Fairness Magazine & Dott. Maurizio Nudo
Dark spots or large white areas on the skin, attributable to hyper- or hypopigmentation, may conceal congenital problems or those related to different pathologies. Usually, there are therapies that can help improve the symptom, but they are only curative in a few cases.
On one hand, there’s an increase in pigmentation, with the appearance of more or less evident dark spots in terms of size and location on the skin. On the other hand, there’s the loss or lack of natural skin coloration. These are the two “faces” of pigmentary disorders, which often manifest primarily on the face and sun-exposed areas, with a significant aesthetic impact and emotional distress for those affected. Some treatments and therapies are possible today, mostly improving symptoms, but only in a few (or rare) cases resolving the underlying problem. A clinical-therapeutic approach tailored to the cause and type of hyper/hypopigmented spot is crucial.
Vitiligo
Among hypopigmentation disorders, it is the most common, affecting about 1% of the world’s population without differences in gender or ethnicity, equating to around 70-100 million cases globally, with 700,000-1 million cases in Italy alone. There are two main critical points related to this pathology characterized by the presence of white, milky-colored patches in sun-exposed areas, mainly hands, feet, legs, and face, lacking melanin: the etiology, still under discussion, and the lack of a definitive therapy. “Vitiligo – explains Dr. Maurizio Nudo, Head of Dermatology at Humanitas Castelli di Bergamo – is the ‘queen’ of dyschromias, a condition in which the body’s own cells attack melanocytes, destroying them, leading to the formation of white areas on the skin. However, autoimmune cause is just one of the hypotheses: there are indeed forms of idiopathic vitiligo, of unknown cause, others related to thyroid diseases, comorbidities more often associated, the most common being Hashimoto’s thyroiditis, although not strictly dependent. In fact, there are patients with thyroiditis who develop vitiligo and others who are affected without any involvement of the gland. Hence the indication for patients with vitiligo to undergo specific blood tests such as anti-thyroglobulin antibody (anti-Tg), anti-microsomal antibodies, FT4, TSH to confirm or exclude the correlation with thyroid issues. Moreover, traumatic forms of vitiligo can occur for example, there is evidence that frequent showers and continuous rubbing can cause, especially in individuals with dark skin, damage to the dermis in regions of the chest and back, leading to true traumatic acromes.”
The severity of vitiligo is estimated using Wood’s lamp: the purple light emitted by the lamp allows evaluating dermal or epidermal damage, mostly at the dermo-epidermal junction level, and the milky coloration, which represents an important differentiating factor from other hypopigmentation pathologies. Therapeutic approach focuses on stimulating melanin with differentiated methods depending on the seasonality. “In winter – the expert states – it is possible to resort to narrow-band UVB rays (312 nanometers) or laser with excimers with the same wavelength that stimulate melanocytes to produce other melanocytes to promote pigmentation of white patches. In summer, in addition to sun exposure, in case of widespread forms, oral furocoumarins can be used (capsules) taken a couple of hours before exposure or, alternatively, 4% Kellin, a topical galenic preparation, also based on furocoumarins, to be applied half an hour before sunbathing followed by gradual exposure: 5 minutes on the first day, increasing by 5 minutes in the following days up to a maximum of 60 minutes, the recommended limit threshold for those with vitiligo to avoid possible burns induced by the drugs used. Therapy with furocoumarins can start from May-June until September, making the most of the exposure period, preferably in the afternoon to avoid possible risks from excessive sun exposure.”
Adherence and therapeutic consistency yield good results, with some exceptions for hands and feet, in the long term (several years), especially if vitiligo is widespread, and with better outcomes in localized forms or if treated from the onset in pediatric age or in young adults. However, outcomes vary from person to person, up to cases of no response to treatment.
Hypopigmentations
They are mainly associated with dermatoses that can also be congenital. “We typically talk about forms of atopic dermatitis – clarifies Nudo – often accompanied by eczemas localized in various districts depending on age and regressing, they can lead to hypopigmentation phenomena, specifically pityriasis alba corporis or faciei. This is a condition that generally affects the face, antecubital folds (or flexor folds of the upper limbs), or popliteal fossae where white patches form, where eczemas were present, more typical in children. Eczemas and itching induce children to scratch themselves, and by scratching, the skin undergoes damage, and trauma inhibits melanin production, hence the usually transient hypopigmentation. These white patches are often a source of concern for parents who mistakenly confuse them for fungi or vitiligo; they should be reassured that with growth, the manifestations will tend to disappear, while they may persist over time if the problem arises in adulthood.”
