Dr. Heather Woolery-Lloyd discusses the evaluation, work-up, and management of new-onset dyschromias from her lecture on Thursday, November 9, 2023, at the 4th Annual Elevate-Derm PA/NP Conference at Coachella Valley, CA.

In this video

Dr. Woolery-Lloyd walks through distinguishing the slate-gray pigmentary disorders as a clinical diagnosis: lichen planus pigmentosus is primarily on the face, sometimes the neck and rarely the forearms, while erythema dyschromicum perstans and ashy dermatosis are "basically the same condition" on the trunk and extremities. Traditionally, preceding erythema pointed to erythema dyschromicum perstans and its absence to ashy dermatosis, but she notes the term erythema dyschromicum perstans is now being adopted across the whole spectrum, even without visible erythema.

For new-onset facial darkening — often in patients in their 50s or 60s — her very first question is whether the patient started a new blood pressure medicine, specifically asking if the bottle says "HCTZ." Because hydrochlorothiazide (and some migraine and anti-seizure medications) is photosensitizing, patients with darker skin don't get the classic itchy rash that would prompt them to stop; their constituent pigment masks it while low-grade inflammation drives progressive darkening. She stresses coordinating with the primary care provider to switch the drug, then treating the pigment with a topical anti-inflammatory plus azelaic acid or a hydroquinone-free brightener across the full face.

  • Distinguishing the dyschromias is clinical: face/neck slate-gray pigment suggests lichen planus pigmentosus, while trunk and extremity involvement is erythema dyschromicum perstans / ashy dermatosis.
  • For new-onset facial darkening, ask first about new blood pressure medication — especially HCTZ — since photosensitizing drugs cause progressive darkening rather than a visible rash in skin of color.
  • Manage drug-related dyschromia by working with the PCP to stop or switch the medication, then treating with a topical anti-inflammatory plus azelaic acid or a hydroquinone-free brightener on the full face.
  • For melasma, use hydroquinone only on the affected patches as short-term treatment (four to six weeks), then maintain with something else — and any redness, burning, or stinging is not good, since irritation can worsen melasma.
  • For acne dark spots, apply hydroquinone precisely to the spot with a Q-tip, let it absorb, then layer the retinoid on top — and "don't make circles," to avoid a hypopigmented hydroquinone halo.