Professional Documents
Culture Documents
, 2007
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DERMATOLOGIC THERAPY
ISSN 1396-0296
patients
122
Introduction
changes are far more disconcerting to these patients retinoid (lower concentrations in cream formula-
than the active acne lesions. Unfortunately, the tions for dry, sensitive skin) a noncomedogenic
dyschromia lasts so much longer than the original moisturizer, and doxycycline 100 mg.
acne lesions, even with intervention. This mottled, If the acne is cyclic and hormonal (evidence of
leopard-like hyperpigmentation is cosmetically excess androgen production including irregular
unacceptable to patients. menses, unwanted hair growth/hirsutism, deepen-
ing voice, and/or resistant acne) after screening
Dr. Swinehart: Patients with pigmented skin and these patients for polycystic ovary syndrome
acne vulgaris tend to develop postinflammatory (PCOS) or ovarian tumors by checking free and
hyperpigmentation. This problem can be treated total testosterone, DHEA, LH/FSH levels, I would
with dry ice cryotherapy, comedone extraction, consider oral contraceptives.
and the use of tretinoin cream to gradually fade Education on the pathogenesis of acne and the
the pigmentation. importance of following a comprehensive regimen
(explaining all of the prescribed products) including
Question gentle skin care and use of oil-free cosmetics is
essential to compliance.
How do you treat richly pigmented patients who At follow-up in 812 weeks, if they have been
present with many (> 50) open and closed come- compliant and have noted some improvement, I
dones, papules, and pustules affecting the facial skin? consider changing their antibiotic and introduc-
ing adjunctive treatments including salicylic peels
Response and/or microdermabrasion in an attempt to help
their acne and postinflammatory hyperpigmenta-
Dr. Quarles: I begin therapy by having patients tion. Alternatively, a series of light-based therapies
apply the least irritating topical retinoid at night. (blue light 2/weeks 8 treatments) or photody-
Glycolic acid cleansers tend to be less irritating namic therapy sessions (four treatments every 24
than salicylic acid cleansers. In some patients weeks) can be beneficial. I introduce the Accutane
with sensitive skin, even very mild cleansers, such option if the patients disease remains refractory
as Cetaphil, may cause irritation. Clindamycin after two courses of antibiotics in addition to the
solution or foam can be applied twice daily to above regimen. For postinflammatory hyperpig-
inflammatory lesions. Combination benzoyl per- mentation, early use of skin lighteners is important.
oxide 5%/clindamycin creams are well tolerated I allow the patient to guide me as to how aggres-
when used daily. Most patients with very oily skin sive I should be. Once the acne is under control, it
tolerate combinations of retinoids at night and is crucial to treat postinflammatory hyperpigmen-
benzoyl peroxide in the morning. Systemic anti- tation; this is usually their chief complaint.
biotics, usually tetracycline 500 mg twice daily as
needed, can be helpful. Dr. Lupo: I do not perform any manipulation
(including extractions) until the patient has been
Dr. Johnson: Comedones respond best to retinoids. using retinoids for at least 24 weeks.
Azelex serves as an alternative hypopigment-
ing and anti-acne agent. Alternatively, a topical Dr. Vause: I begin with an acne face wash twice
retinoid or retinoid derivative could be beneficial daily, benzoyl peroxide/clindamycin combination,
if the patient has very oily skin. azeleic acid, and sunblock plus a moisturizer as
needed. Later, Ill add a retinoid at bedtime. We
Dr. Badreshia: I begin with a discussion of past use oral antibiotics less often than in the past. It is
treatments, hormonal flaring, as well as their important to control the inflammation so well try
psychological scarring from postinflammatory nicotinamide. Concurrently, gentle, yet progressively
hyperpigmentation. If the patient has acne resistant stronger chemexfoliation and/or microdermabra-
to several prescription formulations, I go straight sion augment the results.
to isotretinoin. If they have not tried prescription
anti-acne drugs I use the following regimen: Dr. Brauner: I dont treat them any differently
am benzoyl peroxide 2.55% wash followed by than more lightly pigmented patients: acne
combination benzoyl peroxide antibiotic and a cleansers, benzoyl peroxide, topical retinoids, and
noncomedogenic moisturizer in addition to doxy- oral minocycline or doxycycline to start. I also
cycline 100 mg orally, pm I suggest a 5% glycolic perform acne surgery, comedone extraction as
acid/2% salicylic acid wash followed by a topical necessary.
