Melasma, Vitiligo, Acne, Urticaria, Alopecia Areata, and Androgenetic Alopecia

Bernice Elaine T. Ong, MD, FPDS

Visiting Consultant

The Medical City

Outline

I. Disorders of PigmentationA. MelasmaB. Vitiligo

II. AcneIII. UrticariaIV. Common Hair Disorders

A. Alopecia AreataB. Androgenetic Alopecia

Melasma• acquired hypermelanosis

of sun-exposed areas• presents as symmetric

hyperpigmented macules, which can be confluent or punctate

• cheeks, upper lip, chin, and forehead are the most common locations, but it can occasionally occur in other sun-exposed locations

• chloasma - occurrence of melasma during pregnancy

MelasmaRace• any race can be affected• more common in constitutionally darker skin types • most common in light brown skin types, especially Hispanics and Asians,

from areas of the world with intense sun exposureSex• females are affected in 90% of casesAge• rare before puberty; most commonly occurs in women during their

reproductive yearsPathophysiology• uncertain• genetic predisposition is an important factor• female hormonal activity (pregnancy, use of oral contraceptive pills)• photosensitizing medications, mild ovarian or thyroid dysfunction, and

certain cosmetics• most important factor in the development of melasma is exposure to

sunlight

MelasmaClinical History• progressive

hyperpigmentation of the face, which may be temporally related to pregnancy or to the use of oral contraceptive pills

• intense or chronic exposure to sunlight worsens the condition and may precipitate melasma

Melasma

Melasma

Physical Exam• macular hyperpigmentation

of melasma is commonly tan to brown

• blue or black discoloration may be evident in patients with dermal melasma

• 3 clinical patterns: centrofacial, malar, or mandibular

• rare pattern confined to the forearms

Melasma

Diagnostics

• usually, no laboratory tests are indicated

• Wood’s light examination usually helps to localize the pigment to the epidermis or the dermis (in many cases, the pigment is found in both locations)

Vitiligo

• an acquired pigmentary disorder of the skin and mucous membranes

• characterized by circumscribed depigmented macules and patches

• a disorder in which some or all of the melanocytes in the affected skin are selectively destroyed

VitiligoFrequency• relatively common, with a rate of 0.5-1%• approximately 30% of cases occur with a familial clustering of

casesSex• female preponderance has been reported, but it is not

statistically significant and the discrepancy has been attributed to an increase in reporting of cosmetic concerns by female patients

Age• begins in childhood or young adulthood• rarely seen in infancy or old age• onset is most commonly observed in persons aged 10-30

years, average age of onset is approximately 20 years

Vitiligo

Pathophysiology• multifactorial polygenic disorder with a complex

pathogenesis• related to both genetic and nongenetic factors• precise cause remains unknown• theories regarding destruction of melanocytes

include autoimmune mechanisms, cytotoxic mechanisms, an intrinsic defect of melanocytes, oxidant-antioxidant mechanisms, and neural mechanisms

VitiligoClinical History• amelanotic macule or

patch surrounded by healthy skin

• chalk or milk-white in color; well demarcated

• initial lesions occur most frequently on the hands, forearms, feet, and face, favoring a perioral and periocular distribution

VitiligoPhysical Examination• white or hypopigmented

macules or patches• round, oval, or linear in

shape• range from millimeters to

centimeters in size• may be localized or

generalized• body hair in vitiliginous

macules may be depigmented (leukotrichia/poliosis)

Vitiligo

Localized   • Focal: one or more

macules in one area• Segmental: one or more

macules in a dermatomal or quasidermatomal pattern; occurs most commonly in children; not associated with other autoimmune disorders

Vitiligo

• Dermatome – area of the skin supplied by the sensory fibers of the spinal nerves

VitiligoGeneralized • most common type• symmetric, scattered patches

that are widely distributed• most common sites of

involvement are the face, upper chest, dorsal hands, axillae, groin

• periorificial: eyes, nose, mouth, ears, nipples, umbilicus, penis, vulva, anus

• areas subjected to repeated trauma: elbows, knees

• involvement of the mucous membranes is frequently observed in generalized vitiligo

VitiligoUniversal• complete or nearly

complete depigmentation

Acrofacial• distal fingers and

periorificial areas• “lip-tip” vitiligo

Vitiligo

• incidence of ocular abnormalities (iritis,retinal pigmentary abnormalities) are increased

