How to Approach Disorders of Pigmentation, with Valerie Callender, MD

Valerie Callender, MD/ Credit: Callender Dermatology and Cosmetic Center

Many dermatologists, nurse practitioners, and physician assistants encounter disorders of pigmentation in their every practice. In a presentation at Maui Derm NP+PA Fall 2024 in Nashville, a talk titled ‘Disorders of Pigmentation’ covered diagnostic approaches to pigmentation disorders such as melasma and vitiligo.

The presentation was given by Valerie Callender, MD, Callender Dermatology & Cosmetic Center. Callender delved into the topic of diagnostic approaches, differential diagnoses to consider, and the latest strategies for managing a wide variety of disorders.

“When we think about disorders of pigmentation, you have to think about that melanocyte,” she explained. “That melanocyte is so sensitive, and it's very labile. So with any type of trauma, any inflammation, any disturbance in its activity, it can produce either too much pigment in the skin, too much melanin, not enough melanin, a decrease, or none at all.”

Callender noted that hyperpigmentation is probably one of the most common diagnoses seen in her practice. She also highlighted that she mainly sees patients who are women and patients with skin of color.

“When we think about dyschromia or hyperpigmentation, or really any of the dyschromias, you have to remember that for patients with skin of color, it's always in their top 10,” Callender said. “It's one of the most common conditions that we see in patients with darker skin. There was a study that actually looked at diagnoses and different populations, and for the skin of color patients and mainly the African Americans, this was at the top of the list. The second was alopecia.”

Callender also discussed post-inflammatory hyperpigmentation, which she noted occurs in most of the diagnoses that she observes in her practice.

“Whether they have atopic dermatitis, whether they have acne, whether they have psoriasis, whether they have lichen planus, whether they have a drug eruption, and the list goes on and on, hyperpigmentation is associated with many conditions in my patient population,” Callender said. “We do know that it is a response to inflammation. That's why we see it in acne and atopic dermatitis, psoriasis, etc. But we also know that it can occur from procedures like electrodessication.”

Callender highlighted the fact that health care providers must remember that hyperpigmentation is a common concern and should not be overlooked. She added that the goal of treatment in the case of acne and hyperpigmentation, for example, should be to treat both conditions at the same time using a therapeutic agent.
“Another condition that I see in my practice, not as often as post-inflammatory hyperpigmentation is melasma,” Callender explained. “And we know that melasma is a chronic condition…We also know that this condition, even when you treat it, can relapse and reoccur. A patient can go out in the sun for a day, after you've already cleared their melasma, and then get a little bit of sun exposure and have melasma back. It's very common in women. We know it's associated with hormonal changes.”

Callender noted that ultraviolet light is the driver of this condition, adding that therapy will include not only skin-lightening creams but also sun protection.

“You always have to remember, with these disorders, to get the correct diagnosis,” Callender said. “Because you can be fooled, right? Some of these diagnoses require a laboratory workup. Some of them require biopsy.”

Callendar explained that many patients with skin of color avoid sun protection given the assumption of safety due to pigment and melanin in their skin. She highlighted the importance of broad-spectrum sunscreens which are also mineral based, adding that new sunscreens have tinted options for skin of color patients.

Callender also noted that, in addition to skin-lightening agents to return patients’ skin tone to their natural color, education on duration of treatment is necessary.

“You also have to tell them about the duration of treatment,” Takes time, and it's not going to get better in one day or one week. It's going to take multiple months. It's going to take, maybe in some cases, years for that pigment to return to normal.”

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The quotes contained in this summary were edited for the purposes of clarity.