Pigmentation Disorders

While often considered a problem in white skin, rosacea is also a common concern in skin of color patients.

The clinical signs of rosacea are often hard to diagnose in Fitzpatrick skin types III-VI, and are often not associated with clinical signs and symptoms of flushing or telangiectasias. Trigger factors associated with rosacea flares – hot beverages, spicy foods, caffeine, alcoholic drinks, heat, and exercise – are often completely absent in skin of color.

Rosacea occurs mainly on the central malar cheeks, forehead, chin, and nose.  Erythema and red/brown papules are common and are often confused with acne. As the condition progresses, the skin becomes persistently red and can feel uneven or even thicker. Hyper or hypopigmentation may develop in areas with inflammation. Perioral or periorficial papules, a form of rosacea commonly seen in skin of color, is also often misdiagnosed.

It has been my experience that rosacea in skin of color is often refractory to traditional topical medications and patients will often need a short course of oral antibiotics. Sulfur/sodium sulfacetamide topicals, in addition to azelaic acid, are a great adjunct to oral treatment. Topical steroids may initially improve symptoms, but will actually make the disease progress when the steroids are stopped, so they should be avoided. Strict photo protection should be encouraged.

For years, the cause of rosacea was unknown. However a team of researchers, led by Dr. Richard L. Gallo, chief of dermatology and professor of medicine and pediatrics at the University of California San Diego, found that overproduction of two interactive inflammatory proteins results in excessive levels of a third protein that cause rosacea symptoms. His team found skin antimicrobial peptides, cathelicidins, were altered and overproduced in patients with rosacea (Nat. Med. 2007;13:975-80).

Approximately 14 million people in the United States have rosacea. Early diagnosis and management with combination oral and topical medications are effective at controlling this highly prevalent yet often misdiagnosed disease. Future research into the underlying cause of rosacea will offer targeted therapies aimed at the abnormally processed antimicrobial peptides present in the skin of rosacea patients.

While often considered a problem in white skin, rosacea is also a common concern in skin of color patients.

The clinical signs of rosacea are often hard to diagnose in Fitzpatrick skin types III-VI, and are often not associated with clinical signs and symptoms of flushing or telangiectasias. Trigger factors associated with rosacea flares – hot beverages, spicy foods, caffeine, alcoholic drinks, heat, and exercise – are often completely absent in skin of color.

Rosacea occurs mainly on the central malar cheeks, forehead, chin, and nose.  Erythema and red/brown papules are common and are often confused with acne. As the condition progresses, the skin becomes persistently red and can feel uneven or even thicker. Hyper or hypopigmentation may develop in areas with inflammation. Perioral or periorficial papules, a form of rosacea commonly seen in skin of color, is also often misdiagnosed.

It has been my experience that rosacea in skin of color is often refractory to traditional topical medications and patients will often need a short course of oral antibiotics. Sulfur/sodium sulfacetamide topicals, in addition to azelaic acid, are a great adjunct to oral treatment. Topical steroids may initially improve symptoms, but will actually make the disease progress when the steroids are stopped, so they should be avoided. Strict photo protection should be encouraged.

For years, the cause of rosacea was unknown. However a team of researchers, led by Dr. Richard L. Gallo, chief of dermatology and professor of medicine and pediatrics at the University of California San Diego, found that overproduction of two interactive inflammatory proteins results in excessive levels of a third protein that cause rosacea symptoms. His team found skin antimicrobial peptides, cathelicidins, were altered and overproduced in patients with rosacea (Nat. Med. 2007;13:975-80).

Approximately 14 million people in the United States have rosacea. Early diagnosis and management with combination oral and topical medications are effective at controlling this highly prevalent yet often misdiagnosed disease. Future research into the underlying cause of rosacea will offer targeted therapies aimed at the abnormally processed antimicrobial peptides present in the skin of rosacea patients.

While often considered a problem in white skin, rosacea is also a common concern in skin of color patients.

The clinical signs of rosacea are often hard to diagnose in Fitzpatrick skin types III-VI, and are often not associated with clinical signs and symptoms of flushing or telangiectasias. Trigger factors associated with rosacea flares – hot beverages, spicy foods, caffeine, alcoholic drinks, heat, and exercise – are often completely absent in skin of color.

Rosacea occurs mainly on the central malar cheeks, forehead, chin, and nose.  Erythema and red/brown papules are common and are often confused with acne. As the condition progresses, the skin becomes persistently red and can feel uneven or even thicker. Hyper or hypopigmentation may develop in areas with inflammation. Perioral or periorficial papules, a form of rosacea commonly seen in skin of color, is also often misdiagnosed.

It has been my experience that rosacea in skin of color is often refractory to traditional topical medications and patients will often need a short course of oral antibiotics. Sulfur/sodium sulfacetamide topicals, in addition to azelaic acid, are a great adjunct to oral treatment. Topical steroids may initially improve symptoms, but will actually make the disease progress when the steroids are stopped, so they should be avoided. Strict photo protection should be encouraged.

For years, the cause of rosacea was unknown. However a team of researchers, led by Dr. Richard L. Gallo, chief of dermatology and professor of medicine and pediatrics at the University of California San Diego, found that overproduction of two interactive inflammatory proteins results in excessive levels of a third protein that cause rosacea symptoms. His team found skin antimicrobial peptides, cathelicidins, were altered and overproduced in patients with rosacea (Nat. Med. 2007;13:975-80).

Approximately 14 million people in the United States have rosacea. Early diagnosis and management with combination oral and topical medications are effective at controlling this highly prevalent yet often misdiagnosed disease. Future research into the underlying cause of rosacea will offer targeted therapies aimed at the abnormally processed antimicrobial peptides present in the skin of rosacea patients.

Lignin peroxidase, a novel skin-lightening active agent that is derived from a fungus, is being studied with some interest and is being developed as an ingredient in products to treat pigmentation disorders.

Melanin, the dark pigment in the skin, is produced in the basal layer of the epidermis by melanocytes. Melanocytes make melanin, which is packaged into melanosomes and then transferred to the epidermal cells (keratinocytes). Accumulation of melanin in the epidermis is the main cause of pigmentation disorders, which are observed in all demographic groups but most commonly in people with darker skin types.

Excessive sun exposure in dark and light skin types can lead to unwanted accumulation of pigment (known as solar lentigo) in the skin. Pigmentation disorders are notoriously difficult to treat. Melanin is a very durable compound, and researchers have been largely unsuccessful in finding ways to break down melanin to reduce unwanted skin pigment. The existing topical treatments for skin lightening focus on the prevention of melanin formation by blocking tyrosinase and inhibiting its biosynthesis; by preventing the stimulation of melanocytes by UVA: or by blocking the transfer of melanosomes to keratinocytes via the PAR-2 receptor.

Alternative to Hydroquinone

Historically, the most effective treatments for skin lightening have contained hydroquinone. However, hydroquinone has become controversial, and related safety concerns have prompted research into alternative agents to treat skin pigmentation disorders. In addition, the skin develops tachyphylaxis to hydroquinone requiring 1-month "holidays" in order to maintain effectiveness, and a subset of people may develop contact allergy to hydroquinone. Many other compounds have been studied for the treatment of pigmentation disorders, including retinoids, mequinol, azelaic acid, arbutin, kojic acid, aloesin, licorice extract, ascorbic acid, soy proteins, N-acetyl glucosamine, and most recently, lignin peroxidase.

