients with skin of color (SOC). In acne, cultural habits of Blacks (use of steroid-based lighteners, comedogenic hair care products) may lead to manifestation of specific forms of acne. In addition, postinflammatory hyperpigmentation and keloids pose particular therapeutic challenges in this patient group. Atopic dermatitis in Asians shows a clinical and histological picture that is similar to psoriasis in Whites. By contrast, atopic dermatitis manifests on the extensor side in Black people. Due to the difficulty of recognizing erythema in SOC, the severity of the respective inflammatory diseases in these individuals is often underestimated. The treatment of acne, rosacea, atopic dermatitis, and psoriasis does not differ between people of different skin colors. The exception is the necessary therapy for postinflammatory hyperpigmentation in all the inflammatory dermatoses mentioned, and for keloids in acne.

Facial skin characteristics and concerns in Indonesia: A cross-sectional observational study.

BACKGROUND: Facial skin characteristics and appearance vary according to ethnicity. While much of this knowledge is derived from the Caucasian population, lately there have been efforts to gain such understanding in various regions in Asia.  In this paper, we have built an understanding of such features in Indonesia. In Indonesia, a section of females wears a traditional veil (hijab) to cover the scalp and part of face. The influence of the hijab on facial skin attributes was also investigated. METHODS: In a cross-sectional observational study design involving 419 female volunteers in Jakarta, Indonesia, facial skin attributes (colour, radiance, hydration, trans-epidermal water loss [TEWL], wrinkles, fine lines, pores, and sebum levels) and conditions (melasma, post-inflammatory hyperpigmentation (PIH), solar lentigines/ senile lentigines, seborrheic keratoses and acne) were assessed by trained operators and dermatologists using standard validated instruments and scales. RESULTS: With age, facial skin colour showed darkening in cheek; forehead on the other hand showed slight lightening. The skin evenness and radiance decreased, substantially. Aging attributes measured in terms of lines, wrinkles, and under-eye dark circles showed deterioration with age; the decline was progressively faster than colour change. Facial image data analysis corroborated these findings. Skin hydration remained similar across the age groups even though the skin barrier function measured in terms of TEWL improved with age. Sebum levels in the skin were similar up to the age of 50 but declined in the next group of 50-60 year. Pore severity increased with age. Melasma, seborrheic keratosis and PIH showed a high prevalence (>∼50%) at the young age group (20-30 years), itself. Melasma prevalence attained 100% in the age group of 41-50 year and onwards, and its severity similarly showed a steady rise with age. PIH on the other hand showed a steady decline with age. Solar lentigines prevalence (∼30%) did not change much across age groups, and the severity scores were similar in age groups up to 50 year but increased substantially in 51-60-year age groups. Seborrheic keratosis was similar (∼47%) in age groups up 20-40 year but steadily increased in upper age groups. Its severity was similar in the age groups of 20-30 year and 31-40 year but showed a two-fold increase in subsequent age groups. Acne was 10% in the age group of 20-30 year and declined gradually to 0.7% in the 51-60-year age group. Hijab wearers showed slight protection in skin colour darkening and improvement of evenness and radiance but were similar on aging (fine lines and wrinkles on crow's feet, under eye and peri-oral areas) markers to non-wearers. In general, in majority of age-groups, hijab wearers showed a higher prevalence of melasma, solar/senile lentigines, seborrheic keratosis and PIH.

Higher incidence of neurotoxicity and skin hyperpigmentation in renal transplant patients treated with polymyxin B.

