Differential diagnosis and management of hyperpigmentation.

There is an increasing recognition of ethnic dermatology to reflect the increase in skin of colour (SOC) populations in the UK. Hyperpigmentary disorder is one of the commonest skin concerns in SOC but there has been limited training available in this field of dermatology. Variations in skin colour are genetically determined by the amount of melanin content, the eumelanin/pheomelanin ratio and the size of melanosomes, but is also influenced by other factors such as hormones and extrinsic factors such as ultraviolet radiation. Hyperpigmentation is a broad term to describe increased pigmentation in the skin, and making a correct diagnosis is an important first step in the successful management of hyperpigmentary disorders. A systematic approach based on the disease pathogenesis (e.g. reactive vs. nonreactive, increased melanin vs. increased number of cells or epidermal vs. dermal pigmentation) aided by a detailed history and clinical examination is the best way to diagnose a hyperpigmentary disorder. Based on its pathogenesis, management can be planned. For epidermal hyperpigmentation caused by increased melanin, topical skin-lightening agents targeting inhibition of tyrosinase or melanosome transfer and promotion of keratinocyte turnover can be used. Hydroquinone-containing cream is the gold-standard treatment for epidermal hyperpigmentation. Alternative treatments include laser toning or chemical peels. However, increased dermal pigmentation is more challenging to target with topical treatments. If hyperpigmentation is due to increased numbers of melanocytes or keratinocytes, high-fluence laser is the most appropriate treatment method.

Inhibition of melanogenesis by Aster yomena callus pellet extract in melanoma cells and patients with skin pigmentation.

Plant tissue culture holds immense potential for the production of secondary metabolites with various physiological functions. We recently established a plant tissue culture system capable of producing secondary metabolites from Aster yomena. This study aimed to uncover the mechanisms underlying the potential therapeutic effects of Aster yomena callus pellet extract (AYC-P-E) on photoaging-induced skin pigmentation. Excessive melanogenesis was induced in B16F10 melanoma cells using α-melanocyte stimulating hormone (α-MSH). The effects of AYC-P-E treatment on melanin biosynthesis inducers and melanin synthesis inhibition were assessed. Based on the results, a clinical study was conducted in subjects with skin pigmentation. AYC-P-E inhibited melanogenesis in α-MSH-treated B16F10 cells, accompanied by decreased mRNA and protein expression of melanin biosynthesis inducers, including cyclic AMP response element-binding protein (CREB), tyrosinase, microphthalmia-associated transcription factor (MITF), tyrosinase related protein-1 (TRP-1), and TRP-2. This anti-melanogenic effect was mediated by mitogen-activated protein kinase (MEK)/extracellular signal-regulated kinase (ERK) and protein kinase B (AKT) phosphorylation. Treatment of subjects with skin pigmentation with AYC-P-E-containing cream formulations resulted in 3.33%, 7.06%, and 8.68% improvement in the melanin levels at 2, 4, and 8 weeks, respectively. Our findings suggest that AYC-P-E inhibits excessive melanogenesis by activating MEK/ERK and AKT signaling, potentiating its cosmetic applications in hyperpigmentation treatment.

Presenting status of children with classical congenital adrenal hyperplasia over two decades (1999-2018) in the absence of newborn screening in Sri Lanka.

OBJECTIVES: Although new-born screening (NBS) for classical congenital adrenal hyperplasia (C-CAH) has been available for decades, it is not widely implemented. We assessed the usefulness of introducing NBS for C-CAH, by analyzing presenting status of infants with C-CAH, over the past two decades, in Sri Lanka. METHODS: This retrospective clinic-based study, from the largest tertiary children's hospital in Sri Lanka, analyzed initial presenting features of children with C-CAH from 1999 to 2018, in the absence of NBS for CAH, and included gender-based comparisons. RESULTS: Features suggestive of impending adrenal-crisis were seen at initial presentation in >80 % (dehydration 70%, hyponatremia 65%, hyperkalemia 47%, vomiting 45%, hypoglycemia 22%, collapse 20%). Hyperpigmentation was seen in 78%, and consanguinity in 27%. There were fewer affected males (n = 12) compared to females (n = 28). Most girls (96%) had virilized genitalia, and 16 faced uncertainty about gender at birth. Median age at diagnosis was 20 days. More than 70% of children had SW-CAH (males = 9 and females = 20). There were fewer males with SW-CAH, and all had features of impending adrenal crisis, including severe hyponatremia in 50%, while 62% of girls also developed hyponatremia and 33% had hyperkalemia, prior to treatment. Treatment of SW-CAH was initiated at a median age of 30 days in boys, and 10 days of age in girls. CONCLUSION: Many boys and girls with C-CAH from Sri Lanka presented late with impending adrenal crisis. Males were diagnosed later, and some possibly succumbed to C-CAH undiagnosed. These findings support including CAH in NBS programs to avert preventable childhood morbidity and mortality.