The enzyme lignin peroxidase (LIP) was first identified in 1984 (Arch. Biochem. Biophys. 1984;234:353-62), and has been researched for many years as a potential agent to break down lignin to whiten wood pulp in paper production. It was later found to break down eumelanin, which has a chemical structure similar to lignin. The development of lignin peroxidase as a skin-lightening agent resulted from these discoveries (U.S. Patent and Trademark Office Patent Application 20060051305). This novel skin-lightening active ingredient is produced extracellularly during submerged fermentation of the fungus Phanerochaete chrysosporium 3 (Biotechnol. Bioproc. E. 2004;9:153-68) and then purified from the fermented liquid medium (Lonza of Switzerland).The LIP enzyme (trademarked as Melanozyme) identifies eumelanin in the epidermis and specifically breaks down the pigment without affecting melanin biosynthesis or blocking tyrosinase. Although there are other types of lignin peroxidase enzymes, at this point, Melanozyme is the only one that has been developed and proved to be effective for skin lightening. Melanozyme is a glycoprotein active at pH 2-4.5 and inactive above that pH level. (The normal pH of skin is around 5.5, with slight variations between 5.0 and 6.5.)

Product Based on Lignin Peroxidase

Melanozyme is currently proprietary and is available only in a new skin-lightening product known on the market as Elure The Elure products are presented in a two-sided dispenser with one side containing the Melanozyme component and the other side an activator. Melanozyme alone has little ability to lighten skin, and first needs to be oxidized by hydrogen peroxide (0.012% in the activator) to enter an "activated state." The activator, which contains a small amount of hydrogen peroxide, is applied to the surface of the skin after the Melanozyme.

When applied to skin, the products that contain the Melanozyme and the activator have to be slightly acidic and buffered in order for the enzyme to perform. In addition, the enzyme is required to be first oxidized by H₂O₂, and then reduced by a substrate molecule (for example, veratryl alcohol) before the melanin is oxidized. After application of Elure lotion or cream, the skin pH is temporarily reduced to 3.5 but subsequently increases to its normal level of around 5.5. As the skin surface returns to the normal pH level, the enzyme is inactivated. It becomes a simple glycoprotein and is hydrolyzed in the skin by the naturally present proteases and other glycosidases into amino acids.

The safety of lignin peroxidase as a skin-lightening active ingredient has been demonstrated in preclinical studies (data on file at Rakuto Bio Technologies Ltd., 5 Carmel Street, P.O. Box 528, New Industrial Park, Yokneam 20692 Israel) with doses that are 17,000 times the recommended dose without prompting any side effects. LIP is nonmutagenic and nonirritating to eyes. The potential for skin irritation is very low, and in studies of 50 subjects each, there were no reports of skin irritation during acute sensitivity or cumulative sensitivity, or when used in sensitized skin.

Conclusion

Three open-label clinical trials and one double-blind, split-face controlled study (Rakuto Bio Technologies) in subjects with Fitzpatrick skin types II-IV have confirmed the tolerability of Elure. In all clinical studies conducted with Elure, significant improvement in tone, evenness, and dyspigmentation were achieved in most subjects within 1 month of use. Elure has been shown to be better tolerated and more effective than 2% hydroquinone. However, more studies are needed to compare the product against stronger concentrations of hydroquinone and other existing treatments, as well as to demonstrate its effectiveness in the treatment of other pigmentary conditions in a broader range of patients. The use of Elure in a combination skin care regimen with hydroquinone and glycolic acid has not been studied, but there is no reason to believe that these products would be incompatible. In fact, a glycolic cleanser that lowers the pH of the skin prior to application could theoretically enhance the efficacy of the product.

Dr. Baumann is on the advisory board of Syneron, the manufacturer of Elure.

Lignin peroxidase, a novel skin-lightening active agent that is derived from a fungus, is being studied with some interest and is being developed as an ingredient in products to treat pigmentation disorders.

Melanin, the dark pigment in the skin, is produced in the basal layer of the epidermis by melanocytes. Melanocytes make melanin, which is packaged into melanosomes and then transferred to the epidermal cells (keratinocytes). Accumulation of melanin in the epidermis is the main cause of pigmentation disorders, which are observed in all demographic groups but most commonly in people with darker skin types.

Excessive sun exposure in dark and light skin types can lead to unwanted accumulation of pigment (known as solar lentigo) in the skin. Pigmentation disorders are notoriously difficult to treat. Melanin is a very durable compound, and researchers have been largely unsuccessful in finding ways to break down melanin to reduce unwanted skin pigment. The existing topical treatments for skin lightening focus on the prevention of melanin formation by blocking tyrosinase and inhibiting its biosynthesis; by preventing the stimulation of melanocytes by UVA: or by blocking the transfer of melanosomes to keratinocytes via the PAR-2 receptor.

Alternative to Hydroquinone

Historically, the most effective treatments for skin lightening have contained hydroquinone. However, hydroquinone has become controversial, and related safety concerns have prompted research into alternative agents to treat skin pigmentation disorders. In addition, the skin develops tachyphylaxis to hydroquinone requiring 1-month "holidays" in order to maintain effectiveness, and a subset of people may develop contact allergy to hydroquinone. Many other compounds have been studied for the treatment of pigmentation disorders, including retinoids, mequinol, azelaic acid, arbutin, kojic acid, aloesin, licorice extract, ascorbic acid, soy proteins, N-acetyl glucosamine, and most recently, lignin peroxidase.

The enzyme lignin peroxidase (LIP) was first identified in 1984 (Arch. Biochem. Biophys. 1984;234:353-62), and has been researched for many years as a potential agent to break down lignin to whiten wood pulp in paper production. It was later found to break down eumelanin, which has a chemical structure similar to lignin. The development of lignin peroxidase as a skin-lightening agent resulted from these discoveries (U.S. Patent and Trademark Office Patent Application 20060051305). This novel skin-lightening active ingredient is produced extracellularly during submerged fermentation of the fungus Phanerochaete chrysosporium 3 (Biotechnol. Bioproc. E. 2004;9:153-68) and then purified from the fermented liquid medium (Lonza of Switzerland).The LIP enzyme (trademarked as Melanozyme) identifies eumelanin in the epidermis and specifically breaks down the pigment without affecting melanin biosynthesis or blocking tyrosinase. Although there are other types of lignin peroxidase enzymes, at this point, Melanozyme is the only one that has been developed and proved to be effective for skin lightening. Melanozyme is a glycoprotein active at pH 2-4.5 and inactive above that pH level. (The normal pH of skin is around 5.5, with slight variations between 5.0 and 6.5.)

Product Based on Lignin Peroxidase

Melanozyme is currently proprietary and is available only in a new skin-lightening product known on the market as Elure The Elure products are presented in a two-sided dispenser with one side containing the Melanozyme component and the other side an activator. Melanozyme alone has little ability to lighten skin, and first needs to be oxidized by hydrogen peroxide (0.012% in the activator) to enter an "activated state." The activator, which contains a small amount of hydrogen peroxide, is applied to the surface of the skin after the Melanozyme.

