Skin Hyperpigmentation, Photoaging, Hair Loss

Question 1

Signs and Symptoms: Hyperpigmentation

Answer 1

Persistent macular discoloration
- most common on face or other sun exposed area

Ephelides (Freckles)
- uneven skin pigmentation first appear in childhood and worsened by sun

Melasma (Chloasma)
- macular hyperpigmentation often associated with pregnancy (mask of pregnancy) or birth control use

Lentigines

• appear at any age anywhere on skin
• solar or senile lentigines (age spots or liver spots)

Question 2

Treatment of Skin Hyperpigmentation

Answer 2

• Goal of treating skin hyperpigmentation
• Topical skin-bleaching agents (hydroquinone) with or without alpha-hydroxy acid (AHA)
• Avoid UV radiation
• Use sunscreen agents and protective clothing

Question 3

Exclusions for Self-Treatment: Hyperpigmentation

Answer 3

• < 12 years of age
• Hyperpigmentation of large BSA
• Disease-induced or drug-induced
• Lesions that are changing in shape or color

Question 4

Hydroquinone (MOA, Admin., AE, Pt skin type)

Answer 4

• FDA approved for nonprescription use: 1.5-2%
• MOA: selectively damages melanocyte membrane

Administration Guidelines

• twice a day on clean dry skin, maintenance once or twice daily
• apply before any moisturizers or other products
• on reaching desired skin tone use prn
• if no improvement within 2 months, dc and f/up with PCP

Adverse Effects

• mild tingling or burning
• do sensitivity test
• watch for hypopigmentation

Patient’s Skin Type

• cream base for dry skin
• lotion for normal skin
• gel for oily skin

Question 5

Synthetic Oligopeptide (MOA, adv.)

Answer 5

• 0.01% improves hyperpigmentation
• MOA: similar to hydroquinone, inhibits tyrosinase
• Advantages: well tolerated, less toxic than hydroquinone
• Not approved by FDA, available as Lumixyl
• Apply pea size amount bid with results in 8-16 weeks

Question 6

Kojic Acid (MOA, AE)

Answer 6

• Derived from certain fungus species usually found in cosmetic products
• (1% - 4%) is combined with AHA’s +/- hydroquinone
• MOA: inhibits production of tyrosinase
• Adverse effects: include contact dermatitis, erythema
• KA 2% + glycolic acid 10% has similar results to hydroquinone 2% + glycolic acid 10%

Question 7

Rucinol (MOA, extra)

Answer 7

• MOA: a resorcinol derivative that inhibits both tyrosinase and tyrosinase-related protein-1 (TRP-1), an enzyme used in
  melanin synthesis
• Application: several studies show that rucinol 0.3% serum or cream, applied bid for 8-12 weeks improved pigmentation
• Tolerated well, but expensive. 30ml serum costs $139

Question 8

Tranexamic Acid (MOA, extra)

Answer 8

• MOA: inhibits UV-induced plasmin activity which leads to decreased tyrosinase activity in melanocytes
• Some studies show improvement in hyperpigmentation within 12 weeks
• Studies have looked at topical, IV and oral forms
• Used as adjunct ingredient in some OTC serums, can cause local irritation

Question 9

Mandelic Acid and Niacinamide

Answer 9

Mandelic Acid
- Type of AHA, derived from almonds, works well for hyperpigmentation. Combined with salicyclic acid and used as peel, it has less side effects than a glycolic acid peel with better results

Niacinamide
- A vitamin B3 derivative which works by inhibiting transfer of melanin to keratinocytes. Similar to Niacin with mild side effects

Question 10

Patient Education & Counseling: Hyperpigmentation

Answer 10

• Lighten only hyperpigmented skin
• Use of broad spectrum sunscreen + protective clothing
• Results may take up to 3 months, however follow up with PCP if no improvement within 2 months
• Referral to primary care provider

Question 11

Signs and Symptoms: Photoaging

Answer 11

Skin color changes
- yellow color, discolorations, distended capillaries

Surface texture changes
- loss of smoothness, collagen and elastin, dry coarse skin

