Hyperpigmentation: Is It Medical or Cosmetic?

The most common cosmetic complaint I receive in my 50% medical and 50% cosmetic practice is hyperpigmentation. Hyperpigmentation can be a primary finding but is more often a secondary finding. Approximately 60% to 70% of my patients who present with hyperpigmentation have an underlying medical disease that has not been diagnosed. Many inflammatory skin diseases, including psoriasis, hidradenitis suppurativa, and atopic dermatitis in patients with darker skin types, can present with secondary hyperpigmentation.

Why is this a problem? Many patients are treated for their secondary findings
with agents such as hydroquinone, which also can cause hyperpigmentation, either from irritant contact dermatitis or, rarely, ochronosis. If hydroquinone is compounded with tretinoin, you get a double whammy in a patient with atopic dermatitis who presents with hyperpigmentation from their atopic dermatitis. For example, a Black woman was referred to me for hyperpigmentation and laser consultation. Upon taking her history, she reported that she had severe pruritus (rated to be 7/10 in severity) and had been using hydroxyzine for symptomatic relief. During her exam, I found more than 20 scaly and eroded papules and background hyperpigmented macules. The diagnosis was clear: She had prurigo nodularis. She was completely unaware that her pruritus was abnormal and was focused on the hyperpigmented macules because she wanted to wear a bathing suit in the summer. The patient had been treated with hydroquinone prior to seeing me, but she saw no improvement and continued to develop new nodules. After I started her on dupilumab, she was able to stop taking antihistamines and noticed her hyperpigmentation improving. Over the past few years, we have learned that mast cells may play a role in hyperpigmentation, and this is clinically more meaningful for those with pruritic disorders associated with hyperpigmentation.¹

Another story that hits home is that of a Black woman who was referred to
me for hyperpigmentation on her face. When I examined her face, cheekbones, jawline, and nose, it immediately hit me: She had systemic sclerosis. I examined her chest and saw speckled hypopigmentation, and the story became clear. When I asked about her kidney function, she was surprised. She said it took years for doctors to connect the dots between her kidney dysfunction and skin conditions. She had hyperpigmented patches on her cheeks and temples. Upon further questioning, I learned that she had systemic lupus erythematosus with lupus nephritis and had been on numerous medications. Add living in Arizona to the mix, and out came a wide variety of interface dermatitides.
I was afraid to biopsy her because of her systemic sclerosis, taut skin, and the risk of hypertrophic scarring. However, this appeared to be lichen planus pigmentosus vs other interface/lichenoid dermatitis. She started with broad spectrum sunscreen use, pulsed weekly fluticasone propionate ointment, pulsed weekly hydroquinone and kojic acid combination therapy, and picosecond Nd:Yag laser every 4 to 6 weeks. Figure 1 shows her progress before and after 4 treatment sessions.
Melasma is another common pigmentary disease that is on the border between medical and cosmetic in nature. Many clinicians treat it as a cosmetic disease, but what if cosmetic treatments such as laser therapy were relatively contraindicated? Figure 2 shows a patient in her early 30s who presented to my clinic with vitiligo. She had previously started on topical ruxolitinib cream and excimer lamp therapy. She did not have vitiligo on her face but did have ill-defined, brawny patches on her face. Chemical peels and lasers are relatively contraindicated because they could trigger vitiligo; this was a true concern for her because she had vitiligo resulting from Koebner phenomenon. I decided to put this patient on oral tranexamic acid, and the before and after photos show her successful progress.

Practice Takeaways

As medical spas continue to encroach on the cosmetic space, there is a lot
of room for error. As dermatologists, we have to ethically remember that medical treatments DO exist and if one isn’t comfortable in treating these conditions medically, they should refer patients to those of us that can. Not all of our patients can afford cosmetic treatment, and there are many medical therapies that can make a difference. I always try to treat hyperpigmentation medically with topical and oral therapies for 3 months to see how much of the pigment, whether primary or secondary, will budge. Only then do I bring up cosmetic options to further enhance pigment clearance.

Karan Lal, DO, MS, FAAD, is the first and only dual fellowship-trained pediatric and cosmetic dermatologist at Affiliated Dermatology in Scottsdale, Arizona.

References

1. Nielsen VW, Thomsen SF. The role of
the mast cell in pigmentation disorders. Pigment International. 2021;8(2):73-75. doi:10.4103/pigmentinternational.pigmentinternational_

2. Deo KS, Dash KN, Sharma YK, Virmani NC, Oberai C. Kojic acid vis-a-vis its combinations with hydroquinone and betamethasone valerate in melasma: a randomized, single blind, comparative study of efficacy and safety. Indian J Dermatol. 2013;58(4):281285 2013;58(4):281-285. doi:10.4103/0019- 5154.113940