Dyschromia in Skin of Color

April 2014 | Volume 13 | Issue 4 | Original Article | 401 | Copyright © April 2014

Stephanie J. Kang DO,a Scott A. Davis MA,a Steven R. Feldman MD PhD,a,b,c and Amy J. McMichael MDa

aCenter for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC
bCenter for Dermatology Research, Department of Pathology Wake Forest School of Medicine, Winston-Salem, NC
cCenter for Dermatology Research, Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC

BACKGROUND: Dyschromias are becoming a more common concern among patients, particularly among persons of color. There are a variety of treatments, including more novel agents for dyschromias. Evaluating common agents prescribed among various races may prompt efforts to enhance care for dyschromias in patients of color.
OBJECTIVE: To determine whether racial or ethnic groups are treated differently for dyschromia. The secondary objective is to discover the main treatments used and determine trends over time in demographics.
METHODS: We searched the 1993-2010 National Ambulatory Medical Care Survey (NAMCS) for visits associated with a diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09). The demographics and leading treatments were tabulated, and trends over time were assessed by linear regression.
RESULTS: There were about 24.7 million visits for dyschromia over the 18-year period. Among 5,531,000 patients with the sole diagnosis of dyschromia, there were 2,800 visits from females and 1,200 visits from males per 100,000 population. Females were more likely to receive prescription combination therapy for dyschromia than males by a ratio of 10 to 1. Leading treatments overall prescribed by dermatologists included hydroquinone, topical corticosteroids, and retinoids. Asians were 27% more likely to receive a combination therapy than non-Asians. African Americans and Hispanics were less likely to have a procedure performed for dyschromia.
LIMITATIONS: Data are based on a number of ambulatory care visits, which does not allow direct estimation of prevalence.
CONCLUSIONS: Dyschromia is a significant concern for many patients, and this is especially true among patients of color. Treatment for dyschromia is influenced by skin type, and thus ethnic or racial groups are treated differently. Studies have shown that combination therapy may offer better results than a single medication for hyperpigmentation disorders. Combination agents may be underutilized in African Americans and Hispanics for dyschromia.

J Drugs Dermatol. 2014;13(4):401-406.


Dyschromias, including melasma, post-inflammatory hyperpigmentation, and hypopigmentation, are a common concern especially among women and persons of color. Dyschromia is one of the most common diagnoses in black patients.1 Dyschromia can cause a significant psychological impact on a patient’s quality of life. Dyschromias can decrease social functioning, cause lower workplace productivity, and reduce self-esteem.2 There are various therapies for hyperpigmentation, including depigmentation agents such as hydroquinone, topical corticosteroids, tretinoin, and other agents that act via tyrosinase-mediated pathways. Treatment modalities are often individualized, depending on a patient’s skin type.
For decades, hydroquinone has been the gold standard for treatment of hyperpigmentation disorders such as melasma, lentigines, and post-inflammatory hyperpigmentation.3 However, there are many options for the treatment of dyschromias, including various topical agents, oral medication, chemical peels, or lasers.4 More recent studies show that several non-hydroquinone agents, eg, arbutin, kojic acid, azeleic acid, licorice, vitamin C, retinoic acid, may also play an important role in therapy for hyperpigmentation.5,6 Cestari et al, compared two groups with Fitzpatrick skin type II-V; group B applied HQ 4% twice daily and sunscreen SPF 30+ and group A applied a combination of HQ 4%, retinoic acid 0.05%, and fluocinolone acetone 0.01% daily.7 The combination therapy was more efficacious than monotherapy according to the Melasma Severity Scale.
The primary objective of our study is to determine whether ethnic or racial groups are treated differently for dyschromia by analyzing the top treatments that are prescribed for various ethnic/racial groups. This study also aims to identify if one demographic group is more or less likely to receive treatment or procedure performed for dyschromias. Some demographic populations may seek treatment for hyper or hypopigmentation more often than other groups. In this study, we analyze trends in demographics seeking treatment for dyschromias and determine how treatments and procedures may differ according to race.


This study was approved by our Institutional Review Board and was conducted using the National Ambulatory Medical