When applied to skin, the products that contain the Melanozyme and the activator have to be slightly acidic and buffered in order for the enzyme to perform. In addition, the enzyme is required to be first oxidized by H₂O₂, and then reduced by a substrate molecule (for example, veratryl alcohol) before the melanin is oxidized. After application of Elure lotion or cream, the skin pH is temporarily reduced to 3.5 but subsequently increases to its normal level of around 5.5. As the skin surface returns to the normal pH level, the enzyme is inactivated. It becomes a simple glycoprotein and is hydrolyzed in the skin by the naturally present proteases and other glycosidases into amino acids.

The safety of lignin peroxidase as a skin-lightening active ingredient has been demonstrated in preclinical studies (data on file at Rakuto Bio Technologies Ltd., 5 Carmel Street, P.O. Box 528, New Industrial Park, Yokneam 20692 Israel) with doses that are 17,000 times the recommended dose without prompting any side effects. LIP is nonmutagenic and nonirritating to eyes. The potential for skin irritation is very low, and in studies of 50 subjects each, there were no reports of skin irritation during acute sensitivity or cumulative sensitivity, or when used in sensitized skin.

Conclusion

Three open-label clinical trials and one double-blind, split-face controlled study (Rakuto Bio Technologies) in subjects with Fitzpatrick skin types II-IV have confirmed the tolerability of Elure. In all clinical studies conducted with Elure, significant improvement in tone, evenness, and dyspigmentation were achieved in most subjects within 1 month of use. Elure has been shown to be better tolerated and more effective than 2% hydroquinone. However, more studies are needed to compare the product against stronger concentrations of hydroquinone and other existing treatments, as well as to demonstrate its effectiveness in the treatment of other pigmentary conditions in a broader range of patients. The use of Elure in a combination skin care regimen with hydroquinone and glycolic acid has not been studied, but there is no reason to believe that these products would be incompatible. In fact, a glycolic cleanser that lowers the pH of the skin prior to application could theoretically enhance the efficacy of the product.

Dr. Baumann is on the advisory board of Syneron, the manufacturer of Elure.

Lignin peroxidase, a novel skin-lightening active agent that is derived from a fungus, is being studied with some interest and is being developed as an ingredient in products to treat pigmentation disorders.

Melanin, the dark pigment in the skin, is produced in the basal layer of the epidermis by melanocytes. Melanocytes make melanin, which is packaged into melanosomes and then transferred to the epidermal cells (keratinocytes). Accumulation of melanin in the epidermis is the main cause of pigmentation disorders, which are observed in all demographic groups but most commonly in people with darker skin types.

Excessive sun exposure in dark and light skin types can lead to unwanted accumulation of pigment (known as solar lentigo) in the skin. Pigmentation disorders are notoriously difficult to treat. Melanin is a very durable compound, and researchers have been largely unsuccessful in finding ways to break down melanin to reduce unwanted skin pigment. The existing topical treatments for skin lightening focus on the prevention of melanin formation by blocking tyrosinase and inhibiting its biosynthesis; by preventing the stimulation of melanocytes by UVA: or by blocking the transfer of melanosomes to keratinocytes via the PAR-2 receptor.

Alternative to Hydroquinone

Historically, the most effective treatments for skin lightening have contained hydroquinone. However, hydroquinone has become controversial, and related safety concerns have prompted research into alternative agents to treat skin pigmentation disorders. In addition, the skin develops tachyphylaxis to hydroquinone requiring 1-month "holidays" in order to maintain effectiveness, and a subset of people may develop contact allergy to hydroquinone. Many other compounds have been studied for the treatment of pigmentation disorders, including retinoids, mequinol, azelaic acid, arbutin, kojic acid, aloesin, licorice extract, ascorbic acid, soy proteins, N-acetyl glucosamine, and most recently, lignin peroxidase.

The enzyme lignin peroxidase (LIP) was first identified in 1984 (Arch. Biochem. Biophys. 1984;234:353-62), and has been researched for many years as a potential agent to break down lignin to whiten wood pulp in paper production. It was later found to break down eumelanin, which has a chemical structure similar to lignin. The development of lignin peroxidase as a skin-lightening agent resulted from these discoveries (U.S. Patent and Trademark Office Patent Application 20060051305). This novel skin-lightening active ingredient is produced extracellularly during submerged fermentation of the fungus Phanerochaete chrysosporium 3 (Biotechnol. Bioproc. E. 2004;9:153-68) and then purified from the fermented liquid medium (Lonza of Switzerland).The LIP enzyme (trademarked as Melanozyme) identifies eumelanin in the epidermis and specifically breaks down the pigment without affecting melanin biosynthesis or blocking tyrosinase. Although there are other types of lignin peroxidase enzymes, at this point, Melanozyme is the only one that has been developed and proved to be effective for skin lightening. Melanozyme is a glycoprotein active at pH 2-4.5 and inactive above that pH level. (The normal pH of skin is around 5.5, with slight variations between 5.0 and 6.5.)

Product Based on Lignin Peroxidase

Melanozyme is currently proprietary and is available only in a new skin-lightening product known on the market as Elure The Elure products are presented in a two-sided dispenser with one side containing the Melanozyme component and the other side an activator. Melanozyme alone has little ability to lighten skin, and first needs to be oxidized by hydrogen peroxide (0.012% in the activator) to enter an "activated state." The activator, which contains a small amount of hydrogen peroxide, is applied to the surface of the skin after the Melanozyme.

When applied to skin, the products that contain the Melanozyme and the activator have to be slightly acidic and buffered in order for the enzyme to perform. In addition, the enzyme is required to be first oxidized by H₂O₂, and then reduced by a substrate molecule (for example, veratryl alcohol) before the melanin is oxidized. After application of Elure lotion or cream, the skin pH is temporarily reduced to 3.5 but subsequently increases to its normal level of around 5.5. As the skin surface returns to the normal pH level, the enzyme is inactivated. It becomes a simple glycoprotein and is hydrolyzed in the skin by the naturally present proteases and other glycosidases into amino acids.

The safety of lignin peroxidase as a skin-lightening active ingredient has been demonstrated in preclinical studies (data on file at Rakuto Bio Technologies Ltd., 5 Carmel Street, P.O. Box 528, New Industrial Park, Yokneam 20692 Israel) with doses that are 17,000 times the recommended dose without prompting any side effects. LIP is nonmutagenic and nonirritating to eyes. The potential for skin irritation is very low, and in studies of 50 subjects each, there were no reports of skin irritation during acute sensitivity or cumulative sensitivity, or when used in sensitized skin.

Conclusion

Three open-label clinical trials and one double-blind, split-face controlled study (Rakuto Bio Technologies) in subjects with Fitzpatrick skin types II-IV have confirmed the tolerability of Elure. In all clinical studies conducted with Elure, significant improvement in tone, evenness, and dyspigmentation were achieved in most subjects within 1 month of use. Elure has been shown to be better tolerated and more effective than 2% hydroquinone. However, more studies are needed to compare the product against stronger concentrations of hydroquinone and other existing treatments, as well as to demonstrate its effectiveness in the treatment of other pigmentary conditions in a broader range of patients. The use of Elure in a combination skin care regimen with hydroquinone and glycolic acid has not been studied, but there is no reason to believe that these products would be incompatible. In fact, a glycolic cleanser that lowers the pH of the skin prior to application could theoretically enhance the efficacy of the product.

