Pigmentary Disorders

Pigmentary Disorders

Treatment of Vitiligo With UV-B Radiation vs Topical Psoralen Plus UV-A

Background.—Recent reports have described the use of ultraviolet (UV) lamps with a peak emission of approximately 311 nm for the treatment of skin diseases. These lamps cause less erythema than shorter wavelengths of UV-B radiation, while maintaining a high response rate. For the treatment of vitiligo, 311-nm UV-B radiation was compared with topical psoralen plus UV-A (PUVA).

Pigmentary Disorders

Methods.—Patients with active, extensive, generalized vitiligo were assigned to treatment with topical PUVA or 311-nm UV-B radiotherapy. In the first part of the study, 28 patients received PUVA, and 78 received UV-B for 4 months. In the second part, all patients received twice-weekly treatment with 311-nm UV-B radiation. The follow-up was 3 months in 60 patients, 6 months in 27 patients, 9 months in 37 patients, and 12 months in 51 patients.

Results.—In the first part of the study, the repigmentation rate after 4 months was 46% with topical PUVA therapy and 67% with 311-nm UV-B radiation. In the second part of the study, the percentage of patients with more than 75% repigmentation of lesional skin increased from 8% after 3 months to 63% after 12 months. Repigmentation was good on the face and poor on the hands, and feet, as with other treatments for vitiligo. Adverse effects were absent with UV-B treatment but common with topical PUVA. The new treatment had a lower cumulative UV-B dose than the UVA dose with topical PUVA treatment.

Conclusions.—Narrow-band UV-B therapy, given twice weekly, is a safe and effective treatment for vitiligo. The response is at least as good as with topical PUVA, and there are fewer adverse effects.

► The authors also comment on the observation that fewer sunburn cells are observed in vitiliginous skin than in normally pigmented skin. A previous study has shown a lack of actinic damage in sun-exposed vitiliginous skin vs. normally pigmented skin. Interestingly, there are no reports of malignant neoplasms developing on the depigmented skin of patients with vitiligo: this is in contrast to reports of malignant neoplasms of the skin occurring in patients with albinism and in very fair-skinned individuals. Thus, vitiliginous skin, despite the lack of melanin, may exhibit other compensating photoprotective or immunosurveillance mechanisms.

Epidermal Sheet Grafts for Repigmentation of Vitiligo and Piebaldism,With a Review of Surgical Techniques

Background.—A previous report described good results in patients with vitiligo treated with grafting of thin epidermal sheets obtained with the Zimmer air dermatome. The results of this epidermal sheet graft technique in 19 patients with vitiligo and 1 with piebaldism were reported in the current study.

Technique.—The white areas to be treated were outlined and treated with EMLA cream under occlusion for 1-5 hours. EMLA was also applied to the buttocks, from which the epidermal sheets were obtained, for 2 hours. The patients were given diazepam and ketobemidone before surgery. After the EMLA cream on the recipient areas was wiped off, those areas were dermabraded with a high-speed dermabrader. Lidocaine, 0.5%,-in a bicarbonate solution was available if the patient felt pain during dermabrasion. The denuded areas were then covered with moistened gauze until transplantation.

The donor area was cleaned in a similar way and injected with 1% lidocaine, mixed 1:1 with sodium bicarbonate solution. A Zimmer air dermatome was then used to collect epidermal grafts measuring just 0.1 mm in thickness. The epidermal sheets were then applied to the recipient areas, secured with silicone netting, covered with saline-moistened gauze, and bandaged. The bandages were left in place and the patient took erythromycin for 1 week.After the bandages were removed, the patients were allowed to increase their sun exposure gradually.

Results.—The results were assessed at 4-8 months. The results were excellent, with 100% repigmentation in all patients who had had stable, nonactive lesions for at least 2 years . Good healing and pigmentation without reddening were achieved within 3 months. Milia-like keratinous cysts—perhaps caused by sweat duct occlusion—occurred on the forehead or the hairy part of the back of the neck. This was the main side effect of the technique.

Conclusion.—Epidermal sheet grafts provide excellent repigmentation in patients with stable vitiligo or piebaldism. Providing topical anesthesia with EMLA cream makes the procedure safer and less expensive than performing it in a fully equipped operating theater. This technique may be useful in the treatment of depigmented skin, particularly in larger areas.

► Vitiligo can be a socially devastating disease, and treatment is, for the most part, unsatisfactory. The technique reported here has previously been described in the American literature. Obviously, the treating physician must be fully versed in the methodology to obtain the best results. Patients with stable vitiligo are the best candidates for treatment. It is essential that the transplanted areas be immobilized and that the donor epidermis be of appropriate and even thickness.

Fluorescence Photography in the Evaluation of Hyperpigmentation in Photodamaged Skin

Introduction.—Fluorescence photography can show pigmented and depigmented lesions of the skin. The skin is illuminated with ultraviolet radiation, and the the visible fluorescence stimulated by the ultraviolet radiation is recorded. The fluorescence is emitted by collagen bundles, with hyperpigmentation and erythema appearing as dark areas on black-and- white photographs. Previous studies using tretinoin 0.1% for the treatment of photodamaged skin have shown a decrease in hyperpigmented lesions. Smaller pigmentary changes may be produced by lower concentrations of tretinoin. Fluorescence photography was assessed for use in evaluating diffuse and macular hyperpigmentation in photodamaged skin.