BACKGROUND: Toxicity is a major concern related to the clinical use of polymyxin B, and available safety data for renal transplant patients are limited. AIMS: We investigated the safety of polymyxin B and toxicity risk factors in renal transplant patients. METHODS: A prospective study was performed on a group of renal transplant patients who received intravenous polymyxin B between January 2018 and August 2021. Polymyxin B treatment was monitored to evaluate toxicity and risk factors. RESULTS: A total of 235 courses of polymyxin B were administered to 213 patients. Of these, 121 (51.5%) developed skin hyperpigmentation (SH), 149 (63.4%) developed neurotoxicity and 10 (5.5%) developed acute kidney injury of which 80% was reversible. Risk factors for developing SH included a high total dose by weight (odds ration [OR] 1.31, 95% confidence interval [CI] 1.08-1.60, P = .008) and the presence of neurotoxicity (OR 2.86, 95% CI 1.56-5.26, P = .001). Neurotoxicity manifested during the first 2 days of treatment. Neurotoxicity occurred most commonly in women (OR 3.84, 95% CI 1.82-8.10, P < .0001), and the presence of SH (OR 1.98, 95% CI 1.13-3.46, P = .016) was also an independent risk factor. CONCLUSIONS: Neurotoxicity and SH are the two major adverse effects of polymyxin B in renal transplant patients, which may limit its clinical use.

Adverse Events of Nonablative Lasers and Energy-Based Therapies in Subjects with Fitzpatrick Skin Phototypes IV to VI: A Systematic Review and Meta-Analysis.

BACKGROUND: Although there is an abundance of literature on nonablative laser and energy-based therapies for the management of skin conditions, adverse events are inconsistently addressed and range widely across studies. Fitzpatrick skin phototypes (SPTs) IV to VI are believed to be at higher risk. OBJECTIVES: The aim of this study was to determine the types and rates of adverse events in nonablative laser and energy-based therapies among patients with SPTs IV to VI. METHODS: Articles addressing nonablative laser and energy-based therapies for skin rejuvenation and acne scarring in patients with SPTs IV to VI that provided data on adverse events were included. The pooled prevalence of each adverse event was calculated. To determine whether age, treatment indication, SPT, and device type influenced incidence, subgroup and meta-regression analyses were performed. Heterogeneity was evaluated with the I2 statistic. RESULTS: Forty-three studies were included in the meta-analysis. The sample size was 1654, and the median age of subjects was 39.4 years. The most common adverse events were postinflammatory hyperpigmentation (PIH) (rate, 8.1%) and prolonged erythema (rate, 0.6%). The rate of PIH was significantly higher for diode and erbium-doped lasers compared with intense pulsed light and radiofrequency. PIH correlated positively with SPT, laser density, and total energy delivered. CONCLUSIONS: Although the overall rate of adverse events in nonablative laser and energy-based therapies for SPTs IV to VI is low, the incidence of PIH is not insignificant. Certain lasers, such as diode, Q-switched Nd:YAG, and erbium-doped lasers, tend to have higher rates of PIH, whereas intense pulsed light and radiofrequency have minimal risk. Higher SPTs and higher energy deliverance correlate positively with the incidence of PIH.

Pigmented transverse nasal band: A review.

Pigmented transverse nasal band/groove is an asymptomatic benign condition, characterized by the development of erythematous to hyperpigmented, well-demarcated, transverse groove at the junction of middle and lower two-third of the nasal dorsum. Although the pathogenesis is unclear, embryologic origin seems to be the most plausible hypothesis. This condition is often associated other related dermatological conditions such as milia, comedones, seborrheic dermatitis and atopic dermatitis. Diagnosis is mostly clinical, while reassurance is the mainstay of therapy. In persistent cases, topical retinoids have been used. 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.

Superficial X-ray-induced hyperpigmentation in postoperative keloid radiotherapy: A study of 70 keloids to identify clinical features and risk factors.

