Disorders of Pigmentation Nicole Gunasekera, MD, MBA, FAAD
Nicole Gunasekera, MD, MBA, FAAD, used a case presentation quiz to guide her discussion on disorders of pigmentation in Boston June 22, 2023. Dr. Gunesekara, a dermatologist at Brigham and Women’s Hospital in Boston, reviewed common presentations of post-inflammatory dyspigmentation (PID), which can present as hypopigmentation, hyperpigmentation or erythema. There are numerous causes of PID including acne, inflammatory conditions, infections, trauma, burns and arthropod bites. She said the shape of the dyspigmentation will typically match the preceding condition helping to “clue in” the provider to the cause. Dr. Gunasekera emphasized the importance of educating the patient on the typical duration of dyspigmentation treatment as well as the need to treat any active disease. Improvement of dyspigmentation can take several months to several years. Another key piece of education for patients is sun protection and visible light protection. Visible light protection can typically be accomplished with iron oxide which is found in most tinted sunscreens.
Coverage: SDPA Annual Summer Dermatology Conference, June 22-25, 2023 – BOSTON
Next, Dr. Gunasekera illustrated her approach to and treatment of vitiligo. She shared a pearl of knowledge—if patients are not bothered by their vitiligo, they don’t have to treat it! Treating vitiligo can be both time consuming and expensive; therefore, it is important to evaluate how vitiligo is affecting the patient’s quality of life. While vitiligo is not in dangerous to a patient, it can be “psychologically devastating,” and studies have revealed vitiligo can have a negative impact on patient’s self-esteem and quality of life and create isolation, stigmatization and depression. Dr. Gunasekera’s approach to vitiligo treatment includes stabilizing pigmentation, re-pigmentation and preventing relapse. She reports, “it is easier to shut down active vitiligo than treat lost pigmentation.” For active disease, two steroid options include an oral mini pulse dose with dexamethasone at 2-4 mg once daily for two days or prednisone 0.3 mg/kg daily for two months. Both regimens have shown the ability to halt progression of the condition in more than 85% of cases.
Melasma was the next topic highlighted by Dr. Gunasekera with sun protection always being a mainstay of treatment. In addition to bleaching and brightening agents, she discussed oral tranexamic acid as a novel treatment. Oral tranexamic acid, although not FDA approved for treatment of melasma, is believed to help inhibit UV-induced plasmin activity in the keratinocytes, and thus might be suitable off-label. This medication is contraindicated in patients who have hypercoagulable states due to a small increased risk of DVTs with common side effects including bloating, hypomenorrhea and palpitations. Additional in-office adjunctive treatment of melasma include chemical peels, microneedling and lasers. Dr. Gunasekera cautions the use of lasers due to the risk of further hyperpigmentation and encourages a series of peels. Lastly, the importance of identifying congenital dermal melanocytosis was highlighted in a case presentation.