Functional capacity changes
- sebaceous glands break down, enlarged pores

Question 12

Treatment of Photoaging

Answer 12

Prescription drugs
- tretinoin, adapalene and tazarotene

Cosmeceuticals
- AHAs, BHAs, Kinerase, vitamins A, C, B3, E and coenzyme Q10 products

Question 13

α-Hydroxy Acid (AHAs): Indications, AEs, Product selection

Answer 13

Indications
- melasma, acne, solar lentigos and photoaging

Adverse effects
- mild stinging, burning and dryness, Polyhydroxy Acids are new generation of AHA’s with less irritation and similar results

Product selection guidelines

• creams for dry skins
• lotions for combination or normal skins
• gels or solutions for oily skins
• Cosmetic Ingredient Review Expert Panel, says AHA’s in cosmetic products are safe if <10% concentration and the final pH => 3.5

Question 14

β-Hydroxy Acids (BHAs)

Answer 14

Salicyclic acid

• most common
• less soluble in water than a-hydroxy acids
• may be beneficial to acne prone skin

Question 15

Kinerase (N-furfuryladenine)

Answer 15

Antiwrinkle product

• treat wrinkles, blotchiness & dryness
• expensive product

Question 16

Retinol & Retinaldehyde (Vit A Derivative)

Answer 16

Retinol
- Added to many skin care products, MOA is a two step enzymatic process that converts it to retinaldehyde then retinoic acid

Retinaldehyde
- Well tolerated, similar effects to tretinoin, however very unstable and on light exposure degrades to inactive form

Question 17

Ascorbic Acid (Vitamin C)

Answer 17

• MOA as an antioxidant, removes free radicals
• Has potential to be used topically for prevention and correction of human skin aging
• May have photoprotective properties

Question 18

Idebenone

Answer 18

• A synthetic derivative of Ubiquinone (coenzyme Q10) with potent antioxidant properties
• MOA: quenches free radicals in the epidermis and has a beneficial effect on preventing and/or reversing photoaging
• Found in cosmetic creams and lotions promoted as anti-aging and/or antioxidant properties

Question 19

Patient Education & Counseling: Photoaging

Answer 19

Skin protection
- avoid peak sun exposure, use UVA/UVB sunscreen of at least SPF 30

Good skin hygiene practice
- prevent dry skin, cleanse with mild soap or a soap-free cleanser

Use of an α-hydroxy acid product

• start at hs, qod for 7 days, then use bid as tolerated
• results seen in 2 months, sometime as early as 4 weeks

Question 20

Signs and Symptoms: Hair Loss

Answer 20

Androgenetic alopecia
- family history, non-scarring, - gradual hair loss

Alopecia areata
- patchy hair loss, pre-existing disease eg diabetes

Telogen effluvium
- diffuse hair loss, metabolic/hormonal disturbances

Question 21

Exclusions: Hair Loss

Answer 21

• < 18 yrs age
• no family history of hair loss
• sudden or patchy hair loss
• autoimmune disease or skin infections
• postpartum women with hair loss
• scaling, sunburn, or other damage to scalp

Question 22

Minoxidil (Indication, AE, Contra, Drug Interactions)

Answer 22

At least 4 mo for hair growth, refer after 4-6 mo

Indications

• Minoxidil 2%, 5% solutions and 5% foam products (MEN)
• Minoxidil 2% solution and 5% foam products (WOMEN)

Adverse effects

• local itching or irritation
• with long term use possible transient hypertrichosis

Precautions/Contraindication
- scalp damage, pregnancy, cardiovascular disorders

Drug interactions
- Avoid with topical corticosteroids, retinoids, petrolatum

Question 23

Patient Education and Counseling: Hair Loss

Answer 23

Non drug options
- camouflage, hair transplants

Minoxidil use with expectations

• use for at least minimum recommended period
• use continuously for best results

Referral to a primary care provider