BACKGROUND: Postoperative radiation is one of the most effective treatments for keloid. Radiation-induced hyperpigmentation is, however, a concern for both patients and dermatologists. AIMS: To identify clinical features and risk factors of superficial X-ray-induced hyperpigmentation in postoperative keloid radiotherapy. PATIENTS/METHODS: From November 2019 to November 2020, 70 keloids in 55 patients were treated with superficial X-ray after surgery. Patient data and treatment-related parameters were collected. Follow-up photographs were taken one month after radiotherapy. Three independent dermatologists assessed photographs for pigmentation. The clinical characteristics and severity of pigmentation were summarized. Logistic regression was used to analyze the risk factors associated with occurrence and severity of hyperpigmentation. RESULTS: The pigmentation was a well-defined rectangular brown macule consistent with the unprotected area that involves normal skin, and 82.9% of keloids displayed pigmentation induced by superficial X-ray at one month after treatment. All keloids of trunk appeared to be mild-to-moderately hyperpigmented (100%); 92.89% of limb keloids displayed mainly severe pigmentation. Keloid location was an independent risk factor for the incidence and severity of pigmentation. Longer incision length was also predictive of increased hyperpigmentation severity. CONCLUSIONS: Superficial X-ray-induced hyperpigmentation was common and severe in postoperative keloid radiotherapy. The incidence and severity of pigmentation can be predicted by the location and incision length of the keloid.

Excoriation (skin-picking) disorder among adolescents and young adults with acne-induced postinflammatory hyperpigmentation and scars.

A plethora of health-related concerns, including skin disorders, are particularly common during the critical periods of adolescence and young adulthood. Their reactions to skin-related disorders can be different from their reactions to other disorders. While medical problems could be physiologically impacting, skin disorders like excoriation disorder can, in addition, directly affect their physical appearance in ways that have psychological consequences like anxiety, low self-esteem, and impaired quality of life. The increasing prevalence of excoriation disorder has resulted in its inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the eleventh edition of the International Classification of Diseases (ICD-11) manuals as one of the obsessive-compulsive disorders (OCD)-related disorders. However, health care professionals may not often recognize this important entity especially among adolescents and young adults with acne vulgaris presenting with chronic or recurrent acne-induced postinflammatory hyperpigmentation and scars. A number of self-reported tools are available for use in screening and/or assessment of excoriation disorder and to aid its management. While both pharmacologic and non-pharmacologic therapies are available, patient education is important. Physicians who usually make first contact with patients, such as Family Medicine Physicians, Pediatricians, Dermatologists, and Aesthetic Medicine Physicians, should have a relatively high index of suspicion for this disorder, especially in those presenting rather frequently with new or repeat lesions. Prompt referral to licensed mental health specialists is encouraged in order to ensure the provision of holistic care to affected persons.

Prurigo Pigmentosa: Demographics and Characteristics in 14 Caucasian Patients.

BACKGROUND: Prurigo pigmentosa (PP) is an inflammatory dermatosis typically reported in young Asian women and characterized by recurrent papulovesicular lesions resolving with a postinflammatory reticulated hyperpigmentation. METHODS: We have included all consecutive patients with PP diagnosed in our tertiary center between 2013 and 2020. The clinical information was retrospectively collected from medical records. RESULTS: We identified 14 patients with PP. The median age at the time of diagnosis was 29.5 years (range 17-43 years), while the female-to-male ratio was 13:1. Diagnostic delay varied from 10 days to 10 years (mean of 25 months). Light microscopy studies consistently showed presence of a lymphohistiocytic infiltrate in combination in 40% of cases with neutrophils. Interface changes were found in 60% of cases. In 6 (43%) of 14 cases, there was a chronological relationship between the starting of a new diet and the development of the first flares. Treatment with doxycycline in 9 patients resulted in a complete regression of the lesions. LIMITATION: This was a retrospective study in a tertiary referral hospital. CONCLUSIONS: Our observations indicate that PP is not so rare in Europe as previously thought and is often diagnosed after a long delay. Demographics, clinical characteristics and triggering factors in Caucasian patients are similar to those described in the Asian population. Diagnosis is based on the peculiar recurrent course and distinctive clinicopathological features. Tetracyclines represent the first-line therapy in PP.

Comparison of Fractional Picosecond 1064-nm Laser and Fractional Carbon Dioxide Laser for Treating Atrophic Acne Scars: A Randomized Split-Face Trial.

