Pigmentary Disorders and Their Management-Analyzing Current Evidence: Conference Proceedings and Learning Points. Pigmentarycon 2017. November 10-12, Indore, India.

Sir,

The Pigmentary Disorders Society (PDS) of India organized the 3rd edition of their flagship biennial conference “Pigmentarycon” from 10th to 12th November, 2017 at Indore. Spearheaded by the dynamic Prof. Rashmi Sarkar, President, PDS and her able organizing team, the conference was a delectable academic feast [Figure 1]. It was attended by about 500 delegates from the nooks and corners of our country and 10 international faculties from different parts of the globe. It is a one of its kind conference, focussing on the wide gamut of pigmentary disorders, their management while reviewing the recent trends and current best evidences. The global perspective in this regard was also shared by our international faculties. The conference kick started with several hands-on workshops depicting the conventional and newer approaches to different pigmentary disorders followed by deliberations and presentations encompassing a wide plethora of topics. The highlights, salient features, and take-home messages gathered from this rendezvous have been presented in this paper.

Figure 1

Inauguration and lamp-lighting ceremony of Pigmentarycon 2017 (From left to right: Dr Subhash Jain, Dr Yogesh Marfatia, Dr Narendra Gokhale, Dr George T. Reizner, Dr Rashmi Sarkar)

Workshops: a Sneak Peek

A total of five workshops were arranged with topics ranging from chemical peels, lasers, periorbital rejuvenation, non-cultured melanocyte transplantation in vitiligo surgery, and role of dermoscopy in pigmentary disorders. Dr. Rashmi Sarkar spearheaded the workshop on chemical peels giving the participants an idea about the conventional and recent peels as well as their usage to improve the outcome of different amenable pigmentary disorders. Dr. Jagdish Sakhiya, Dr. Bhavesh Swarnkar, and others enthralled the delegates by sharing their knowledge regarding the use of different types of lasers to combat pigmentary disorders. The pitfalls of laser therapy were discussed by Dr. Ishad Agarwal and Dr. Madhuri Agarwal, and her team graciously explained the different modalities (botulinum toxin and fillers), which are in vogue to obtain periorbital rejuvenation. A recent approach to vitiligo surgery, non-cultured melanocyte transplantation, was taken up by the masters of vitiligo surgery including Dr. Somesh Gupta and Dr. Davinder Parsad. Last but not the least, Dr. Sidharth Sonthalia and his team dwelled on one of the latest introductions in the field of dermatology –dermoscopy –and discussed its utility in the realm of pigmentary disorders. All the workshops were followed by live demonstrations, which kept the audience engrossed. The workshops attained astounding success, with huge participation; one of the largest in an Indian conference till date.

Session I: Plenary Session

The conference started with the plenary session on 11th November 2017. Dr. Vijay Setaluri from USA, opened the proceedings by providing an insight to the newer modalities being tried for the management of vitiligo.

He acknowledged the role of genetic engineering as a modality to prevent the occurrence of vitiligo in the coming days

Changes in microscopic RNA (miRNA) may be induced by genetic modification to prevent the occurrence of vitiligo in the progeny

He predicted the association of hypopigmentation and ataxia (future syndrome) which may occur due to Purkinje cell degeneration resulting from ARCN gene defect, which may lead to defective protein transport

Night blindness may occur more frequently in patients with pigmentary disorders due to mutation in the TRPM1 gene resulting in defective calcium homeostasis and melanisation

So, we should be vigilant and look out for ataxia and night blindness in patients suffering from vitiligo.

Prof. Rashmi Sarkar elaborated the variety of interesting cases published in Pigment International, the flagship journal of PDS, and spoke about the growth of this wonderful journal over the years.

She highlighted articles which discussed about the pathogenesis of melasma, especially emphasizing the role of oxidative stress

She brought forth the Hindi version of MELASQoL, which will be a great boon for our patients. Incidentally, the validation has been done by Dr. Sarkar herself

She discussed about the wide plethora of systemic agents being used in melasma, tranexamic acid appears to be our best choice while glutathione seems to lack any credible evidence

Perifollicular depigmentation was proposed as an impending sign of vitiligo under the dermoscope

Best original study, case report, review article, and winners of “Pigmentcross” were awarded attractive prizes.

Dr. Seemal Desai from USA shared his knowledge about cosmetic procedures showing good results on the darker skin.

He stressed on the usage of Q-switched Nd:YAG laser in melasma with 1.6–2 J/cm2 and spot size 5–6 mm to obtain best results

He clarified that recent evidences do not recommend ablative lasers such as carbon dioxide for the treatment of melasma

He also stressed on the usage of peels as first line agents to reduce pigmentation in these patients.