Hyperpigmentation of the legs.

Was a drug or a comorbidity to blame for this patient's hyperpigmentation?

A Clinical Anti-Ageing Comparative Study of 0.3 and 0.5% Retinol Serums: A Clinically Controlled Trial.

BACKGROUND: Retinol influences the process of keratinization of the epidermis, which improves stratum corneum structure and reduces transepidermal water loss. It also significantly enhances mature skin by brightening hyperpigmentation and reducing the signs of photoageing. Cosmeceuticals are intended to both provide aesthetic effects for the skin and allow dermatological treatment. The aim of the study was to assess the rejuvenating effect of retinol serum on facial skin at concentrations of 0.3 and 0.5%, as well as any improvements in skin brightening and elasticity. MATERIALS AND METHODS: Thirty-seven volunteers were included in the study, after confirming tolerance. The novel formula was applied once daily to the face for a period of 12 weeks: one retinol concentration on the left side and the other on the right. The initial study with liquid crystal formula (study vehicle) was carried out for 8 weeks on 28 volunteers. Treatment efficiency was evaluated at baseline, and 56 and 84 days following treatment using the multi probe adapter and Fotomedicus imaging system. PRIMOS was used to measure skin surface roughness. The visual analogue scale method enabled the results to be determined by 3 independent specialists. RESULTS: Skin hyperpigmentation, unevenness, and wrinkles gradually decreased over the course of treatment, both on the left and right parts of the face. Adverse events were predominantly mild or moderate skin irritation. More frequent and more intense symptoms were observed on the left side (0.5%). CONCLUSION: Retinol in liquid crystal formulation is safe and provides significant clinical benefits associated with unification of skin colour, overall skin tone, skin elasticity, and moisture. Regular use of retinol typically results in brightening of the skin and reduced signs of ageing. The objective findings confirmed the effectiveness of the procedures.

Effect of the Stromal Vascular Fraction on Changes in Melanin Formation in B16 Cells Treated by IBMX.

OBJECTIVE: To investigate the effect of the stromal vascular fraction (SVF) on changes in melanin formation and tyrosinase activity in B16 cells treated by 3-isobutyl-1 methylxanthine (IBMX) and to explore the mechanism of SVF-mediated inhibition of pigmentation. METHODS: We co-cultured extracted SVFs and B16 cells treated with IBMX in a certain proportion, and the marker molecule HMB-45 was detected by immunochemistry. Melanin content was determined by NaOH lysis. Activity of tyrosinase was measured by the DOPA oxidation method. RESULTS: HMB-45 was commonly expressed in B16 cells induced by IBMX. After the addition of SVFs, the expression of HMB-45 decreased significantly and positively correlated with increases in SVFs. After the induction of B16 cells by IBMX, melanin content increased significantly. However, melanin decreased after SVF and B16 co-culturing; the effect was more substantial with the increase and decrease in SVFs, and the activity of tyrosinase decreased. CONCLUSION: SVFs inhibit the production of melanin and reduce the activity of tyrosinase, possibly providing a new breakthrough for the treatment of pigment disorders. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ashy dermatosis: a review.

Ashy dermatosis is characterized by asymptomatic, symmetrically-distributed, gray-colored macules located on the trunk, neck, face, and upper extremities. The condition occurs most commonly in patients with Fitzpatrick phototype III-V skin. The etiology is unknown, but drug ingestion, infection, and genetic factors have been suggested to elicit ashy dermatosis. No gold standard treatments have been established yet. The most successful treatment to date has been clofazimine, although topical tacrolimus, oral dapsone, narrowband ultraviolet light B phototherapy, and isotretinoin have shown treatment success. Ashy dermatosis is primarily a cosmetic concern, but can be a very distressing condition, especially for dark skinned individuals. Therefore, an increase in clinician awareness and more studies are needed to further understand the etiology and treatment options for this disease. This review serves as a single source for clinicians to stay up-to-date regarding the history, clinical presentation, histology, pathogenesis, differential diagnosis, and management options for ashy dermatosis. It also suggests an alternative name that more appropriately encompasses the clinical and histopathologic features, while acknowledging our lack of understanding of its etiology: macular hyperpigmentation of indeterminate etiology.