BACKGROUND: To date, no studies have compared the fractional picosecond 1064-nm laser (FxPico) and fractional carbon dioxide laser (FxCO2) for the treatment of acne scars. OBJECTIVE: To compare the efficacy and safety between FxPico and FxCO2 for treating facial atrophic acne scars. MATERIALS AND METHODS: Twenty-five Asian patients with mild to moderate atrophic acne scars underwent single sessions of randomized split-face treatment with FxPico and FxCO2. Clinical efficacy was assessed by photographs, skin imaging analysis, and patient satisfaction. The adverse events were recorded on every visit. Skin biopsies were performed immediately and 3 months after treatment. RESULTS: The physician improvement scores for skin texture and atrophy significantly increased on the FxPico sides, but no significant difference was observed between FxPico and FxCO2. Skin imaging also showed significant improvement on both sides for scar volume. Postinflammatory hyperpigmentation (PIH) was not reported on FxPico sides, whereas 6 patients (24%) experienced mild PIH on FxCO2 sides. Immediate post-FxPico skin biopsy revealed laser-induced optical breakdown with photoacoustic columns. Collagen and elastic fibers increased at 3 months after both treatments. CONCLUSION: FxPico was as effective as FxCO2 in treating atrophic acne scars, correlating with evidence of tissue remodeling with more safety profiles.

Botulinum toxin type A versus 5-Fluorouracil in treatment of keloid.

Most therapeutic approaches for keloids remain clinically unsatisfactory. In the last years, intralesional botulinum toxin-A (IL BTX-A) was proposed for treatment of keloids. Our aim of the study was to compare the clinical efficacy of IL BTX-A and IL 5-Fluorouracil (IL 5-FU) in treatment of keloids. A total of 50 patients with keloids were included in the study, 22 patients (with 26 keloids) were treated with IL BTX-A monthly for up to 6 months and other 22 patients (with 27 keloids) were treated with IL 5-FU weekly for up to 6 weeks, while the remaining 6 patients, each having multiple keloids, were treated with both IL BTX-A for some lesions (8 keloids) and IL 5-FU for their remaining lesions (8 keloids). The clinical improvement was assessed according to flattening of the lesions. Side effects were recorded. A significantly better therapeutic response of keloids was detected after IL BTX-A than IL 5-FU (P = 0.041). IL BTX-A achieved excellent and good flattening of the lesions (58.8% and 20.6%) compared to (31.4% and 17.1%) after IL 5-FU, respectively. In BTX-A treated group, there was no statistically significant difference between the clinical response in small lesions compared to medium and large ones (P = 0.476). While in 5-FU treated group, small and medium lesions showed significantly better response than larger ones (P = 0.009). IL BTX-A caused fewer side effects than IL 5-FU, less pain, itching, no hyperpigmentation and less recurrence. Both IL BTX-A and IL 5-FU showed positive results in treatment of keloids. However, IL BTX-A showed higher clinical efficacy even in large size keloids with less side effects.

GWAS Analysis of 17,019 Korean Women Identifies the Variants Associated with Facial Pigmented Spots.

Variation in skin pigmentation can be affected by both environmental factors and intrinsic factors such as age, gender, and genetic variation. Recent GWASs revealed that genetic variants of genes functionally related to a pigmentation pathway were associated with skin pigmentary traits. However, these GWASs focused on populations with European ancestry, and only a few studies have been performed on Asian populations, limiting our understanding of the genetic basis of skin pigmentary traits in Asians. To evaluate the genetic variants associated with facial pigmented spots, we conducted a GWAS analysis of objectively measured facial pigmented spots in 17,019 Korean women. This large-scale GWAS identified several genomic loci that were significantly associated with facial pigmented spots (five previously reported loci and two previously unreported loci, to our knowledge), which were detected by UV light: BNC2 at 9p22 (rs16935073; P-value = 2.11 × 10-46), PPARGC1B at 5q32 (rs32579; P-value = 9.04 × 10-42), 10q26 (rs11198112; P-value = 9.66 × 10-38), MC1R at 16q24 (rs2228479; P-value = 6.62 × 10-21), lnc01877 at 2q33 (rs12693889; P-value = 1.59 × 10-11), CDKN2B-AS1 at 9p21 (rs643319; P-value = 7.76 × 10-9), and MFSD12 at 19p13 (rs2240751; P-value = 9.70 × 10-9). Further functional characterization of the candidate genes needs to be done to fully evaluate their contribution to facial pigmented spots.