123
Introduction
FIG. 1. (a) Hispanic male with acne vulgaris. (b) African American female with post inflammatory hyperpigmentation
secondary to acne. (c) Hispanic female keloids secondary to acne vulgaris.
124
Introduction
for acne that is resistant to two different antibiotics. If the lesions are diffuse, I use the more aggres-
Education is also important regarding proper sive prescription combination hydroquinone; spot
skin care and avoidance of excessive perspiring chemical peels (every 2 weeks for 5 weeks) in
from exercise/sports related activities or occlusive addition to glycolic peels. The patients main-
sports gear when possible. tenance regimen with evening retinoic acid will
help increase superficial exfoliation and melanin
Dr. Vause: We treat the torso similar with the face dispersion. Azelaic acid can also be used as it
but in a more aggressive manner. inhibits melanin synthesis.
Used in combination, the synergy between
Dr. Breadon: Treatment of the chest and back over-the-counter products, prescription products,
areas with similar lesions consists of the same and chemical peels are more effective. Daily
regimen I use for facial disease. broad-spectrum sunscreen use with micronized
titanium or zinc oxide is cosmetically pleasing
Question and mandatory to prevent worsening. Cosmetic
camouflage is important to many of my patients
Which therapies have you used for the post- during the healing stages.
inflammatory hyperpigmented macules in this
patient group? Dr. Lupo: In general, I find that richly pigmented
skin has more dermal pigment, especially after
Response picking and damaging the pilosebaceous unit. The
deeper the pigment, the darker it appears and the
Dr. Quarles: Four percent hydroquinone is the harder it is to get it to fade. I believe strongly in
work horse. I prefer it in combination with a topical and oral retinoids. Isotretinoin is a favorite
retinoid/corticosteroid, which is applied nightly. because I think it helps the postinflammatory
On occasion, Ill have 6% hydroquinone com- hyperpigmentation the fastest. I use hydroquinone
pounded with desonide lotion 0.05% and ascorbic only after the active acne is under control and
acid, which is applied to the dark spots in the usually I do not need it unless the patient is very
morning. Addition of ascorbic acid minimizes impatient. I use microdermabrasion and salicylic
oxidation of hydroquinone. The addition of salicylic acid peels. Laser can be great for acne, scars,
acid chemical peels and/or microdermabrasion and postinflammatory hyperpigmentation. Its
and glycolic cleansers is very helpful. important to avoid irritation, which could
increase pigmentation.
Dr. Brody: I like hydroquinone bleaches, includ-
ing Bleach Eze. Dr. Vause: We explain that treatment of post-
inflammatory hyperpigmentation requires patience
Dr. Johnson: Early postinflammatory hyper- and compliance. We like to avoid the spotted
pigmentation is treated with: chemical peels, halos often seen with higher concentrations of
microdermabrasion, and hydroquinones (as long hydroquinones. We are able to achieve a more
as the latter remains available). Azelex helps uniform correction (the goal) with combinations
when the pigmentation is secondary to acne. Its of chemexfoliation with salicylic, glycolic, and
very important to instruct patients not to aggra- trichloroacetic acids plus home treatments with
vate the problem by over-washing/scrubbing with kojic, lactic, and azeleic acids. Finally, sunblock,
beads, particles, loofas, or cleansing cloths. Richly sunblock, and sunblock!
pigmented individuals may need to be reminded
that sunscreens should be applied to all hyper- Dr. Brauner: I prescribe hydroquinone solution
pigmented areas before each sun exposure. first as initial therapy. If the response is less than
ideal, I switch the patient to one of the variations
Dr. Badreshia: My aggressiveness is determined on Dr. Kligmans formula. For minimal acne and
by the patients level of psychological scarring. minimal dyschromia I may use only azelaic acid.
I advise patience as the lightening agents will
help but the fading may take weeks to months. Dr. Breadon: In-office series of mild lipophilic
For early localized disease, I give the patient the chemical peels such as Jessners solution and the
option of using an over-the-counter hydroquinone beta-hydroxy acid peels are helpful in exfoliating
or a prescription-strength product. Postinflam- the superficial pigmentation, as well as penetrat-
matory hyperpigmentation. ing the acne lesions. These are applied every 24
125
Introduction
weeks, according to the patients needs, in con- weeks. Hyper or hypopigmentaion can be treated
junction with the acne regimen. Milder acids, such with intralesional hydroquinone.
as the amino fruit acids, or lower concentrations
of beta-hydroxy acids can be applied to the chest Dr. Swinehart: Chemical peels are more effective
and back, at less frequent intervals. for wrinkles and, in my opinion, have a limited
benefit in acne pigmentation. However, dry-ice
Question cryotherapy has been used for many decades to
treat this problem.