• conditions associated with vitiligo : IDDM, pernicious anemia, Hashimoto’s thyroiditis, Graves’ disease, Addison’s disease, alopecia areata

Acne

chronic inflammatory disease of the pilosebaceous follicle

Acne• disease of the adolescent – 85% of teens

affected; greatest frequency between ages 15-18

• usually involutes by age 25; persists to age 44 in 12% of F and 3% of M

• causes: androgens, disordered keratinization, Propionibacterium acnes, inflammation

Acne

pilosebaceous unit microcomedo

Acne

closed comedoneopen comedone

Acne

papule pustule

Acnenodule or cyst

Acne

• characterized by comedones, papules, pustules, nodules/cysts, scars

• comedo – primary lesion of acne

• areas of predilection – face, neck, upper trunk, upper arms

• face: cheeks, nose, forehead, chin, ears

Acne - Comedonal

Acne - Papulopustular

Acne - Cystic

Acne - Scars

Acne - Keloidal

Acne - Neonatal

Urticaria

• hives, is a common skin condition that affects 15-25% of the population at some point in their lives

• classified as either acute or chronic (>6 weeks)

• angioedema is a condition that involves swelling of the deep dermal and subcutaneous/submucosal tissues

Urticaria

Chronic Idiopathic Urticaria

• when no specific cause is identified by history, physical examination, or laboratory findings

• >50% can be classified as idiopathic

• 7-17% of chronic urticaria cases are caused by physical stimuli (not idiopathic)

Urticaria

Physical Urticarias• Dermatographism• Cold• Heat• Solar• Cholinergic• Aquagenic• Exercise-induced• Pressure• Vibratory

Urticaria

Frequency• affects 15-25% of the population at some time in

their lives; CIU affects up to 3% of the populationSex• Chronic urticaria affects females more often than

males (F:M ratio is approximately 2:1)Age• acute urticaria - children and young adults• CIU - adults; middle-aged women seem to be

most affected

Urticaria

PathophysiologyMast cell

Release of histamine

Increased capillary permeability

• serotonin, leukotrienes, prostaglandins, kinins – can also cause vasodilation and increased capillary permeability

Urticaria

Clinical History

• often described as welts or hives

• generally pruritic; itching of nonlesional skin may also occur

• dermatographism is often observed in conjunction with urticaria

• individual lesions usually fade within 24 hours, but new lesions may be developing continuously

UrticariaImportant questions: • Are the hives associated with any foods? Have any new foods been

added to the diet? • Is the patient taking any regular medications or have any new

medicines been started? In particular, ask about aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, over-the-counter medications, herbs, and supplements.

• Does the patient have any recent or chronic infections? • Are the hives caused by any physical stimuli (eg, heat, cold,

sweating, exercise, pressure, vibration)? • Does the patient have any chronic medical conditions? • Is the urticaria associated with any substances that are inhaled or in

contact with the skin (which may occur in an occupational setting)? • Is the urticaria associated with insect bites or stings?

UrticariaCauses• Food allergies

– should be considered in acute urticaria and urticaria in children– unlikely to be a cause in adults with chronic urticaria, especially if it is not obvious by the

history; occurs in fewer than 2% of cases. – food additives or preservatives have been reported to be a cause of chronic urticaria in 3-

4% of cases• Drug allergies

– antibiotics, such as penicillin, have been implicated most frequently• Contact urticaria

– an allergic reaction to a substance that comes into contact with the skin• Papular urticaria

– a variation caused by insect bites; the lesions may last longer than 24 hours• Other immediate hypersensitivity allergic reaction to an ingested, inhaled, or percutaneously

inoculated substance (eg, latex, stinging insects, occupational exposures) • Nonallergic release of mediators

– drugs such as aspirin, NSAIDs, opiates, succinylcholine, and certain antibiotics (eg, polymyxin, ciprofloxacin, rifampin, vancomycin, some beta-lactams) can cause urticaria by a nonallergic mechanism rather than by IgE-mediated hypersensitivity

– certain foods or beverages, such as spoiled fish (scombroidosis), aged cheeses, or red wine; can contain histidine, which is closely related to histamine

– certain venoms – radiocontrast media sensitivity is not related to iodine, fish, or shellfish allergy