Defining dose constraints for catheter insertion sites to minimize toxicity after interstitial breast brachytherapy.

PURPOSE: The purpose of this study was to define dose constraints for catheter insertion sites to minimize probability of prominent post-therapy skin marks after interstitial breast brachytherapy. METHODS AND MATERIALS: Forty patients who had undergone interstitial breast brachytherapy were studied at followup at least 2 years after the procedure. Their implant marks were compared with background skin and areola and scored as Gr0 = invisible (same color as surrounding skin), Gr1 = darker than surrounding skin but lighter than areola or hypopigmentation, and Gr2 = same color as areola or darker. Highest point doses received in each plane of implant and their corresponding closest distances from clinical target volume, 85% isodose, and closest catheter dwell point were used for analysis. A logistic regression was performed to ascertain effects of various dosimetric parameters on the probability of Gr2 marks. Receiver operating characteristic curve was generated to derive cutoffs. RESULTS: A total of 280 dose points were studied. Median values for various parameters were 1.4 Gy (0.24-3.74) for Dose max and 1.6 cm, 1.5 cm, and 1.0 cm for Dist CTV min, Dist Iso min, and Dist Dwell min, respectively. On logistic regression, increasing Dose max alone was associated with an increased likelihood of developing Gr2 marks. Each unit increase of Dose max increased probability of development of Gr2 skin marks by 5.0% (2.391-10.328). Receiver operating characteristic analysis also showed greatest odd ratio (8.0), sensitivity (74.8%), and specificity (73%) for Dose max. CONCLUSIONS: It seems prudent to restrict dose to catheter insertion sites for better cosmesis.

Comparing the Efficacy of Radiofrequency Ablation Versus Laser Ablation for Chronic Venous Insufficiency in the Lower Extremities: a Vietnamese Report.

INTRODUCTION: Chronic venous insufficiency (CVI) is a chronic condition, triggered by reflux through the saphenous vein network. AIM: To determine the efficacy of endovenous laser ablation (LA) and radiofrequency ablation (RFA) for CVI treatment in the lower extremities, at the Bach Mai Radiology Center. METHODS: This retrospective study was approved by the institutional review board of Bach Mai Hospital. The study recruited 49 people, from August 2016 to April 2018, with recurrent venous insufficiency in the lower extremities and measured 56 ablated veins. RESULTS: In this study, 8 patients (10 veins, with a mean diameter of 5.83 ± 0.96 mm) were treated with RFA, and 41 patients (46 veins, with a mean diameter of 7.96 ± 3.47 mm) were treated with LA. The occlusion rates for LA- and RFA-treated veins were very effective, at 95.7% and 90%, respectively. No significant differences in occlusion rates or clinical improvements were observed between the two ablation methods. On the first day post-treatment, the visual analog score (VAS) value for the LA group was significantly higher than that for the RFA group. Furthermore, ecchymosis, 1 day after treatment, and hyperpigmentation, paresthesia, and numbness, 1 month after treatment, were only observed in the LA group. CONCLUSION: Both LA and RFA were minimally-invasive and safe therapies. No serious complications requiring further interventions were reported and the treatment effectively improved the clinical symptoms of patients. Based on our study, we recommend that RFA should be considered for moderate dilated saphenous vein cases, whereas LA should be indicated for large dilated saphenous vein cases, with or without aneurysm.