Over the next couple of days, the conference witnessed several wonderful deliberations from esteemed faculties. Some of the notable “take-home messages” have been listed below:

Dr Yogesh Marfatia, President IADVL, gracefully presided over the plenary session. He also highlighted the following observations.

Topical calcineurin inhibitors appear to work best on facial vitiligo, they seem to lack any effect on covered areas

Tacrolimus has been found to enhance the efficacy of excimer laser in vitiligo

Topical decapeptides, calcipotriol, and tacalcitol demonstrate synergistic effect with NBUVB in treating vitiligo

A new therapy was mentioned for vitiligo: dead sea chemotherapy

Basic FGF (Basic fibroblast growth factor) has adjuvant role in treatment of vitiligo.

Dr. Kanika Sahni:

Mentioned about the possible role of simvastatin in the treatment of vitiligo

Prostaglandin analogues such as latanoprost and bimatoprost have a definite role in melanogenesis, proliferation, and maturation of melanocytes

She also mentioned some antioxidants which have been used successfully in vitiligo such as Cucumis melo and L-carnosine.

Dr. Sunil Dogra shared his observations to obtain optimum results from NBUVB phototherapy:

Fixed dosing protocol is recommended (200 J/cm2); the maximum permissible dose being 1500 mJ for body and 300 mJ for face

The optimum frequency is thrice/week, while twice/week is also acceptable

One must wait for 4 months or 18–36 exposures before labelling NBUVB therapy as ineffective. However, for slow responders at least 72 exposures need to be considered

NBUVB therapy should be tapered off gradually, rather than an abrupt stoppage

An interval of 2 hours must be allowed between NBUVB therapy and application of topical tacrolimus.

Dr. K.A. Seetharam dealt with various aspects of hyperpigmentation.

Hyperpigmentation of palms may be caused by cyclophosphamide and doxorubicin

Metformin is one of the causative drugs of vitamin B12 deficiency

Diltiazem has been reported to cause reticulate pigmentation in photoexposed areas

Minocycline is one of the causative drugs of persistent supravenous serpentine hyperpigmentation

Autoimmune progesterone dermatitis, a recently introduced entity, is characterized by recurrent crops of cyclical erythematous macules around each menstrual period and peripheral blood eosinophilia. This condition can be diagnosed by the intradermal progesterone challenge test, which results in exaggeration of skin lesions after 48 hours, if positive

Laser therapy is the treatment of choice for nevus of Hori.

Dr. Trilokraj Tejasvi

Eumelanin is protective against UV induced skin damage; it filters almost twice the amount of UV light compared to pheomelanin

Dark skin has been shown to have an intrinsic sun protection factor (spf) of 13.4; thus, sunscreens are not mandatory for darker skins

Thermal burn may induce the formation of squamous cell carcinoma (SCC), called Kangri ulcer

A new stain has been reported to effectively demonstrate malignant melanoma –May–Grunwald–Giemsa stain.

Dr. Soumya Jagadeesan updated the delegates with recent and updated information regarding a couple of common conditions –idiopathic guttate hypomelanosis (IGH) and lichen sclerosus et atrophicus (LSA)

The newer name for IGH is hypomelanosis of Cummins and Cottel

These lesions do not increase in size; vellus hairs retain pigmentation (dermoscopic finding)

Skin biopsy demonstrates skipped areas of retained melanin in the basal layer

Various local treatment options such as 88% phenol application, cryotherapy, and fractional laser have been reported to be effective

The new name for lichen sclerosus et atrophicus (LSA) is Csillag's disease

Dermoscopy shows white structure-less areas, telangiectasia, and comedo-like openings

Histological hallmark of this condition is loss of elastic fibres in the dermis.

Dr. Rajetha Demishetty spoke about different types of facial pigmentation not responding to conventional therapy.

Many cases of resistant facial pigmentation have been found to be facial acanthosis nigricans after histological examination, so we should proceed with treatment in that direction

Some of the emerging therapies for acanthosis nigricans include myoinositol, N-acetyl cysteine, alpha lipoic acid, glitazone, and leptin.

Dr. Steven Thng, Associate professor, National Skin centre, Singapore shared his knowledge regarding the new management strategies of melasma.

Blue and red light are predisposing factors for the occurrence of melasma, which act by stimulating melanocytes through opsin 3

Iron oxide provides physical protection against visible light, hence, patients should be advised to use cosmetics with iron oxide.

Dr. George Reizner, our esteemed faculty from USA and current director of the International society of Dermatology discussed the newer treatments of melanoma.

Recently, BRAF inhibitors have been recommended for the treatment of melanoma such as vemurafenib and dabrafenib

Some other newer drugs for melanoma include:

Mek inhibitor –trametinib

Anti cltl-4 inhibitor–ipilimumab

PD-1L blocker –nivolumab, pembrolizumab, pidilizumab, and lambrolizumab

Recently, USFDA has approved the use of a melanoma vaccine – TVEC – talimogene laherparepvec.

