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Primary Care Management of Skin Pigmentation Disorders Reviewed

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January 28, 2009 — Practice recommendations for primary care clinicians to diagnose and treat skin pigmentation disorders are provided in a review in the January 15 issue of American Family Physician.

Although most pigmentation disorders are benign or nonspecific, some disorders of skin pigmentation present cosmetic or psychological challenges to the patient, necessitating evaluation and treatment,” write Scott Plensdorf, MD, from Michigan State University College of Human Medicine in Flint, and Joy Martinez, MD, from Kaiser Permanente, San Diego, California.

Others may be indicators of underlying systemic disease or primary skin malignancy.

Proper diagnosis of these common skin conditions will allow the physician to facilitate appropriate skin treatment and reassure the patient.

Hyperpigmented lesions frequently encountered by the primary care clinician include postinflammatory hyperpigmentation, melasma, solar lentigines, ephelides (freckles), nevi, and café-au-lait macules.

Most hyperpigmented lesions seen in this setting are benign and are easily diagnosed.

However, the clinician must rule out melanoma and its precursors and be able to diagnose skin manifestations of systemic disease.

Postinflammatory hyperpigmentation consists of irregular, darkly pigmented macules or patches located at previous sites of injury or inflammation.

Specific types of postinflammatory hyperpigmentation include acne, psoriasis, atopic and contact dermatitis, lichen planus, trauma, drug reactions, and fixed-drug eruptions.

Combination therapy is most effective for postinflammatory hyperpigmentation, with a regimen involving hydroquinone, azelaic acid, retinoids, chemical peels, and/or laser therapy.

Melasma are light brown-, brown-, or gray-pigmented, well-defined macules found on the face (63% centrofacial, 21% malar, 16% mandibular) or forearms.

These may be idiopathic or caused by pregnancy or by use of oral contraceptives or phenytoin.

Treatment may include use of sunscreen and pharmacotherapy with combinations of hydroquinone, retinoids, glycolic acid peels, and/or topical steroids.

Laser therapy or intense pulsed light therapy may be useful for dermal lesions.

Topical agents, chemical peels, cryotherapy, or laser therapy may be useful in the treatment of postinflammatory hyperpigmentation, melasma, solar lentigines, and ephelides.

Surgical excision or laser treatment is recommended for café-au-lait macules.

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