Dr. Baumann is on the advisory board of Syneron, the manufacturer of Elure.

Black market skin bleaching agents with potentially unsafe ingredients are a growing concern in some countries, according to an article published yesterday, April 11, by the Associated Press, "Skin Bleaching a Growing Problem in Jamaican Slums."

The use of these agents stems from societal and cultural beliefs that lighter skin could lead to a better way of life, particularly for those that are impoverished.

In Jamaica, for example, a "23-year-old resident of a Kingston ghetto hopes to transform her dark complexion to a cafe-au-lait-color common among Jamaica's elite and favored by many men in her neighborhood. She believes a fairer skin could be her ticket to a better life. So she spends her meager savings on cheap black-market concoctions that promise to lighten her pigment," (excerpt from AP story).

This phenomenon is not exclusive to Jamaica, but is inherent to many nations around the world. It has been documented in India, the Americas, the Middle East, the Philippines, and in some parts of Africa and Asia.

Lightening agents, such as hydroquinone, have been banned in over the counter preparations in Japan, the European Union, and Australia. OTC hydroquinone is still available in the United States in percentages of up to 2%. While hydroquinone use may lead to adverse events such as ochronosis, it is a rare event typically seen with use of much higher concentrations over longer periods of time. In my opinion, it is not low concentrations of hydroquinone, but other potentially harmful ingredients that may be found in some of the black market products that are of major concern.

"Lightening creams are not effectively regulated in Jamaica, where even roadside vendors sell tubes and plastic bags of powders and ointments from cardboard boxes stacked along sidewalks in market districts," according to the AP story. "Many of the tubes are unlabeled as to their actual ingredients," said Dr. Richard Desnoes, president of the Dermatology Association of Jamaica.

"Hardcore bleachers use illegal ointments smuggled into the Caribbean country that contain toxins like mercury, a metal that blocks production of melanin, which give skin its color, but can also be toxic," the story continued.

In addition, potent topical corticosteroids have been found in some of these products, leading to reports of atrophy, striae, and even symptoms of Cushing’s syndrome.

Black market skin bleaching agents with potentially unsafe ingredients are a growing concern in some countries, according to an article published yesterday, April 11, by the Associated Press, "Skin Bleaching a Growing Problem in Jamaican Slums."

The use of these agents stems from societal and cultural beliefs that lighter skin could lead to a better way of life, particularly for those that are impoverished.

In Jamaica, for example, a "23-year-old resident of a Kingston ghetto hopes to transform her dark complexion to a cafe-au-lait-color common among Jamaica's elite and favored by many men in her neighborhood. She believes a fairer skin could be her ticket to a better life. So she spends her meager savings on cheap black-market concoctions that promise to lighten her pigment," (excerpt from AP story).

This phenomenon is not exclusive to Jamaica, but is inherent to many nations around the world. It has been documented in India, the Americas, the Middle East, the Philippines, and in some parts of Africa and Asia.

Lightening agents, such as hydroquinone, have been banned in over the counter preparations in Japan, the European Union, and Australia. OTC hydroquinone is still available in the United States in percentages of up to 2%. While hydroquinone use may lead to adverse events such as ochronosis, it is a rare event typically seen with use of much higher concentrations over longer periods of time. In my opinion, it is not low concentrations of hydroquinone, but other potentially harmful ingredients that may be found in some of the black market products that are of major concern.

"Lightening creams are not effectively regulated in Jamaica, where even roadside vendors sell tubes and plastic bags of powders and ointments from cardboard boxes stacked along sidewalks in market districts," according to the AP story. "Many of the tubes are unlabeled as to their actual ingredients," said Dr. Richard Desnoes, president of the Dermatology Association of Jamaica.

"Hardcore bleachers use illegal ointments smuggled into the Caribbean country that contain toxins like mercury, a metal that blocks production of melanin, which give skin its color, but can also be toxic," the story continued.

In addition, potent topical corticosteroids have been found in some of these products, leading to reports of atrophy, striae, and even symptoms of Cushing’s syndrome.

Black market skin bleaching agents with potentially unsafe ingredients are a growing concern in some countries, according to an article published yesterday, April 11, by the Associated Press, "Skin Bleaching a Growing Problem in Jamaican Slums."

The use of these agents stems from societal and cultural beliefs that lighter skin could lead to a better way of life, particularly for those that are impoverished.

In Jamaica, for example, a "23-year-old resident of a Kingston ghetto hopes to transform her dark complexion to a cafe-au-lait-color common among Jamaica's elite and favored by many men in her neighborhood. She believes a fairer skin could be her ticket to a better life. So she spends her meager savings on cheap black-market concoctions that promise to lighten her pigment," (excerpt from AP story).

This phenomenon is not exclusive to Jamaica, but is inherent to many nations around the world. It has been documented in India, the Americas, the Middle East, the Philippines, and in some parts of Africa and Asia.

Lightening agents, such as hydroquinone, have been banned in over the counter preparations in Japan, the European Union, and Australia. OTC hydroquinone is still available in the United States in percentages of up to 2%. While hydroquinone use may lead to adverse events such as ochronosis, it is a rare event typically seen with use of much higher concentrations over longer periods of time. In my opinion, it is not low concentrations of hydroquinone, but other potentially harmful ingredients that may be found in some of the black market products that are of major concern.

"Lightening creams are not effectively regulated in Jamaica, where even roadside vendors sell tubes and plastic bags of powders and ointments from cardboard boxes stacked along sidewalks in market districts," according to the AP story. "Many of the tubes are unlabeled as to their actual ingredients," said Dr. Richard Desnoes, president of the Dermatology Association of Jamaica.

"Hardcore bleachers use illegal ointments smuggled into the Caribbean country that contain toxins like mercury, a metal that blocks production of melanin, which give skin its color, but can also be toxic," the story continued.

In addition, potent topical corticosteroids have been found in some of these products, leading to reports of atrophy, striae, and even symptoms of Cushing’s syndrome.

Despite being the most common pattern of scarring hair loss among African American women, central centrifugal cicatricial alopecia is still poorly understood, according to a report published online April 11 in Archives of Dermatology.

The etiology of and risk factors for the disorder have not been established. And although African American women commonly present with the condition, the exact prevalence remains unknown, said Dr. Angela Kyei and her associates at the Cleveland Clinic Institute of Dermatology and Plastic Surgery.

Photo credit: Dr. Valerie Callender

Central centrifugal cicatricial alopecia (CCCA) – previously known as hot comb alopecia or follicular degeneration syndrome – is a scarring hair loss centered on the vertex of the scalp and spreading peripherally, which is described almost exclusively in African American women. In the late 1960s it was linked to the use of hot combs, but since then almost every method of hair grooming in this population has been associated, albeit weakly, with the disorder. Few studies have examined other possible etiologies, such as immunologic, dermatologic, or genetic factors.

"Given the lack of epidemiologic data, the main goal of [our] study was to elucidate environmental as well as medical risk factors that may be associated with CCCA," the researchers wrote.

They administered questionnaires to 326 African American women attending two churches and a health fair in the Cleveland area. Sixteen of the women ended up being excluded from the analysis.

