Pigmentary Potpourri: How to Evaluate, Diagnose, and Treat Pigmentary Conditions

March 2nd, 2019, AAD Annual Meeting, Washington DC

Nada Elbuluk, MD, MSc Neelam Vashi MD Assistant Professor of Dermatology Associate Professor of Dermatology University of Southern California Boston University Director, Skin of Color Center Director, Center for Ethnic Skin Director, Pigmentary Disorders Clinic Director, Cosmetic and Laser Center  

Pigmentary disorders are common dermatologic conditions seen more frequently in darker skin types (Fitzpatrick skin type 4-6). These conditions are typically among the top chief complaints for which skin of color patients seek evaluation from a dermatologist. These conditions can be challenging to diagnose and treat. Proper evaluation and work-up along with consideration of a broad differential are important for determining appropriate treatment options and prognosis. Below are important diseases to consider in one’s pigmentary differential along with clinical pearls in the evaluation and treatment process.

Differential for Diseases of Hyperpigmentation: • Erythema Dyschromicum Perstans • Lichen Planus Pigmentosus

• Can be associated with frontal fibrosing alopecia and facial papules. This triad has been seen more commonly in women of color.

• Idiopathic eruptive macular pigmentation • Ochronosis • Melasma • Nevus of Ota/Ito • Hori’s nevus • Lentigines • Dermatosis Papulosa Nigra • Maturational Hyperpigmentation • Riehl’s melanosis • Connective Tissue Disease • Pellagra • CARP • Acanthosis Nigricans • Treponemal Diseases • Endocrinopathies • Urticaria pigmentosa • Postinflammatory hyperpigmentation • Fixed Drug eruption • Lichenoid drug • Phototoxic or photoallergic

• Vasculitis • Macular Lymphocytic Arteritis

• Drug induced pigmentation: • Chlorpromazine, TCA, tetracyclines, amiodarone, HRT, aspirin, chemotherapy,

minocycline, HCTZ, sulfasalazine, hydroxychloroquine Differential for Diseases of Hypopigmentation and Depigmentation:

• Vitiligo • Can present with various presentations including inflammatory, confetti,

trichrome. • Hansens/Leprosy • Tinea Veriscolor • Pityriasis Alba • Post inflammatory hypopigmentation • Pityriasias Lichenoides Chronica • Hypopigmented Mycosis Fungoides • Tuberous Sclerosis- Ash Leaf Macules • Hypomelanosis of Ito • Piebaldism • Waardenburg • Treponemal: Syphilis, Pinta

Clinical Pearls in the evaluation and treatment of pigmentary disorders:

• Obtain detailed clinical history • Go through medication list, medical history, and prior records thoroughly • Low threshold for biopsy

• In cases of dyspigmentation, biopsy lesional and normal skin • Have established relationship with your dermatopathologist to discuss

cases in which there is a lack of clin-path discorrelation • Use easy accessible diagnostic tools: Wood’s lamp, dermatoscope • Have patient change into gown to check entire body • Take photographs • Advise patient’s on prognosis while setting realistic expectations • Counsel on sunscreen importance when treating disorders of hyperpigmentation • Keep in mind patients can have more than one pigmentary condition • Certain pigmentary conditions can indicate underlying systemic diseases • Common pigmentary conditions can occur in uncommon places • Not all pigmentary conditions are from underlying changes in melanin or melanocytes,

other pathogenetic factors can contribute to clinically apparent changes in skin color

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