When do you consider using chemical peels as part
of your anti-acne armamentarium in richly pig- Question
mented patients?
In your experience, are there differences in the
Response development of acne scars (or types of acne scars)
in these patients? If so, how do you treat them?
Dr. Badreshia: After at least 4 weeks of acne regi-
men and giving adequate time to adjust to these Response
medicines I described consider, I give patients the
option of salicylic acid or glycolic acid (every 2 Dr. Quarles: Hypertrophic papular scarring on the
4 weeks) to improve active acne as well as any nose and chin, similar to rhinophyma, is not rare
residual postinflammatory hyperpigmentation in this patient group. If recognized during the
peels. The key is to perform staged peels starting early inflammatory stage then intralesional triam-
with safe superficial peels at low concentrations cinolone 5 mg/cc is helpful. Once the scarring has
and individualized to skin type/color. Spot peeling occurred, I find very little if anything will reduce
is another great approach to improve postinflam- the scarring. If the patient does not keloid, then
matory hyperpigmentation. I am more cautious of perhaps dermabrasion will be helpful; however,
using glycolic acid peels in skin types VVI because proceed with caution!
of the higher propensity to hyperpigment from
irritant contact dermatitis. A test spot is preformed. Dr. Brody: Postinflammatory hyperpigmentation
Glycolic acid is a humectant and works best for is not an acne scar.
dry skin, whereas salicylic acid is lipophilic and
works best for oily, acne-prone skin. After treating Dr. Johnson: I think scarring isnt that different
active acne and postinflammatory hyperpigmen- except that it is riskier to use some modalities
tation, superficial acne scarring can be improved such as fractional laser, dermabrasion, and deeper
with glycolic acid (used in all skin colors) or peels in pigmented patients.
Jessners/trichloroacetic acid peel (only in type IV
with test spots done initially). I do not use Dr. Badreshia: Patients whose chief complaint is
medium-depth peels in types VVI. to treat acne scars are usually concerned about
postinflammatory hyperpigmentation. In superfi-
Dr. Vause: We always employ chemexfoliation cial acne scarring, I perform a series of superficial
and/or microdermabrasion in the management of chemical peels and microdermabrasion. Although
acne and its sequela. dermabrasion and laser treatments have good
results, significant adverse effects limit their use.
Dr. Brauner: I perform Jessners peels predomi- The newer nonablative treatments may be associ-
nantly for resistant comedones. ated with less side effects but are also less effec-
tive. The literature is scant with short follow-up
Dr. Breadon: In my clinical experience, ice-pick times to make any definitive conclusions with
acne scarring is more common in patients of these new modalities. The 1450-nm diode laser
color having grades III and IV acne. Treatment of over four to six treatment sessions and fractional
these scars is difficult in general, but particularly resurfacing to promote collagen remodeling
so when dyschromia from the correction of the has been attempted in skin of color with some
scarring is factored in. Application of 100% success.
trichloroacetic acid into the depth of the scar
only is achieved by applying perilesional petrola- Dr. Brauner: I dont think there are any differences
tum to the surrounding normal skin. Healing from in scarring the difference is in dyschromia, which
this intentional wound takes approximately 23 is as or more visible than a scar contour shadow.
126
Introduction
Dr. Breadon: Punch grafting, followed by regional can precipitate or exacerbate hyperpigmentation
diamond-fraise dermabrasion, or ultrapulsed car- (creams and lotions are preferred to gels and solu-
bon dioxide laser resurfacing every 46 weeks after tions). Hyperpigmentation, the most distressing
skin grafting gives excellent results. Again, possible aspect of disorder responds to: kojic and lactic
dyschromia postresurfacing is a possibility but acids, hydroquinone, microdermabrasion, super-
in my experience can be resolved nicely with the ficial chemical peels (beta-hydroxyacids for oily
new hydroquinone preparations. skin, alpha-hydroxy acids for dry skin), and Jessners.
Nodulocystic acne may be less prevalent in this
Dr. Swinehart: Acne scarring can, of course, be patient group. Scarring in these patients can be
treated with punch grafting, punch elevation, treated with dermabrasion and grafting. In South
dermal grafting, and wire brush dermabrasion. Asian patients who may be using alternative skin
products, it is important to get a good medical
history. The rare keloid responds to intralesional
Summary or topical steroids.
127