The questionnaires asked detailed information about family history of male- and female-pattern hair loss; personal medical history, including bacterial and fungal skin infections, autoimmune conditions, and hormonal dysregulation; and hair grooming methods used. The study subjects also underwent a scalp examination that included the grading of hair loss.

A total of 86 of the 310 women (28%) were judged to have central hair loss. Of these, 52 women – 17% of the total study population – had CCCA.

It appeared that hair grooming practices that cause traction, such as weaves and braids, may contribute to the development of CCCA, as women with the most severe central hair loss used these styles more frequently than did those without hair loss. "This has some clinical bearing because traction can clinically produce folliculitis of the scalp, which can cause scarring if this inflammation is prolonged," noted Dr. Kyei and her colleagues (Arch. Dermatol. 2011 April 11 [doi:10.1001/archdermatol.2011.66]).

After paying hundreds of dollars for such hair styling, women often maintain weaves and braids for weeks to months, so any reactive inflammation usually is prolonged, the investigators added.

However, "the relationship between chemical relaxer use and the development of CCCA continues to be murky," they noted. These products clearly weaken the hair shaft, which can cause breakage, but that does not necessarily lead to CCCA. "The fact that most African Americans use chemical relaxers in combination with braiding and other hair grooming practices makes it even more difficult to tease out a relationship," Dr. Kyei and her associates added.

It is difficult to find subjects who do not use chemical relaxers for comparison, since most African Americans begin the practice in childhood. In this study, 91% of the women reported using chemical relaxers, and began doing so at an average age of 10 years.

Nevertheless, "we feel that it is not unreasonable to assume that the scalp may absorb some of the caustic chemicals found in relaxers, which in time leads to damage of the scalp in the form of scarring," they wrote.

Although the prevalence of bacterial skin infections in these study subjects was only 11%, there was a significant elevation among women with CCCA, compared with women who did not have CCCA. The rate of acne also was elevated in affected subjects, but not to a significant degree. Thus, the researchers said that their study "demonstrates that inflammation in the form of bacterial infection and acne may also be contributing to the development of CCCA, a finding consistent with the histopathologic characteristics of this disease," which show a lymphocytic perifollicular infiltrate in its early stages.

In contrast, there was no such association with fungal infections of the scalp, ringworm, or vaginal yeast infections, which was "surprising given how prone this population is to fungal infection," they added.

"One of the most surprising findings ... was the overrepresentation of type 2 [diabetes mellitus] in those with CCCA," the authors noted. Again, the prevalence of type 2 diabetes was low, at 8%, but it was significantly elevated in women with CCCA, compared with those without CCCA.

"These are important data that need further study because CCCA may be a marker of metabolic dysfunction and, when present, can prompt clinicians to do further testing for diabetes mellitus," Dr. Kyei and her colleagues wrote.

Only 9% of the study subjects had thyroid abnormalities, and three-fourths of them had no or minimal hair loss.

A history of male-pattern baldness in the maternal grandfather was found to be a risk factor for CCCA, which suggests that genetics may play a role.

Hormonal dysregulation did not appear to be associated with development of CCCA. Neither were scarring disorders, since only 6% of the subjects reported a history of keloids, and the rate was no higher in women with CCCA than in those without CCCA.

Similarly, there were relatively high prevalences of seborrheic dermatitis (24%), eczema (13%), and contact dermatitis from chemical relaxers (9%), as would be expected in an African American population. However, these conditions were unrelated to CCCA.

This study was supported in part by the North American Hair Research Society and Procter & Gamble. No financial conflicts of interest were reported.

Despite being the most common pattern of scarring hair loss among African American women, central centrifugal cicatricial alopecia is still poorly understood, according to a report published online April 11 in Archives of Dermatology.

The etiology of and risk factors for the disorder have not been established. And although African American women commonly present with the condition, the exact prevalence remains unknown, said Dr. Angela Kyei and her associates at the Cleveland Clinic Institute of Dermatology and Plastic Surgery.

Photo credit: Dr. Valerie Callender

Central centrifugal cicatricial alopecia (CCCA) – previously known as hot comb alopecia or follicular degeneration syndrome – is a scarring hair loss centered on the vertex of the scalp and spreading peripherally, which is described almost exclusively in African American women. In the late 1960s it was linked to the use of hot combs, but since then almost every method of hair grooming in this population has been associated, albeit weakly, with the disorder. Few studies have examined other possible etiologies, such as immunologic, dermatologic, or genetic factors.

"Given the lack of epidemiologic data, the main goal of [our] study was to elucidate environmental as well as medical risk factors that may be associated with CCCA," the researchers wrote.

They administered questionnaires to 326 African American women attending two churches and a health fair in the Cleveland area. Sixteen of the women ended up being excluded from the analysis.

The questionnaires asked detailed information about family history of male- and female-pattern hair loss; personal medical history, including bacterial and fungal skin infections, autoimmune conditions, and hormonal dysregulation; and hair grooming methods used. The study subjects also underwent a scalp examination that included the grading of hair loss.

A total of 86 of the 310 women (28%) were judged to have central hair loss. Of these, 52 women – 17% of the total study population – had CCCA.

It appeared that hair grooming practices that cause traction, such as weaves and braids, may contribute to the development of CCCA, as women with the most severe central hair loss used these styles more frequently than did those without hair loss. "This has some clinical bearing because traction can clinically produce folliculitis of the scalp, which can cause scarring if this inflammation is prolonged," noted Dr. Kyei and her colleagues (Arch. Dermatol. 2011 April 11 [doi:10.1001/archdermatol.2011.66]).

After paying hundreds of dollars for such hair styling, women often maintain weaves and braids for weeks to months, so any reactive inflammation usually is prolonged, the investigators added.

However, "the relationship between chemical relaxer use and the development of CCCA continues to be murky," they noted. These products clearly weaken the hair shaft, which can cause breakage, but that does not necessarily lead to CCCA. "The fact that most African Americans use chemical relaxers in combination with braiding and other hair grooming practices makes it even more difficult to tease out a relationship," Dr. Kyei and her associates added.

It is difficult to find subjects who do not use chemical relaxers for comparison, since most African Americans begin the practice in childhood. In this study, 91% of the women reported using chemical relaxers, and began doing so at an average age of 10 years.

Nevertheless, "we feel that it is not unreasonable to assume that the scalp may absorb some of the caustic chemicals found in relaxers, which in time leads to damage of the scalp in the form of scarring," they wrote.

Although the prevalence of bacterial skin infections in these study subjects was only 11%, there was a significant elevation among women with CCCA, compared with women who did not have CCCA. The rate of acne also was elevated in affected subjects, but not to a significant degree. Thus, the researchers said that their study "demonstrates that inflammation in the form of bacterial infection and acne may also be contributing to the development of CCCA, a finding consistent with the histopathologic characteristics of this disease," which show a lymphocytic perifollicular infiltrate in its early stages.

In contrast, there was no such association with fungal infections of the scalp, ringworm, or vaginal yeast infections, which was "surprising given how prone this population is to fungal infection," they added.

"One of the most surprising findings ... was the overrepresentation of type 2 [diabetes mellitus] in those with CCCA," the authors noted. Again, the prevalence of type 2 diabetes was low, at 8%, but it was significantly elevated in women with CCCA, compared with those without CCCA.

