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Introduction
CHAPTER 76 Approaches to
Dyspigmentation
Seemal R. Desai Rashmi Sarkar Pallavi Ailawadi Kevin Prier
SUMMARY
The classification of dyschromias is based on the location of melanin in the skin.
This can be seen clinically by variation in color of the lesion, Woodโs lamp examination, as well as histopathologically.
The therapeutic plan primarily consists of identification and removal of
causative as well as triggering factors and stringent photoprotection coupled with the use of depigmenting agents.
Beginner Pearls
Sun avoidance is the most important part of the treatment of hypermelanoses, both for
current improvement and future prevention of recurrence.
Hydroquinone (HQ) is a mainstay topical depigmenting agent in the treatment of
dyschromias, particularly melasma and postinflammatory hyperpigmentation.
Multiple chemical peels have efficacy for dyspigmentation, including glycolic acid,
Jessnerโs, and TCA peels.
Expert Pearls
Laser and light options include IPL, QS Nd:YAG, QS ruby, and QS alexandrite.
The patient should be adequately primed for around 2 to 4 weeks pre-peel with topical
skin lightening agents such as HQ, GA and kojic acid, or tretinoin, coupled with regular sunscreens.
Donโt Forget!
Regardless of intervention used, fundamental medical management, including religious
photoprotection, is absolutely essential and even the most complex intervention will
fail if the patient does not comply with the fundamentals.
Melasma patterns include centrofacial, malar, and mandibular patterns.
Pitfalls and Cautions
Combination peels should be used cautiously in darker-skinned patients because of the
risk of PIH and scarring. Patients with long-term use of HQ increase their risk for exogenous ochronosis.
Patient Education Points
Rigorous sun protective behavior should be instilled in patients, including the use of
broad spectrum (ideally physical blocking) sunscreens with a minimum sun protection factor of 30, along with sun protective hats and clothing.
Patients should understand that multiple treatments may be required and that their
degree of improvement with each treatment session may be unpredictable.
Always err on the side of underestimating the improvement that will be seen.
CHAPTER 76 Approaches to