Skin Problems in Pigmented Skin Flashcards
What is the cause of PIH?
Increase melanin in the dermis and epidermis.
What sort of dermatoses are particularly susceptible to PIH?
Dermatoses with both dermal and epidermal changes.
- Lichen planus
- Lupus erythematosus
- Fixed drug eruption
If the pigmentation is mainly epidermal, how long can it take to resolve?
6 months
What can help PIH resolve quicker?
Bleaching agents like Hydroquinone
What is essential in PIH?
To use daily sunscreen
Dermal PIH is resistant and can last for long periods of time. What can help it?
Laser therpay
What types of scars are more prominent in coloured skin types?
Keloid scarring
If you do decide to excise a keloid scar, what can you do?
Inject it with triamcinolone
- This can help to reduce the chance of recurrence - though the chance is still high.
What is a more favourable approach to keloid scars than excision?
- Triamcinolone and cryotherapy
- Shave excision and hyfrecation.
What is this?
Acne keloidis nuchae
- Keloidal bands with scarring alopecia.
- If chronic, pustules and subcutaneous abscesses with sinuses can form.
What is this?
Pseudofolliculitis barbae
What is the treatment for pseudofoliculitis barbae?
- 6 months of anti-inflammatory antibiotic (e.g. minocycline) for 6 months.
-
Stop shaving for 3 to 6 months.
- Keep the hair 5mm long with clippers.
- Look for ingrown hairs daily and remove with sterile needles.
- Warm compress and mild steroids are useful.
-
Shaving
- Do not pull the skin
- Do not shave against the direction of growth.
Does Acne keloidis nuchae cause scarring or non-scarring alopecia?
Scarring
Where is the most common place for vitiligo to appear?
- Perioral region
- Dorsa of the hands
- Feet
- Elbows
- Ankles.
What is the pathophysiology of vitiligo?
The exact pathogenesis is uncertain.
- Can be familial.
- Positive association with HLA type DR4
- Negative association with HLA type DR3.
What is vitiligo associated with?
Vitiligo is associated with autoimmune endocrinopathies:
- Thyroid disease
- Pernicious anaemia
- Addison’s disease.
What is the treatment for vitiligo?
- Localized:
- Potent topical steroids (e.g betamethasone) for local areas.
- If no improvement after 2 months then discontinued.
- Generalized
- Narrow band UVB - use for 1 year.
- Pigmentation may recur when discontinued.
- If considering, specialist review is essential.
- Hydroquinone (monobenzyl ether of hydroquinone).
- Induces irreversible bleaching of the normal skin.
- The depigmented skin of vitiligo is susceptible to sunburn and a sunscreen should be used.
What is this?
Melasma
What gender is melasma more common in?
Women
What ethnicity is Melasma more common in?
Hispanic and Asian
What factors can contribute to melasma formation?
- Genetic Predisposition
- UV light
- COCP use
- Pregnancy
What other pigmentation conditions can be mistook for melasma?
- Drug-Induced pigmentation
- PIH
- Acitinic lichen planus
- External ochronosis
What is the treatment for melasma?
- Sun protection
- Stop hormonal therapies - COCP and HRT.
- Hydroquinone
- Tretinoin - takes 6 months.
- Azelaic acid
- Kligman’s solution
- Chemical peels - glycolic acid.
What is Kligmann’s Solution made of?
How do you advise someone to take it?
- (Hydroquinone, topical tretinoin and 1% hydrocortisone)
- Apply to small areas for 20 minutes at a time intially.
- Then build up to keep on overnight and wash off in the AM.
- it can burn the skin so warn patients.
What is this?
Dermatosis Papulosa Nigra
When do they first appear?
In Puberty (increase in number over time)
What is the treatment?
Consider Snip Excision or hyfrectation
Be mindful of cosmetic outcomes - they can be worse than the lesions themselves.
What are the 3 major types of primary cutaneous amyloidosis?
- Macular
- Lichen
- Nodular.
(Note: Macular & Lichen are more common in skin types 3 and 4)
Amyloidosis - is the abnormal extracelluarl deposition of amyloid.
How do you divide it?
- Systemic
- Localised (Primary Cutaneous forms)
What is this?
Where does it most commonly occur?
What symptoms come with it?
Macular amyloidosis
Upper back.
Pruritus
What is this?
How does it usually present?
Lichen Amyloidosis
Persistent pruritic plaques
What is this?
How does it usually appear?
Nodular amyloidosis
A waxy infiltration that usually appears on the trunk.
What are the two types of lichen planus that are more relavant to the physician treating pigmented skin?
- Hypertrophic lichen planus
- Acitinic Lichen planus
What is this?
How does it appear different in patients of colour?
Hypertrophic Lichen Planus
Black flat-topped papules
What countries more commonly get hypertrophic lichen planus?
Southern india and Sri Lanka
What is this?
What causes it?
Who gets it?
What are the 3 clinical presentations?
Acitinic Lichen Planus (This is the Annular type)
Sun Exposure
Children and young adults - more common in middle eastern
- Annular
- Dyschromic
- Pigmented
What is the most common form of lichen planus?
- Annular type
- Brownish plaques with an annular configuration most commonly affecting the lateral aspects of the forehead, dorsum of the hands, forearms, lower lip, cheeks, and the V shaped area of the neck.
- Annular lesion develops hypopigmentation centrally and some subtle atrophy.
- Dark skinned individuals.
- Women are affected more than men
- Younger age of onset than classic lichen planus.
What skin serology is annular lichen planus associated with?
None
What is the treatment for lichen planus?
- Avoidance of precipitant factors -scratching or UV.
- Sunscreen.
- Topical steroids +/- occlusion or intralesional steroids.
- Systemic steroids if severe or rapid progression.
- Systemic retinoids have been used successfully in widespread lichen planus as well as cyclosporin, dapsone, and antimalarials.
- Actinic lichen respond to systemic anti malarials.
-
Hypertrophic lichen planus = intralesional steroids and topical steroids under occlusion.
- We find that a potent steroid combined with 5 or 10% Salicylic acid is particularly effective put on twice a day for a period of at least 3 to 6 weeks.
- Phototherapy can be used to treat most cutaneous forms of lichen planus apart from actinic lichen planus.
What is this?
Eczema
It patients of colour it usually presents with a follicular pattern
What is this?
Pityriasis alba – hypopigmented patches on the face.
Occurs in white patients but less obvious.
More common in children
Associated with atopic dermatitis.