"These are important data that need further study because CCCA may be a marker of metabolic dysfunction and, when present, can prompt clinicians to do further testing for diabetes mellitus," Dr. Kyei and her colleagues wrote.

Only 9% of the study subjects had thyroid abnormalities, and three-fourths of them had no or minimal hair loss.

A history of male-pattern baldness in the maternal grandfather was found to be a risk factor for CCCA, which suggests that genetics may play a role.

Hormonal dysregulation did not appear to be associated with development of CCCA. Neither were scarring disorders, since only 6% of the subjects reported a history of keloids, and the rate was no higher in women with CCCA than in those without CCCA.

Similarly, there were relatively high prevalences of seborrheic dermatitis (24%), eczema (13%), and contact dermatitis from chemical relaxers (9%), as would be expected in an African American population. However, these conditions were unrelated to CCCA.

This study was supported in part by the North American Hair Research Society and Procter & Gamble. No financial conflicts of interest were reported.

Despite being the most common pattern of scarring hair loss among African American women, central centrifugal cicatricial alopecia is still poorly understood, according to a report published online April 11 in Archives of Dermatology.

The etiology of and risk factors for the disorder have not been established. And although African American women commonly present with the condition, the exact prevalence remains unknown, said Dr. Angela Kyei and her associates at the Cleveland Clinic Institute of Dermatology and Plastic Surgery.

Photo credit: Dr. Valerie Callender

Central centrifugal cicatricial alopecia (CCCA) – previously known as hot comb alopecia or follicular degeneration syndrome – is a scarring hair loss centered on the vertex of the scalp and spreading peripherally, which is described almost exclusively in African American women. In the late 1960s it was linked to the use of hot combs, but since then almost every method of hair grooming in this population has been associated, albeit weakly, with the disorder. Few studies have examined other possible etiologies, such as immunologic, dermatologic, or genetic factors.

"Given the lack of epidemiologic data, the main goal of [our] study was to elucidate environmental as well as medical risk factors that may be associated with CCCA," the researchers wrote.

They administered questionnaires to 326 African American women attending two churches and a health fair in the Cleveland area. Sixteen of the women ended up being excluded from the analysis.

The questionnaires asked detailed information about family history of male- and female-pattern hair loss; personal medical history, including bacterial and fungal skin infections, autoimmune conditions, and hormonal dysregulation; and hair grooming methods used. The study subjects also underwent a scalp examination that included the grading of hair loss.

A total of 86 of the 310 women (28%) were judged to have central hair loss. Of these, 52 women – 17% of the total study population – had CCCA.

It appeared that hair grooming practices that cause traction, such as weaves and braids, may contribute to the development of CCCA, as women with the most severe central hair loss used these styles more frequently than did those without hair loss. "This has some clinical bearing because traction can clinically produce folliculitis of the scalp, which can cause scarring if this inflammation is prolonged," noted Dr. Kyei and her colleagues (Arch. Dermatol. 2011 April 11 [doi:10.1001/archdermatol.2011.66]).

After paying hundreds of dollars for such hair styling, women often maintain weaves and braids for weeks to months, so any reactive inflammation usually is prolonged, the investigators added.

However, "the relationship between chemical relaxer use and the development of CCCA continues to be murky," they noted. These products clearly weaken the hair shaft, which can cause breakage, but that does not necessarily lead to CCCA. "The fact that most African Americans use chemical relaxers in combination with braiding and other hair grooming practices makes it even more difficult to tease out a relationship," Dr. Kyei and her associates added.

It is difficult to find subjects who do not use chemical relaxers for comparison, since most African Americans begin the practice in childhood. In this study, 91% of the women reported using chemical relaxers, and began doing so at an average age of 10 years.

Nevertheless, "we feel that it is not unreasonable to assume that the scalp may absorb some of the caustic chemicals found in relaxers, which in time leads to damage of the scalp in the form of scarring," they wrote.

Although the prevalence of bacterial skin infections in these study subjects was only 11%, there was a significant elevation among women with CCCA, compared with women who did not have CCCA. The rate of acne also was elevated in affected subjects, but not to a significant degree. Thus, the researchers said that their study "demonstrates that inflammation in the form of bacterial infection and acne may also be contributing to the development of CCCA, a finding consistent with the histopathologic characteristics of this disease," which show a lymphocytic perifollicular infiltrate in its early stages.

In contrast, there was no such association with fungal infections of the scalp, ringworm, or vaginal yeast infections, which was "surprising given how prone this population is to fungal infection," they added.

"One of the most surprising findings ... was the overrepresentation of type 2 [diabetes mellitus] in those with CCCA," the authors noted. Again, the prevalence of type 2 diabetes was low, at 8%, but it was significantly elevated in women with CCCA, compared with those without CCCA.

"These are important data that need further study because CCCA may be a marker of metabolic dysfunction and, when present, can prompt clinicians to do further testing for diabetes mellitus," Dr. Kyei and her colleagues wrote.

Only 9% of the study subjects had thyroid abnormalities, and three-fourths of them had no or minimal hair loss.

A history of male-pattern baldness in the maternal grandfather was found to be a risk factor for CCCA, which suggests that genetics may play a role.

Hormonal dysregulation did not appear to be associated with development of CCCA. Neither were scarring disorders, since only 6% of the subjects reported a history of keloids, and the rate was no higher in women with CCCA than in those without CCCA.

Similarly, there were relatively high prevalences of seborrheic dermatitis (24%), eczema (13%), and contact dermatitis from chemical relaxers (9%), as would be expected in an African American population. However, these conditions were unrelated to CCCA.

This study was supported in part by the North American Hair Research Society and Procter & Gamble. No financial conflicts of interest were reported.

NEW ORLEANS - Treatment for melasma can be effective, although the search continues for the ideal clinical strategy that yields optimal outcomes with minimal adverse effects, according to Dr. Amit G. Pandya.

The first challenge is to get patients into treatment. "There is a huge number of people out there with melasma who we are not seeing. A lot are being treated with over-the-counter products or are not being treated [at all]," he said at the annual meeting of the American Academy of Dermatology.

Melasma is a common condition. For example, Dr. Pandya and his colleagues found in a telephone survey that 8.8% of Latino women in the Dallas and Fort Worth, Texas, areas reported melasma (Arch. Dermatol. 2007;143:424-5).

"If I had a buck for each case of melasma, I could retire already," said session moderator Dr. Harvey Lui, professor and chair of dermatology and skin science at the University of British Columbia, Vancouver. "I just don't know what to do with these patients."

Much of the treatment and management of melasma rely on physicians' clinical expertise. "The evidence we have out there is not huge," Dr. Pandya said. He is professor of dermatology at the University of Texas Southwestern Medical Center at Dallas.

The differential diagnosis includes ruling out postinflammatory hyperpigmentation and drug-induced photosensitivity. Also, "with the growing obesity epidemic, we also see more acanthosis nigricans on the face," Dr. Pandya said.

Treatment of melasma is important – whether it be with a hydroquinone preparation, a chemical peel, or microdermabrasion – because it improves quality of life for patients living with melasma, Dr. Pandya said. Multiple studies have demonstrated that melasma can have a significant negative effect on a person's social life, recreation and leisure activities, and emotional well-being (Brit. J. Dermatol. 2003;149:572-7; J. Am. Acad. Dermatol. 2006;55:59-66).