Urticaria• Medical causes

– Infectious causes • viral infections, such as acute viral syndromes, hepatitis (A, B, and C), Epstein-Barr

virus, and HSV• chronic parasitic infections• may possibly be caused by sinusitis, cutaneous fungal infections, Helicobacter pylori

infection, or other occult infection. – Hormonal causes

• Endocrine tumors (rare) • Ovarian pathology (rare) • Oral contraceptive use or changes in the menstrual cycle

– Cryoglobulinemias (ex., associated with hepatitis C, chronic lymphocytic leukemia) – Serum sickness – Other immune complex–mediated inflammation – SLE, RA, JRA or other rheumatological diseases (rare causes of urticaria) – Hypo- and hyperthyroidism, and in euthyroid patients with antithyroid antibodies – Lymphoreticular malignancies

• Physical causes (physical urticaria) – cold, pressure, vibration, water, sunlight – cholinergic (triggered by heat, exercise, or emotional stress)

Urticaria

Physical Examination• if any feature of anaphylaxis (ex. hypotension,

respiratory distress, stridor, gastrointestinal distress) is present, immediate medical intervention should occur

• lesions are edematous pink or red wheals of variable size and shape, with surrounding erythema

• look for typical and atypical skin lesions• examine for dermatographism

Urticaria

Urticaria

Angioedema

Dermatographism

Cholinergic Urticaria

Cold Urticaria

Alopecia Areata

• common; prevalence is ~1-2%

• recurrent, non-scarring type of hair loss that can affect any hair-bearing area

• can cause tremendous emotional and psychosocial stress

• etiology unknown

Alopecia Areata

• occurs equally in both sexes, usually <age 25

• autoimmune condition occurring in genetically predisposed individuals

• natural history of alopecia areata is unpredictable

• extreme variation in duration and extent of the disease

Localized Alopecia Areata

• <50% involvement

• usually self-limited

• spontaneous regrowth occurs in most patients within a few months, with or without treatment

Extensive Alopecia Areata

• >50% involvement

• AA Totalis-total loss of hair on the scalp

• AA Universalis- loss

of hair over the entire scalp and body; rarest form

History & P.E.

• hair loss is usually gradual

• “exclamation point hairs”

• scalp shows no scarring or atrophy

• ophiasis – bandlike pattern of hair loss

History & P.E.

• regrowing hairs are usually fine, often white or gray

• “hammered brass nails”

• examine other parts of the body

History & P.E.

Associated Conditions:• Hashimoto’s

thyroiditis• Vitiligo• Myasthenia gravis• Atopic dermatitis

Precipitating factors:• can be found in 15%

of patients• major life events,

febrile illnesses, drugs, pregnancy, trauma, etc.

• no clear conclusions can be drawn

Pathogenesis

• autoimmune disease; not a sign of any multi-system disease

• follicular damage occurs in anagen followed by rapid transformation to telogen

• Review:

Anagen – growth phase

Catagen – degenerative phase

Telogen – resting stage

Androgenetic Alopecia (AGA)

• most common cause of hair loss; ♂>>♀

• ♂-may begin anytime after puberty; ♀- 40% occur in the 6th decade

• combined effects of androgen on genetically-predisposed hair follicles

• hair loss is gradual• affects men and women

differently

Androgenetic Alopecia (AGA)

• In females: more diffuse and located centroparietally; frontal hairline is usually intact

• In males: hair loss occurs in the fronto-temporal regions and on the vertex of the scalp

Classification of AGA

Norwood-Hamilton Classification

Ludwig Classification

Pathophysiology

• Role of testosteronePre-natal: internal male sex organ dev’t

Post-natal: spermatogenesis, libido, muscle/bone mass

• Role of dihydrotestosterone (DHT)Pre-natal: external male genitalia

Post-natal: scalp hair loss, prostate enlargement

• uptake, metabolism, and conversion of testosterone to DHT by Type II 5-α-reductase is increased in balding hair follicles

• DHT causes terminal follicles to transform into vellus follicles which later atrophy

Other Considerations

• essentially a cosmetic disorder, but has significant psychological impact

• may increase the amount of actinic damage on the scalp

• in females, check for signs of virilization to determine endocrine dysfunction

The end.Thank you for listening!