Calf Reduction by Partial Resection of Gastrocnemius Using a Suction-Assisted Cartilage Shaver.

BACKGROUND: Long-term aesthetic reduction of the legs in Asians is gaining increasing popularity among cosmetic patients. Current treatment options include botulinum toxin injection, radiofrequency, neurectomy, and total, subtotal, or partial muscle resection of the gastrocnemius. Partial resection using Kelly forceps was introduced in 2000. This article presents the use of a suction-assisted cartilage shaver to perform partial resection, describing the procedures and shaver modifications and evaluating its use. METHODS: A retrospective review of 71 cases with a minimum 6-month follow-up (average, 36.5 months; range, 6 to 160 months) was performed. Twenty partial calf reductions were performed with a short shaver, 27 with a long shaver, and 24 with an endoscope-guided long shaver. RESULTS: Mean reduction of calf circumference was 2 cm (range, -1 to 6 cm); the mean preoperative and postoperative calf circumferences were 35.8 cm and 33.8 cm, respectively. Mean tissue reduction per calf was 110 g (range, 25 to 300 g).Two patients developed larger calves after surgery, one because of weight gain and the other because of weight training. Complications included surface irregularity (n = 4, 5.6 percent), numbness over the lateral ankle or lateral foot (n = 9, 12.7 percent), hematoma clot requiring surgical evacuation (n = 11, 15.5 percent), prolonged seroma (n = 2, 2.8 percent), and left ankle plantar-flexion contracture due to tight, sustained postsurgery bandaging (n = 1, 1.5 percent). Scar-related complications were hyperpigmentation (n = 6, 8.5 percent), depressed scars (n = 5, 7 percent), and hypertrophic scars (n = 2, 2.8 percent). CONCLUSIONS: Short, long, and endoscope-guided long suction-assisted cartilage shavers for partial resection of calf muscles can be used effectively to reduce the calf. Several mostly treatable complications were noted. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Scar Assessment After Breast Reconstruction: Risk Factors for Hypertrophy and Hyperpigmentation in Asian Patients.

BACKGROUND: Breast scars after breast reconstruction can be hypertrophic and/or hyperpigmented, especially in Asian patients, whose skin is thicker and has increased melanin. Few studies have focused on breast scars after breast reconstruction, and the risk factors for an abnormal breast scar remain unknown. METHODS: We examined 257 Asian patients who underwent an immediate 2-stage unilateral implant-based breast reconstruction. Vascularity, hypertrophy, and hyperpigmentation of the patients' breast scars were assessed at 1 year postoperatively. Risk factors for an abnormal scar were analyzed statistically. Analyzed patient factors included age, body mass index, incision site (frontal or lateral), breast size (the weight of the resected specimen), skin necrosis at the initial operation (expander placement), and adjuvant therapy. RESULTS: At 1 year postoperatively, 161 patients (63%) showed normal vascularity, 77 patients (30%) showed mild vascularity, 18 patients (7%) showed moderate vascularity, and 1 patient (0.4%) showed severe vascularity. No patient factors were correlated with vascularity. Thirty-two patients (12%) showed hypertrophy, and the rate of hypertrophy was significantly higher in the patients with a lateral incision (n = 59) compared with those with a frontal incision (n = 198) (28.8% vs 7.6%, P < 0.01). Even in the frontal incision group, a lateral part of the frontal scar was likely to be hypertrophic. Forty-six patients (18%) showed hyperpigmentation, and the rate of hyperpigmentation was significantly higher in the patients with skin necrosis (n = 47) at the initial operation than those without skin necrosis (n = 210) (57.4% vs 9.0%, P < 0.01). Large breast was also a risk factor for hyperpigmentation due to its higher frequency of skin necrosis. CONCLUSIONS: In Asian patients who undergo breast reconstruction, the use of a lateral incision is a risk factor for hypertrophy, and skin necrosis at the initial operation is a risk factor for hyperpigmentation at the breast scar.