Dioic acid is a new treatment showing promise in the treatment of melasma, Dr. Pandya said. He cited results of a study of 96 Mexican females treated with 1% dioic acid cream twice daily vs. 2% hydroquinone cream twice daily (Int. J. Dermatol. 2009;48:893-5). After 12 weeks, both treatments were associated with significant decreases in Melasma Area Severity Index (MASI) scores. There were no significant differences in efficacy, and adverse events were similar, except for more pruritus associated with hydroquinone treatment. "This may be an agent we can use in the future," Dr. Pandya said.

Oral antioxidants for melasma also showed promise in a randomized, double-blind, placebo-controlled trial (Int. J. Dermatol. 2009;48:896-901). Researchers assessed a combination of oral procyanidin (a component of pine bark) plus vitamins A, C, and E in 60 women with bilateral epidermal melasma. Study participants took either the oral treatment or a placebo twice daily with meals for 8 weeks. Clinicians observed significant reductions, compared with baseline in pigmentation and significant improvements in MASI scores in the malar regions of faces treated with the antioxidants vs. placebo. The investigators said the combination was well tolerated with minimal side effects.

"This may be something else we can use in the future," Dr. Pandya said.

The tyrosine inhibitor hydroquinone remains a mainstay of melasma treatment, Dr. Pandya said. "Hydroquinone remains the most effective depigmentation agent." There are nine marketed products that contain hydroquinone 4%. Although higher concentrations might be more effective, skin irritation and tolerance become an important consideration.

Monitor patients for development of exogenous ochronosis, a rare but important adverse effect, Dr. Pandya advised. Also, some patients can develop telangiectasias after prolonged use.

Hydroquinone 4% is often found in combination products designed to balance efficacy and tolerability. For example, Tri-Luma Cream (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%, Galderma) is a triple combination product that was "shown to be better than any two components in the largest study done so far in melasma," Dr. Pandya said (Cutis 2003;72:67-72). Researchers in this study found a 75% reduction in melasma at 8 weeks in more than 70% of patients, compared with 30% of participants treated with a dual-ingredient product.

A majority "seem to do well, but the problem is irritation, especially in skin of color," Dr. Pandya said. "I usually start patients on this product every other day and then try to increase it, but in some cases, I cannot because of irritation." He emphasized the importance of monitoring patients closely to ensure they do not develop erythema or postinflammatory hypopigmentation.

Evidence on the efficacy of chemical peels in treating melasma is mixed, Dr. Pandya said. In one study of 40 women in India, glycolic acid and a modified Kligman's formula peel showed "some improvement, but it took six glycolic acid peels," Dr. Pandya said (Derm. Surg. 2002;28:828-32).

In his own study, Dr. Pandya and his associates compared a glycolic acid peel and hydroquinone to hydroquinone treatment alone in a split-face study of 21 women (Arch. Dermatol. 2002;138:1578-82). "The peel did not make a difference versus the side of face treated with hydroquinone only," Dr. Pandya said.

Although there are no published studies supporting or not supporting microdermabrasion in melasma, caution is advised when this approach is used, Dr. Pandya said. "If you are too aggressive, you can induce hyperpigmentation."

One of the biggest challenges for dermatologists may be convincing patients of the importance of using sunscreen for UV protection, not only while outside but if they remain indoors as well. "Visible light can also induce melanocyte formation, not just UVA or UVB," Dr. Pandya said. "That's bad news, because how many companies at this convention center will have a product that says 'This blocks visible light?’ The only thing we have is the thick stuff lifeguards put on their noses."

Dr. Pandya said, "Frequent application of broad spectrum and physical sunscreens, as well as avoidance of UV and visible light, are critical for long-term success."

Dr. Pandya said that he is a consultant for Galderma.

NEW ORLEANS - Treatment for melasma can be effective, although the search continues for the ideal clinical strategy that yields optimal outcomes with minimal adverse effects, according to Dr. Amit G. Pandya.

The first challenge is to get patients into treatment. "There is a huge number of people out there with melasma who we are not seeing. A lot are being treated with over-the-counter products or are not being treated [at all]," he said at the annual meeting of the American Academy of Dermatology.

Melasma is a common condition. For example, Dr. Pandya and his colleagues found in a telephone survey that 8.8% of Latino women in the Dallas and Fort Worth, Texas, areas reported melasma (Arch. Dermatol. 2007;143:424-5).

"If I had a buck for each case of melasma, I could retire already," said session moderator Dr. Harvey Lui, professor and chair of dermatology and skin science at the University of British Columbia, Vancouver. "I just don't know what to do with these patients."

Much of the treatment and management of melasma rely on physicians' clinical expertise. "The evidence we have out there is not huge," Dr. Pandya said. He is professor of dermatology at the University of Texas Southwestern Medical Center at Dallas.

The differential diagnosis includes ruling out postinflammatory hyperpigmentation and drug-induced photosensitivity. Also, "with the growing obesity epidemic, we also see more acanthosis nigricans on the face," Dr. Pandya said.

Treatment of melasma is important – whether it be with a hydroquinone preparation, a chemical peel, or microdermabrasion – because it improves quality of life for patients living with melasma, Dr. Pandya said. Multiple studies have demonstrated that melasma can have a significant negative effect on a person's social life, recreation and leisure activities, and emotional well-being (Brit. J. Dermatol. 2003;149:572-7; J. Am. Acad. Dermatol. 2006;55:59-66).

Dioic acid is a new treatment showing promise in the treatment of melasma, Dr. Pandya said. He cited results of a study of 96 Mexican females treated with 1% dioic acid cream twice daily vs. 2% hydroquinone cream twice daily (Int. J. Dermatol. 2009;48:893-5). After 12 weeks, both treatments were associated with significant decreases in Melasma Area Severity Index (MASI) scores. There were no significant differences in efficacy, and adverse events were similar, except for more pruritus associated with hydroquinone treatment. "This may be an agent we can use in the future," Dr. Pandya said.

Oral antioxidants for melasma also showed promise in a randomized, double-blind, placebo-controlled trial (Int. J. Dermatol. 2009;48:896-901). Researchers assessed a combination of oral procyanidin (a component of pine bark) plus vitamins A, C, and E in 60 women with bilateral epidermal melasma. Study participants took either the oral treatment or a placebo twice daily with meals for 8 weeks. Clinicians observed significant reductions, compared with baseline in pigmentation and significant improvements in MASI scores in the malar regions of faces treated with the antioxidants vs. placebo. The investigators said the combination was well tolerated with minimal side effects.

"This may be something else we can use in the future," Dr. Pandya said.

The tyrosine inhibitor hydroquinone remains a mainstay of melasma treatment, Dr. Pandya said. "Hydroquinone remains the most effective depigmentation agent." There are nine marketed products that contain hydroquinone 4%. Although higher concentrations might be more effective, skin irritation and tolerance become an important consideration.

Monitor patients for development of exogenous ochronosis, a rare but important adverse effect, Dr. Pandya advised. Also, some patients can develop telangiectasias after prolonged use.

