Pigmentation Disorders: Diagnosis and Management

 

Am Fam Physician. 2017 Dec 15;96(12):797-804.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/melasma/.

Author disclosure: No relevant financial affiliations.

Pigmentation disorders are commonly diagnosed, evaluated, and treated in primary care practices. Typical hyperpigmentation disorders include postinflammatory hyperpigmentation, melasma, solar lentigines, ephelides (freckles), and café au lait macules. These conditions are generally benign but can be distressing to patients. Appropriate dermatologic history, skin examination, and skin biopsy, when appropriate, can help exclude melanoma and its precursors. In addition to addressing the underlying condition, hyperpigmentation is treated with topical agents, chemical peels, cryotherapy, light or laser therapy, or a combination of these methods. Café au lait macules are treated with surgical excision or laser therapy if treatment is desired. Hypopigmentation disorders include vitiligo, pityriasis alba, tinea versicolor, and postinflammatory hypopigmentation. Treatment of vitiligo depends on the distribution and extent of skin involvement, and includes topical corticosteroids and calcineurin inhibitors, ultraviolet A therapy (with or without psoralens), narrowband ultraviolet B therapy, and cosmetic coverage. Patients with stable, self-limited vitiligo may be candidates for surgical grafting techniques, whereas those with extensive disease may be candidates for depigmentation therapy to make skin tone appear more even. Other hypopigmentation disorders may improve or resolve with treatment of the underlying condition.

Pigmentation disorders of the skin are commonly encountered in primary care practice. Although they are often benign and easily distinguishable based on appearance and location, it may be necessary to perform a skin biopsy to exclude melanoma and its precursors. Some disorders result in cosmetic or psychological concerns to the patient, necessitating evaluation and treatment. Proper diagnosis allows the physician to facilitate appropriate skin treatment, provide reassurance, or initiate appropriate referral.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Triple combination therapy (fluocinolone 0.01%/hydroquinone 4%/tretinoin 0.05% [Tri-luma]) is the most effective agent for treatment of moderate to severe epidermal melasma.

C

1, 7

Triple combination therapy (fluocinolone 0.01%/hydroquinone 4%/tretinoin 0.05%) can enhance resolution of solar lentigines treated with cryotherapy.

B

11

Class III corticosteroids and narrowband ultraviolet B are the most effective and safest treatments for localized and generalized vitiligo, respectively.

B

14

Topical tacrolimus (Protopic) 0.1% ointment is a safe and effective alternative to topical corticosteroids for treatment of pityriasis alba.

B

26

Topical antifungal agents and topical adapalene (Differin) gel are effective treatments for tinea versicolor.

A

27, 28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Triple combination therapy (fluocinolone 0.01%/hydroquinone 4%/tretinoin 0.05% [Tri-luma]) is the most effective agent for treatment of moderate to severe epidermal melasma.

C

1, 7

Triple combination therapy (fluocinolone 0.01%/hydroquinone 4%/tretinoin 0.05%) can enhance resolution of solar lentigines treated with cryotherapy.

B

11

Class III corticosteroids and narrowband ultraviolet B are the most effective and safest treatments for localized and generalized vitiligo, respectively.

B

14

Topical tacrolimus (Protopic) 0.1% ointment is a safe and effective alternative to topical corticosteroids for treatment of pityriasis alba.

B

26

Topical antifungal agents and topical adapalene (Differin) gel are effective treatments for tinea versicolor.

A

27, 28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Hyperpigmentation is the result of excess melanin production, distribution, or transport. Common etiologies include postinflammatory hyperpigmentation, melasma, solar lentigines, ephelides, and café au lait macules. Hypopigmentation results from a reduction of melanocytes or an inability of the melanocytes to produce melanin or properly transport melanosomes. Vitiligo, pityriasis alba, tinea versicolor, and postinflammatory effect are common causes of pigment loss. This article discusses clinical features of each condition, updated and novel treatments, and current evidence supporting their use. Table 1 summarizes current treatments.1

The Authors

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SCOTT PLENSDORF, MD, is a family physician and associate director of the Lancaster (Pa.) General Health Family Medicine Residency Program. At the time the article was submitted, Dr. Plensdorf was a faculty family physician at the Mclaren-Flint Family Medicine Residency Program, Flint, Mich....

MARIA LIVIERATOS, MD, is a family physician in private practice at Mayville (Mich.) Family HealthCare. At the time the article was submitted, Dr. Livieratos was a faculty family physician at the Mclaren-Flint Family Medicine Residency Program.

NABIL DADA, MD, is a family physician and hospitalist at Norton Audobon Hospital in Louisville, Ky. At the time the article was submitted, Dr. Dada was a third-year family medicine resident at the Mclaren-Flint Family Medicine Residency Program.

Author disclosure: No relevant financial affiliations.

Address correspondence to Scott Plensdorf, MD, Lancaster General Health Family Medicine Residency Program, 540 N. Duke St., Lancaster, PA 17602 (e-mail: scott.plensdorf@gmail.com). Reprints are not available from the authors.

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