Primary Care Management of Skin Pigmentation Disorders Reviewed

Laurie Barclay, MD

January 29, 2009

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January 28, 2009 — Practice recommendations for primary care clinicians to diagnose and treat skin pigmentation disorders are provided in a review in the January 15 issue of American Family Physician.

"Although most pigmentation disorders are benign or nonspecific, some disorders of skin pigmentation present cosmetic or psychological challenges to the patient, necessitating evaluation and treatment," write Scott Plensdorf, MD, from Michigan State University College of Human Medicine in Flint, and Joy Martinez, MD, from Kaiser Permanente, San Diego, California. "Others may be indicators of underlying systemic disease or primary skin malignancy. Proper diagnosis of these common skin conditions will allow the physician to facilitate appropriate skin treatment and reassure the patient."

Hyperpigmented lesions frequently encountered by the primary care clinician include postinflammatory hyperpigmentation, melasma, solar lentigines, ephelides (freckles), nevi, and café-au-lait macules. Most hyperpigmented lesions seen in this setting are benign and are easily diagnosed. However, the clinician must rule out melanoma and its precursors and be able to diagnose skin manifestations of systemic disease.

Postinflammatory hyperpigmentation consists of irregular, darkly pigmented macules or patches located at previous sites of injury or inflammation. Specific types of postinflammatory hyperpigmentation include acne, psoriasis, atopic and contact dermatitis, lichen planus, trauma, drug reactions, and fixed-drug eruptions.

Combination therapy is most effective for postinflammatory hyperpigmentation, with a regimen involving hydroquinone, azelaic acid, retinoids, chemical peels, and/or laser therapy.

Melasma are light brown-, brown-, or gray-pigmented, well-defined macules found on the face (63% centrofacial, 21% malar, 16% mandibular) or forearms. These may be idiopathic or caused by pregnancy or by use of oral contraceptives or phenytoin. Treatment may include use of sunscreen and pharmacotherapy with combinations of hydroquinone, retinoids, glycolic acid peels, and/or topical steroids. Laser therapy or intense pulsed light therapy may be useful for dermal lesions.

Topical agents, chemical peels, cryotherapy, or laser therapy may be useful in the treatment of postinflammatory hyperpigmentation, melasma, solar lentigines, and ephelides. Surgical excision or laser treatment is recommended for café-au-lait macules.

Solar lentigines are well-circumscribed, light yellow to dark brown, or variegated in color 1- to 3-cm macules on the face, hands, forearms, chest, back, or shins. These lesions, which are caused by acute or chronic exposure to ultraviolet light, may respond to hydroquinone, retinoids, chemical peels, laser therapy, or cryotherapy.

Ephelides are red, tan or light brown, sharply defined macules, 1 to 2 mm in size. They typically appear in childhood on the face, neck, chest, arms, and legs, resulting from sun exposure in susceptible persons with skin types I to II. No treatment is needed for these lesions, which usually fade spontaneously in the winter months.

Café-au-lait macules are tan-to-brown epidermal patches measuring 1 to 20 cm, usually present at birth or appearing in early childhood. They are characteristically located on the trunk but may appear in any location. The appearance of café-au-lait macules results from increased melanin in melanocytes and basal keratinocytes. These lesions may respond to laser therapy, surgical excision, or cosmetic treatment.

Although disorders of hypopigmentation may present diagnostic challenges, those linked to health risks are infrequently encountered and are usually congenital. These include albinism, piebaldism, tuberous sclerosis, and hypomelanosis of Ito.

Examples of commonly encountered acquired disorders are vitiligo, pityriasis alba, tinea versicolor, and postinflammatory hypopigmentation. Vitiligo consists of sharply defined, unpigmented macules and patches, 5 to 50 mm, coalescent over the face, hands, forearms, neck, genitalia, body folds, and around the body orifices. Although the cause is unknown, immune factors may play some role.

For widespread or generalized vitiligo, appropriate therapeutic options may include cosmetic coverage, psoralen ultraviolet A-range therapy (with or without psoralens), or narrow-band ultraviolet-B therapy. Surgical grafting techniques may be suitable for patients with stable, limited vitiligo, whereas depigmentation therapy may be needed for those with extensive disease.

For other acquired disorders, treatment of the underlying condition may allow improvement or resolution of the skin pigmentation disorder.

Specific clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

  • Some combination of hydroquinone, azelaic acid, retinoids, glycolic acid peels, and laser therapy may be helpful for postinflammatory hyperpigmentation. However, monotherapy is seldom effective (level of evidence, C).

  • Triple therapy is more effective for treatment of epidermal melasma vs treatment with hydroquinone, fluocinonide, or tretinoin alone or in double combination (level of evidence, B).

  • For solar lentigines, chemical peels and brief cryotherapy offer effective ablation (level of evidence, C).

  • High-potency steroids, topical or oral psoralens with psoralen ultraviolet A-range, and narrow-band ultraviolet-B therapies are helpful to treat localized and generalized vitiligo. The best treatment response is achieved with vitiligo of the head and neck (level of evidence, B).

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;79:109-116.


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