Hydroquinone 4% is often found in combination products designed to balance efficacy and tolerability. For example, Tri-Luma Cream (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%, Galderma) is a triple combination product that was "shown to be better than any two components in the largest study done so far in melasma," Dr. Pandya said (Cutis 2003;72:67-72). Researchers in this study found a 75% reduction in melasma at 8 weeks in more than 70% of patients, compared with 30% of participants treated with a dual-ingredient product.

A majority "seem to do well, but the problem is irritation, especially in skin of color," Dr. Pandya said. "I usually start patients on this product every other day and then try to increase it, but in some cases, I cannot because of irritation." He emphasized the importance of monitoring patients closely to ensure they do not develop erythema or postinflammatory hypopigmentation.

Evidence on the efficacy of chemical peels in treating melasma is mixed, Dr. Pandya said. In one study of 40 women in India, glycolic acid and a modified Kligman's formula peel showed "some improvement, but it took six glycolic acid peels," Dr. Pandya said (Derm. Surg. 2002;28:828-32).

In his own study, Dr. Pandya and his associates compared a glycolic acid peel and hydroquinone to hydroquinone treatment alone in a split-face study of 21 women (Arch. Dermatol. 2002;138:1578-82). "The peel did not make a difference versus the side of face treated with hydroquinone only," Dr. Pandya said.

Although there are no published studies supporting or not supporting microdermabrasion in melasma, caution is advised when this approach is used, Dr. Pandya said. "If you are too aggressive, you can induce hyperpigmentation."

One of the biggest challenges for dermatologists may be convincing patients of the importance of using sunscreen for UV protection, not only while outside but if they remain indoors as well. "Visible light can also induce melanocyte formation, not just UVA or UVB," Dr. Pandya said. "That's bad news, because how many companies at this convention center will have a product that says 'This blocks visible light?’ The only thing we have is the thick stuff lifeguards put on their noses."

Dr. Pandya said, "Frequent application of broad spectrum and physical sunscreens, as well as avoidance of UV and visible light, are critical for long-term success."

Dr. Pandya said that he is a consultant for Galderma.

NEW ORLEANS - Treatment for melasma can be effective, although the search continues for the ideal clinical strategy that yields optimal outcomes with minimal adverse effects, according to Dr. Amit G. Pandya.

The first challenge is to get patients into treatment. "There is a huge number of people out there with melasma who we are not seeing. A lot are being treated with over-the-counter products or are not being treated [at all]," he said at the annual meeting of the American Academy of Dermatology.

Melasma is a common condition. For example, Dr. Pandya and his colleagues found in a telephone survey that 8.8% of Latino women in the Dallas and Fort Worth, Texas, areas reported melasma (Arch. Dermatol. 2007;143:424-5).

"If I had a buck for each case of melasma, I could retire already," said session moderator Dr. Harvey Lui, professor and chair of dermatology and skin science at the University of British Columbia, Vancouver. "I just don't know what to do with these patients."

Much of the treatment and management of melasma rely on physicians' clinical expertise. "The evidence we have out there is not huge," Dr. Pandya said. He is professor of dermatology at the University of Texas Southwestern Medical Center at Dallas.

The differential diagnosis includes ruling out postinflammatory hyperpigmentation and drug-induced photosensitivity. Also, "with the growing obesity epidemic, we also see more acanthosis nigricans on the face," Dr. Pandya said.

Treatment of melasma is important – whether it be with a hydroquinone preparation, a chemical peel, or microdermabrasion – because it improves quality of life for patients living with melasma, Dr. Pandya said. Multiple studies have demonstrated that melasma can have a significant negative effect on a person's social life, recreation and leisure activities, and emotional well-being (Brit. J. Dermatol. 2003;149:572-7; J. Am. Acad. Dermatol. 2006;55:59-66).

Dioic acid is a new treatment showing promise in the treatment of melasma, Dr. Pandya said. He cited results of a study of 96 Mexican females treated with 1% dioic acid cream twice daily vs. 2% hydroquinone cream twice daily (Int. J. Dermatol. 2009;48:893-5). After 12 weeks, both treatments were associated with significant decreases in Melasma Area Severity Index (MASI) scores. There were no significant differences in efficacy, and adverse events were similar, except for more pruritus associated with hydroquinone treatment. "This may be an agent we can use in the future," Dr. Pandya said.

Oral antioxidants for melasma also showed promise in a randomized, double-blind, placebo-controlled trial (Int. J. Dermatol. 2009;48:896-901). Researchers assessed a combination of oral procyanidin (a component of pine bark) plus vitamins A, C, and E in 60 women with bilateral epidermal melasma. Study participants took either the oral treatment or a placebo twice daily with meals for 8 weeks. Clinicians observed significant reductions, compared with baseline in pigmentation and significant improvements in MASI scores in the malar regions of faces treated with the antioxidants vs. placebo. The investigators said the combination was well tolerated with minimal side effects.

"This may be something else we can use in the future," Dr. Pandya said.

The tyrosine inhibitor hydroquinone remains a mainstay of melasma treatment, Dr. Pandya said. "Hydroquinone remains the most effective depigmentation agent." There are nine marketed products that contain hydroquinone 4%. Although higher concentrations might be more effective, skin irritation and tolerance become an important consideration.

Monitor patients for development of exogenous ochronosis, a rare but important adverse effect, Dr. Pandya advised. Also, some patients can develop telangiectasias after prolonged use.

Hydroquinone 4% is often found in combination products designed to balance efficacy and tolerability. For example, Tri-Luma Cream (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%, Galderma) is a triple combination product that was "shown to be better than any two components in the largest study done so far in melasma," Dr. Pandya said (Cutis 2003;72:67-72). Researchers in this study found a 75% reduction in melasma at 8 weeks in more than 70% of patients, compared with 30% of participants treated with a dual-ingredient product.

A majority "seem to do well, but the problem is irritation, especially in skin of color," Dr. Pandya said. "I usually start patients on this product every other day and then try to increase it, but in some cases, I cannot because of irritation." He emphasized the importance of monitoring patients closely to ensure they do not develop erythema or postinflammatory hypopigmentation.

Evidence on the efficacy of chemical peels in treating melasma is mixed, Dr. Pandya said. In one study of 40 women in India, glycolic acid and a modified Kligman's formula peel showed "some improvement, but it took six glycolic acid peels," Dr. Pandya said (Derm. Surg. 2002;28:828-32).

In his own study, Dr. Pandya and his associates compared a glycolic acid peel and hydroquinone to hydroquinone treatment alone in a split-face study of 21 women (Arch. Dermatol. 2002;138:1578-82). "The peel did not make a difference versus the side of face treated with hydroquinone only," Dr. Pandya said.

Although there are no published studies supporting or not supporting microdermabrasion in melasma, caution is advised when this approach is used, Dr. Pandya said. "If you are too aggressive, you can induce hyperpigmentation."

One of the biggest challenges for dermatologists may be convincing patients of the importance of using sunscreen for UV protection, not only while outside but if they remain indoors as well. "Visible light can also induce melanocyte formation, not just UVA or UVB," Dr. Pandya said. "That's bad news, because how many companies at this convention center will have a product that says 'This blocks visible light?’ The only thing we have is the thick stuff lifeguards put on their noses."

Dr. Pandya said, "Frequent application of broad spectrum and physical sunscreens, as well as avoidance of UV and visible light, are critical for long-term success."

Dr. Pandya said that he is a consultant for Galderma.