Hyperpigmentation after Foamed Bleomycin Sclerotherapy for Vascular Malformations.

The present report documents 6 patients who developed distinctive hyperpigmented skin lesions after bleomycin sclerotherapy for vascular malformations of the face, neck, and extremities. The patients ranged in age from 2 to 65 years and included both black and white and male and female patients. The bleomycin treatment dose varied from 15 to 45 U, with 5 of the 6 patients receiving foamed bleomycin. The hyperpigmented lesions were near the patient's vascular anomaly and attributable to postprocedural cutaneous pressure (eg, electrocardiographic [ECG] leads or tape). Hyperpigmentation faded slowly over time but was visible up to 3 years after the procedure.

Atrophoderma of Pasini and Pierini in a young adult: a case report.

Atrophoderma of Pasini and Pierini is a skin atrophy presenting as single or multiple sharply demarcated, hyperpigmented, non-indurated patches, with a slight depression of the skin, that can converge and form a confluent area with atrophy as a consequence. The condition was first described by Pasini in 1923 and subsequently by Pierini in 1936. They distinguished this form of atrophy from other diseases and conditions in which the atrophy is morphologically and clinically different. The disease was initially associated with Borrelia burgdorferi infection; however, at present, various theories have emerged for the appearance of the disease, linked to genetic, neurogenetic, and immunological factors. Here we present a patient that was admitted to the hospital due to disseminated lesions on the skin of the lower limbs, with slightly pigmented and atrophic skin along with irregular borders varying in size, from several mm to a few cm, clearly demarcated from the healthy skin, with no history of a tick bite or a family history of similar skin disorders.

Reliability assessment and validation of the dermal pigmentation area and severity index: a new scoring method for acquired dermal macular hyperpigmentation.

BACKGROUND: Dermal pigmentation area and severity score (DPASI) is a recently proposed scoring system for acquired dermal macular hyperpigmentation (ADMH). OBJECTIVE: To determine the reliability and validity of DPASI. METHODS: After standardized training, three researchers independently rated 55 patients with ADMH on two consecutive days within 1 week, to determine intra-rater and inter-rater reliability. Validation was performed by comparing DPASI with the physician global assessment score. RESULTS: Test-retest reliability of individual raters tested by Pearson's r showed good correlation for all three raters (r = 0.984, P < 0.0001; r = 0.983, P < 0.000 and r = 0.970, P < 0.0001). Inter-rater agreement computed by intra-class correlation coefficient also showed good correlation (ICC = 0.997, P < 0.0001). Internal consistency as measured by Cronbach's alpha was 0.997. The score faired well in face and content validity (I-CVI of 0.87). On usability assessment, the scale had a median score of 4 on a scale from 1 to 5. The meantime taken to score the patients were 307.2 ± 83, 308.9 ± 84.4, 350.15 ± 91.8 s by three observers, respectively. CONCLUSION: The DPASI is a reliable measure of ADMH severity. The use of dermoscopy decreases inter and intra-observer variation resulting in a more objective score.

Crusted nipple and areola: A new aetiology of secondary hyperkeratosis of the nipple and areola.

Hyperkeratosis of the nipple and areola is a rare condition first described by Tauber in 1923. Less than 100 cases have been reported in the literature. Hyperkeratosis of the nipple and areola presents as hyperkeratotic, hyperpigmented plaques on the nipple and areola. It is more common in females. An 18-year-old female patient presented with hyperkeratotic, plaque-like, hard crusts on both nipples and areolas. The examining physician could successfully remove this crust using his finger. The crust had accumulated as a result of the patient's reluctance to touch or clean the breast area due to psychological issues. A crusted nipple and areola may occur as a secondary condition due to a patient's reluctance to touch or clean their breasts.

Hiperqueratosis acral focal: correlación clínica, histopatológica y ecográfica / Correlation Between Clinical, Histopathologic, and Ultrasound Findings in Focal Acral Hyperkeratosis

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