Once again, Wood’s lamp can help differentiate the diagnosis: the light hazel, typical of pityriasis alba, will exclude vitiligo. Among hypopigmentations, pityriasis versicolor is also quite frequent due to the fungus Pityrosporum ovalis or Malassezia furfur, which selectively localizes on the face but also on the chest and back, generating the formation of coffee-colored or pinkish, desquamating patches. “Pityrosporum ovalis – informs the dermatologist – is a parasite present on everyone’s skin surface, which normally remains in a parasitic state, but which in predisposed subjects or if conditions favorable to microclimate or pH variations are generated, can change to a pathogenic state, giving rise to the formation of these typical patches, because the fungus, in addition to damaging the superficial layers of the dermis, temporarily destroys melanocytes, leaving acromic outcomes.”
“The therapeutic goal should be to first bring the fungus back to a parasitic state – clarifies Nudo – with antifungal creams in case of localized forms or in combination with an oral antifungal for at least 7-10 days in diffuse forms. Only secondarily should the acromic outcome be ‘treated,’ resorting to narrow-band UVA lamps also used in the treatment of atopic dermatitis/eczema. Therapies should only be performed in specialized medical centers, not in aesthetic centers.”
Hyperpigmentation
The most common pathologies are melasma and chloasma: brown spots localized in sun-exposed areas such as the face, forearms, and arms, predominantly affecting Caucasian women, but more so the populations of South America (Brazil and Argentina). It is in these territories, in fact, that treatment techniques have been developed, including a mask containing a mix of acids, which act on the skin by exfoliating it, allowing the acids themselves to reach the melanin deep within, promoting partial lightening of the skin areas. “Laser – continues Nudo – especially if melanin extends beyond the corneal layer invading the dermis, is not effective and may sometimes induce contrary effects as the laser beam, expressing energy and attracting melanin, could exacerbate the spot instead of lightening it.” Melasma and chloasma may be attributable to hormonal imbalance, medication use, or self-injurious traumas, such as nodular prurigo, a frequent pathology in psychopaths caused by excessive and repeated scratching, to the extent that the skin takes on a lichenified, more often pigmented appearance. Finally, hyperpigmentation, as in the case of acanthosis nigricans that can affect the posterior and anterior neck, armpits, and inguinal regions, may correlate with endocrinological pathologies. “In the case of hormonally based hyperpigmentation – declares Nudo – the aesthetic problem can be addressed with the application of the mask or with the use of specific creams that work better than laser. The best therapeutic choice is determined by the careful study of the spot with Wood’s light: if superficial and of light phototype, it can be treated even with laser, if deep and of dark phototype, the indication is for the mix of acids. The study of the spot is of fundamental importance in case of hyperpigmentations of pathological origin, as in the case of acanthosis nigricans, which requires the definition of the underlying cause – endocrinopathy, diabetes, adrenal or thyroid problems – with specific hematological analyzes, hence the need for a close collaboration between endocrinologist and dermatologist where the correct management of the upstream problem favors the improvement/resolution of hyperpigmentation. More complex is the management of self-induced melasmas in psychiatric patients, where dermatologists and psychiatrists/psychologists provide means to improve the problem (stop scratching obsessively), but in the absence of the patient’s willingness to follow indications, every attempt is thwarted with the persistence/worsening of the problem.“
Sun exposure
Beneficial or harmful: the action depends on the downstream pigmentary disorder: in case of hypopigmentation, sunlight represents a valuable aid capable of stimulating melanin production. “Important – recommends Nudo – in the case of pityriasis versicolor, one should not expose oneself during the acute phase, or in the case of topical eczema in areas where the skin has been inflamed or very dry with intense desquamation, a cutaneous manifestation called pityriasis alba develops in the summer, which can benefit from the sun and the application of creams that stimulate melanin. Conversely, in cases of hyperpigmentation, sun action should be screened with sunscreens SPF 50+, with high protection to be applied from morning to evening.”
The pharmacist’s contribution
They can play a counseling role, “suggesting the most suitable sunscreens in case of hyperpigmentation – concludes Nudo – or proposing the temporary use of specific supplements, for example, with vitamin PP which can help prepare the skin for the sun. Or, when observing different/suspicious spots, the pharmacist can encourage the patient to seek specialized dermatologists.”
➡️ Thanks to Dr. Maurizio Nudo for the contents
➡️ For information ➡️ https://maurizionudo.it/
Ig – @fairness_mag