Methods.—The study included 32 white patients with type I to III skin and mild-to-moderate photodamage. They were entered in a 36-week, double-blind, vehicle-controlled trial of tretinoin 0.025%. The fluorescence photography equipment was selected to avoid overlap between the filtered flash and the light captured by the camera. Clinical evaluation included scoring of mottled hyperpigmentation and sallowness. The 2 main features observed on the black-and-white fluorescence photographs were (1) a macular feature, which appeared as a dark gray to black, oval to irregular area with well-defined borders and a diameter of 1-10 mm and (2) a diffuse granular feature, characterized by varying gray intensities and no definite borders.

Results.—By the end of treatment, the decrease from baseline in mottled hyperpigmentation was 7% in the tretinoin group vs. 2% in the vehicle group. Tretinoin was associated with a 14% reduction in sallowness, compared with a 5% reduction with vehicle. On the fluorescence photographs, several macules that were present at baseline had disappeared by the end of tretinoin treatment . Neither group had new macules by week 36. The decrease in mean macule counts was 31% with tretinoin vs. 11% with vehicle. The fluorescence photographs showed more and better-defined hyperpigmented macules than did visible-light photographs. Wrinkles and other surface details sometimes made it difficult to evaluate macules. In most subjects—regardless of their assigned treatment or the time at which the photographs were taken—diffuse hyperpigmentation had a blotchy appearance. However, the tretinoin group had a significantly greater average percentage decrease in the gray scale score. This group had a 16% reduction in diffuse hyperpigmentation, compared with a 5% increase in the vehicle group.

Conclusion.—Treatment of photodamaged skin with tretinoin cream 0.025% reduces the number of hyperpigmented macules as well as diffuse background hyperpigmentation, as assessed by fluorescence photography. There is no significant reduction in the clinical features of mottled hyperpigmentation and sallowness, however. Fluorescence photography is a noninvasive and sensitive method for evaluating hyperpigmentation in photodamaged skin.

► Most of us look at the world through human eyes and not through the fluorescent lens; Thus, despite the interesting fluorescent photographs, “the eyes do not lie,” and assessment by the naked eye still remains the standard to which all cosmetic treatments must be held.

Actinic Lichen Planus Simulating Melasma

Introduction.—Actinic lichen planus (ALP), a rare clinical variant of lichen planus, has itself 4 variants: annular, plaquelike, lichenoid, and pigmented. The patient reported here had pigmented ALP simulating melasma.

Case Report.-Woman, 23, sought treatment for a pigmentary facial disorder of 2 years’ duration. The dermatosis began in the summer and was considerably improved during winter. The patient had no family history of a similar condition, no history of drug intake or contact, and no previous injury or inflammation at the affected sites. She had large, asymptomatic areas of brown hypermelanosis on the cheeks and chin , with some small, round papules and fine scales within and at the periphery of the patches.Routine laboratory tests, an endocrine profile, and photopatch testing yielded no abnormal findings. Skin biopsy specimens showed orthokeratosis, focal hypergranulosis, and jagged epidermal hyperplasia, with a bandlike inflammatory infiltrate obscuring the dermo-epidermal junction. Treatment with 5% salicylic acid ointment alternating with betamethasone dipropionate brought little improvement.

Discussion.—Only a few cases of ALP simulating melasma are to be found in the literature. Except for this patient, all were of Asian origin. Those previously reported, 5 females and 2 males, ranged in age from 14 to 56 years. The dermatosis persists for a long time, and no cause has been determined. Sunlight appears to play a significant etiologic role, however, and the female predominance suggests that hormonal factors may be involved.

► A Wood’s light examination in a patient with facial ALP would likely make the pigmentation more difficult to see, suggesting a dermal location of the pigmentation. This is consistent with the histologic demonstration of melanophages in the superficial dermis. Such a patient would likely be quite difficult to treat with topical depigmenting agents.

Treatment of Melasma With Jessner’s Solution Versus Glycolic Acid: A Comparison of Clinical Efficacy and Evaluation of the Predictive Ability of Wood’s Light Examination

Background.—Melasma, an acquired hyperpigmentation of the face occurring mostly in women, can be resistant to topical therapy. The efficacy of superficial peels combined with topical tretinoin and hydroquinone in patients with melasma was assessed. The value of Wood’s light examination for predicting the treatment response was also determined.

Methods.—Sixteen women were enrolled in the study. The melasma ranged from mild and discontinuous to severe and homogeneous. After pretreatment with 0.05% tretinoin for 1-2 weeks and vigorous preparation, peel solutions were applied. Each patient received 70% glycolic acid treatment on the right side of the face and Jessner’s solution on the left side. The increased light reflectance in melasma regions was measured with a colorimeter. Clinical scores were assigned through an index designed to weigh homogeneity, intensity of color, and area of melasma numerically.

Findings.—Colorimetric analysis demonstrated a mean lightening of 3.14 on the glycolic acid-treated side compared with 2.96 on the Jessner’s solution-treated side. These values were not significantly different. Overall, the melasma area and severity decreased by 63%.

Conclusions.—Peels tend to hasten the results of topical therapy in patients with melasma. Wood’s light examination was not clinically helpful in predicting the response to peels, probably because mixed epidermal- dermal melasma is more common than previously believed. Patients with predominantly epidermal melasma may respond better than patients with a large dermal component.

► This side-by-side comparison between glycolic acid and Jessner’s solution showed no statistically significant difference. There was a significant response to treatment in both treatment groups, a 63% reduction in the severity of the melasma. Minimal adverse effects were noted. Contrary to widely-published opinions, the Wood’s lamp examination did not help to predict the treatment response. Superficial chemical peeling is an important adjuvant to topical therapy for effective treatment of melasma.