Topical Retinoids for Pigmented Skin

May 2011 | Volume 10 | Issue 5 | Original Article | 483 | Copyright © May 2011


Aanand N. Geria MD, Christina N. Lawson MD, Rebat M. Halder MD

The only trial, to the best of our knowledge, to investigate the use of topical retinoids in PFB looked at the combination of tretinoin 0.025% cream at night and hydrocortisone 2.5% cream twice daily for eight weeks in 10 black subjects with mild-to-moderate PFB. Results showed a reduction in the number of papules and hyperpigmented macules in eight out of 10 subjects. 1 This is limited in that this was not a randomized placebo controlled study and had a small number of subjects. In our personal experience, however, topical retinoids are a useful adjunct in treating PFB.

Keloids

The incidence of keloids is five to 16 times greater in blacks, Asians and Latinos compared to Caucasians.24 These overgrowths of scar tissue commonly occur following trauma, surgical incisions, earlobe piercing, and may also develop spontaneously.1 In the 1980s, researchers observed that retinoids markedly reduced the production of pro-collagen in keloid fibroblast cultures.40
There is evidence to suggest that topical retinoids may be useful therapy for the treatment of keloids. A study consisting of 11 subjects treated with tretinoin 0.05% cream for 12 weeks demonstrated a significant decrease in the weight and size of long-standing keloids as compared with baseline measurements. 41 Another study of 28 subjects with hypertrophic scars treated with daily topical 0.05% tretinoin solution not only found a reduction in the size of the lesions, but also a decrease in complaints of pruritus in the majority of subjects.42 The significance of both the aforementioned trials is marred by their lack of placebo-controlled randomization.

Cutaneous T-cell Lymphoma and Kaposi Sarcoma

Topical bexarotene and alitretinoin are FDA-approved for the treatment of refractory stage IA/B CTCL and cutaneous Kaposi sarcoma, respectively. At present, information regarding the efficacy and tolerability of these agents specifically in patients of pigmented skins is limited; however, both are currently used for these specific indications in pigmented skins.

Practice Guidelines

There is widespread, but largely unproven, belief that people with darker skins are more prone to contact irritation.43 Based on the previously reviewed studies, there is little evidence to suggest that patients with darker skins are more susceptible to retinoid dermatitis. In fact, the contrary may be true.44 Often times, there is greater variation with respect to irritant response within a particular group than between groups.43 Further complicating matters, irritant response may be expressed differently or appear less evident in darker skins.45 Unfortunately, there is a paucity of quality studies looking specifically at the relationship between skin color and susceptibility to irritation from topical retinoids. Simply asking the patient about their personal history with skin irritation may be a good starting point when initiating topical retinoid therapy.
Selection of the appropriate vehicle, concentration, and dosing frequency of a topical retinoid is critical in minimizing the risk of an irritant reaction to topical retinoids (Table 1). For patients with sensitive, dry skin or those with a prior history of skin reactions, a cream is favored over a gel formulation.24 In addition, therapy should be initiated at a lower concentration of a retinoid with alternate- day dosing for the first two weeks and increased to once nightly as tolerated.46 After four to six weeks of treatment with a tolerated lower strength retinoid, the concentration may be increased. 46 To further minimize the irritation and drying effect of topical retinoids, patients should be advised to use a mild cleanser, a non-comedogenic moisturizer with a sun protection factor of 15, as well as discontinue the use of over-the-counter treatments.47

CONCLUSION

Topical retinoids are utilized for a wide variety of dermatologic conditions in patients with pigmented skins. Dermatologists must be mindful of the irritant effects associated with these agents which can potentially lead to PIH in darker skin. A balance must be maintained between early, aggressive therapy with topical retinoids to address the underlying skin disorder and the selection of a tolerable treatment regimen that curtails the risk of retinoid dermatitis with ensuing PIH.46 Certain guidelines, beginning with proper patient education, should be implemented to minimize the risk of an irritant reaction to topical retinoids in pigmented skins. Further investigation is needed to determine whether a difference in topical retinoid tolerability exists among different racial groups.

DISCLOSURES

The authors have no conflicts of interest to disclose.

REFERENCES

  1. Halder RM. The role of retinoids in the management of cutaneous conditions in blacks. J Am Acad Dermatol. 1998;39(2 Pt 3):98-103.
  2. Kang S, Leyden J, Lowe N, Ortonne JP, et al. Tazarotene Cream for the Treatment of Facial Photodamage. Arch Dermatol. 2001;137:1597-1604.
  3. Chandraratna R. Tazarotene - first of a new generation of receptor-selective retinoids. Br J Dermatol. 1996;135:18-25.
  4. U.S. Census Bureau, 2004. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Available at: http://www.census.gov/ipc/www/usinterimproj. Date accessed: November 10, 2010.
  5. Alexis A, Sergay A, Taylor S. Common dermatologic disorders in skin of color: A comparative practice survey. Cutis. 2007;80:387-394.
  6. Halder RM, Grimes P, McLaurin C, Kress M, et al. Incidence of common dermatoses in a predominantly black dermatologic practice. Cutis. 1983;32:388-390.
  7. Halder RM, Nootheti P. Ethnic skin disorders overview. J Am Acad Dermatol. 2003;48:143-148.