1. LIGHT RELATED AND PIGMENTATION DISORDERS

2. DR DE-KAA NIONGUN.L.PAUL MBBS(JOS), FWACP,Grdt. Cert.in Derm(BKK),PGDE, MNIM, JP.

3. Objectives At the end of the discussion, Participants should: Know and draw the structure of the skin Have an overview of Light related and pigmentation disorders Be able to discuss them Be able to diagnose Benign and Malignant skin tumors

4. Objectives Know treatment modalities and the relevance of the treatment Know when to refer patients for appropriate treatment

5. OUTLINE Definition Epidemiology Pathogenesis Stages/Presentation Severity classification Types Treatment

7. Skin or hair pigmentation (color) is a combination of the amount of melanin, type of melanin (eumelanin versus pheomelanin), degree of vascularity, presence of carotene and thickness of stratum corneum Other materials can be deposited abnormally in the skin to pigmentation Eumelanin is primary pigment producing brown coloration while pheomelanin produces yellow or red Melanin is formed in melanosomes in the melanocyte Melanin is transported in melanosomes in epidermal melanin unit

8. Variation in skin color between individuals and races depends on degree of melanization, the amount & their distribution in the epidermal melanin unit Pigmentation disorders can therefore be localized or generalized, can be genetic or as a result of hormonal changes and as a result of exposure to varying agents or UV light. focus is on Polymorphous light euption(PMLE), porphyria cutaneous tarda, Vitiligo and melasma

9. MELASMA Very common disorder Tends to affect dark-complexioned persons especially East, West, and Southeast Asians, Hispanics and black persons who live in areas of intense sun exposure & have Fitzpatrick skin types IV and V More common in women than men Pathogenesis is unknown however observations suggest sun exposure is primary trigger Genetic component is also associated Prevalence increases in both men and women

10. Melasma affects the face, sun exposed areas and worsens in summer More common & severe in women than men, as it occurs more frequently in pregnancy, with contraceptive use or with Hormone replacement therapy(HRT) at menopause. Characterized by brown patches mostly on malar prominences and forehead Pigmentary patches in melasma are sharply demarcated

11. Pattern Common in people who tan and naturally have brown skin(Fitzpatricks skin type 3 & 4) compared to those with fair skin (type 1 & 2) or black skin (type 5 & 6) Centrofacial pattern-central face, forehead & nose Malar pattern-cheeks & nose Lateral cheek pattern Mandibular pattern :- jawline

12. Pattern Reddened or inflammed form (reythrosis pigmentosa faciel) Poikiloderma of Civatte-reddened photoaging changes seen on the side of the neck, mostly affecting persons over 50 years Brachial type-affecting shoulders & upper arm (acquired Brachial cutaneous dyschromatosis) Melasma is usually separated using Wood lamp which emits black light (UVA1) into the various types

13. Melasma

15. Diagnosis/differential Diagnosis is clinical Biopsy—melanin deposits in basal & suprabasal keratinocytes; melanin in dermis within melanophages; highly dendritic (branched) deeply pigmented melanocytes DD:- Post inflammatory pigmentation; solar lentiges & other forms of lentigo; drug induced pigmentation eg minocycline, NSAIDS; Lichen planus; Naevus of Ota & Naevus of Hori; Guttate hypomelanosis

16. Types of Melasma Epidermal:-well defined border, more obvious under black light, dark brown color,responds to treatment. Dermal:-ill-defined border, light brown or bluish in color, unchanged under black light and responds poorly to treatment. Mixed:-most common type, combination of dark,bluish and light brown, partially responds to treatment

17. Treatment A number of topical therapies are available Avoid exposure to sunlight & use of complete sun blocks daily Bleaching creams:- 2-4% hydroquinone are gold standards. Add 0.05% tretinoin to increase efficacy kligman’s formular is excellent:- 0.05% tretinoin + steroid +2-4% hydroquinone Other agents are azaleic acid, kojic acid, ellagic acid, mequinol, liquorice extract, glucosamine, niacinamide, vit C & E, phytosterol, arbutin, 4% pidobenzone

18. Treatment Surgical treatment involve use of peels. However most of the people in whom peels are used have been placed on hydroquinone and other bleaching agents So surgical treatment should be used with caution Laser treatment: intense pulse light, fractional resurfacing, erbium:YAG resurfacing, 578nm copper bromide, and Q-switched Nd:YAG have also proved effective.