Skin Problems in Pigmented Skin

Question 1

What is the cause of PIH?

Answer 1

Increase melanin in the dermis and epidermis.

Question 2

What sort of dermatoses are particularly susceptible to PIH?

Answer 2

Dermatoses with both dermal and epidermal changes.

• Lichen planus
• Lupus erythematosus
• Fixed drug eruption

Question 3

If the pigmentation is mainly epidermal, how long can it take to resolve?

Answer 3

6 months

Question 4

What can help PIH resolve quicker?

Answer 4

Bleaching agents like Hydroquinone

Question 5

What is essential in PIH?

Answer 5

To use daily sunscreen

Question 6

Dermal PIH is resistant and can last for long periods of time. What can help it?

Answer 6

Laser therpay

Question 7

What types of scars are more prominent in coloured skin types?

Answer 7

Keloid scarring

Question 8

If you do decide to excise a keloid scar, what can you do?

Answer 8

Inject it with triamcinolone

• This can help to reduce the chance of recurrence - though the chance is still high.

Question 9

What is a more favourable approach to keloid scars than excision?

Answer 9

• Triamcinolone and cryotherapy
• Shave excision and hyfrecation.

Question 10

What is this?

Answer 10

Acne keloidis nuchae

• Keloidal bands with scarring alopecia.
• If chronic, pustules and subcutaneous abscesses with sinuses can form.

Question 11

What is this?

Answer 11

Pseudofolliculitis barbae

Question 12

What is the treatment for pseudofoliculitis barbae?

Answer 12

• 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.

Question 13

Does Acne keloidis nuchae cause scarring or non-scarring alopecia?

Answer 13

Scarring

Question 14

Where is the most common place for vitiligo to appear?

Answer 14

• Perioral region
• Dorsa of the hands
• Feet
• Elbows
• Ankles.

Question 15

What is the pathophysiology of vitiligo?

Answer 15

The exact pathogenesis is uncertain.

• Can be familial.
• Positive association with HLA type DR4
• Negative association with HLA type DR3.

Question 16

What is vitiligo associated with?

Answer 16

Vitiligo is associated with autoimmune endocrinopathies:

• Thyroid disease
• Pernicious anaemia
• Addison’s disease.

Question 17

What is the treatment for vitiligo?

Answer 17

• 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.

Question 18

What is this?

Answer 18

Melasma

Question 19

What gender is melasma more common in?

Answer 19

Women

Question 20

What ethnicity is Melasma more common in?

Answer 20

Hispanic and Asian

Question 21

What factors can contribute to melasma formation?

Answer 21

• Genetic Predisposition
• UV light
• COCP use
• Pregnancy

Question 22

What other pigmentation conditions can be mistook for melasma?

Answer 22

• Drug-Induced pigmentation
• PIH
• Acitinic lichen planus
• External ochronosis

Question 23

What is the treatment for melasma?

Answer 23

• Sun protection
• Stop hormonal therapies - COCP and HRT.
• Hydroquinone
• Tretinoin - takes 6 months.
• Azelaic acid
• Kligman’s solution
• Chemical peels - glycolic acid.

Question 24

What is Kligmann’s Solution made of?

How do you advise someone to take it?

Answer 24

• (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.

Question 25

What is this?

Answer 25

Dermatosis Papulosa Nigra

Question 26

When do they first appear?

Answer 26

In Puberty (increase in number over time)

Question 27

What is the treatment?

Answer 27

Consider **Snip Excision** or **hyfrectation** Be mindful of cosmetic outcomes - they can be worse than the lesions themselves.

Question 28

What are the 3 major types of primary cutaneous amyloidosis?

Answer 28

* **Macular** * **Lichen** * **Nodular**. (Note: **Macular** & **Lichen** are more common in **skin types 3 and 4**)

Question 29

Amyloidosis - is the abnormal extracelluarl deposition of amyloid. How do you divide it?

Answer 29

* **Systemic** * **Localised** (Primary Cutaneous forms)

Question 30

What is this? Where does it most commonly occur? What symptoms come with it?

Answer 30

Macular amyloidosis Upper back. Pruritus

Question 31

What is this? How does it usually present?

Answer 31

Lichen Amyloidosis Persistent pruritic plaques

Question 32

What is this? How does it usually appear?

Answer 32

Nodular amyloidosis A waxy infiltration that usually appears on the trunk.

Question 33

What are the two types of lichen planus that are more relavant to the physician treating pigmented skin?

Answer 33

* Hypertrophic lichen planus * Acitinic Lichen planus

Question 34

What is this? How does it appear different in patients of colour?

Answer 34

**Hypertrophic Lichen Planus** Black flat-topped papules

Question 35

What countries more commonly get hypertrophic lichen planus?

Answer 35

Southern india and Sri Lanka

Question 36

What is this? What causes it? Who gets it? What are the **3 clinical presentations**?

Answer 36

**Acitinic Lichen Planus (This is the Annular type)** Sun Exposure Children and young adults - more common in middle eastern 1. **Annular** 2. **Dyschromic** 3. **Pigmented**

Question 37

What is the most common form of lichen planus?

Answer 37

* **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.

Question 38

What skin serology is annular lichen planus associated with?

Answer 38

None

Question 39

What is the treatment for lichen planus?

Answer 39

* **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.

Question 40

What is this?

Answer 40

Eczema It patients of colour it usually presents with a follicular pattern

Question 41

What is this?

Answer 41

**Pityriasis alba** – **hypopigmented patches** on the **face**. Occurs in **white patients** but **less obvious**. More common in **children** **Associated** with **atopic dermatitis**.