Dr. Yasmeen Bhat also updated the delegates regarding the recent advances in the field of melanoma.

Malignant melanoma is an uncommon disease in India, which is often underreported

Often melanomas are missed at anatomical sites not visible to the patient

Often these are diagnosed at more advanced stages due to lower suspicion and decreased awareness in patients and their physicians

Its management is still not clear regarding the optimum use and schedule of treatment modalities

More studies are needed to validate these treatment modalities and reach a conclusion regarding their use.

Apart from these deliberations, the controversial issues were discussed in some debate sessions chaired by Dr. Jayesh Kothari and Dr. Rajeev Saxena. Topics for “Short Debates” were carefully selected and eminent speakers and moderators participated in these brainstorming sessions and shared their experiences. A brief summary of presentations and expert comments of the debate sessions are given below:

Debate 1

Lichen planus pigmentosus –can it be treated?

Dr. Zubin Mandlewala versus Dr. Sendhil Kumaran; moderated by Dr. Sunil Dogra.

Inflammatory activity of lichen planus pigmentosus (LPP) must be confirmed histologically in all situations

Stabilization of disease is of prime importance to prevent further spread. If the disease is in active state, one out of many immunomodulators, such as methotrexate, can be used after appropriate laboratory assessment to prevent the further spread of inflammation

Once stability has been achieved (e.g., no new lesions and spread of existing lesions stalled), treating hyperpigmentation is the biggest challenge. The reason it's a challenge, is because of a long interval between the initiation of therapy and remission of hyperpigmentation, which thereby leads to a lot of dropouts as patients may lose hope

Low-dose oral isotretinoin (20 mg/day) is a good therapeutic option in LPP in view of its anti-inflammatory activity

Few studies have demonstrated the effectiveness of low-fluence 1064 Q-Switched Nd:YAG Laser in completely clearing the hyperpigmentation of LPP, but it is always better to do a small test patch first in skin of color

Many studies have favoured the role of tacrolimus (0.1% ointment) in reducing hyperpigmentation, and it should be used regularly in the treatment regimen of LPP

Several other modalities such as oral corticosteroids, dapsone, colchicine, chemical peels, skin lightening topical agents, and microdermabrasion have been tried with varying and conflicting results

Sunscreens are very underutilized in the Indian context and must be used routinely and regularly

There is a relative dearth of studies on LPP; more therapy-based studies/reports need to be published with larger sample sizes to validate the treatment modalities

As it is usually difficult to delineate hyperpigmentary disorders such as LPP, Reihl's melanosis, IMEP both clinically and histologically, an umbrella term “acquired dermal macular pigmentation” has been proposed, which still holds good until further molecular studies differentiates each one of them

In all these cases, counselling patients regarding time taken for hyperpigmentation to disappear is of paramount importance.

Debate 2

Tranexamic acid: is it too much of a good thing?

Dr. Sendhil Kumaran versus Dr. MukeshGirdhar; moderated by Dr. P. Narasimha Rao.

Tranexamic acid is a breakthrough therapy for the treatment of melasma withgood evidence as far as efficacy and side-effect profile of the drug are concerned

It is the most widely studied systemic agent for the treatment of melasma, with most studies showing favorable results

However, the optimum duration of treatment and the most appropriate dosage is yet to be elucidated.

A unique session was organized in this conference called “pearls from practice;” where distinguished speakers discussed about several recently described entities and their salient features:

Dr. Aarti Sarda spoke about serpentine supravenous hyperpigmentation which initially presents as red streaks commonly over the injected veins, followed by hyperpigmentation. The condition is benign and self-limiting, most commonly induced by antineoplastic drugs. Minocycline is also a recently reported causative agent

Dr. Sidharth Sonthalia enlightened the audience about maturational hyperpigmentation, a recently described entity, which presents as diffuse areas of dark brown-black pigmentation on the lateral face, including the malar and zygomatic areas, but unlike PDL, has ill-defined borders blending with the surrounding skin

Dr. Anupam Das discussed about the diagnostic criteria essential to diagnose progressive cribriform and zosteriform hyperpigmentation: (1) uniformly tan cribriform macular pigmentation in a zosteriform distribution, (2) histology showing an increase in basal layer melanin along with complete absence of nevus cells, (3) absence of history of rash, injury, or inflammation to suggest post-inflammatory hyperpigmentation, (4) onset well after birth with gradual extension, and (5) lack of other associated cutaneous or internal abnormalities. In addition, he also mentioned that linear and whorled nevoid hypermelanosis and progressive cribriform and zosteriform hyperpigmentation belong to the same spectrum

Dr. Atotha Kavitha spoke about acquired brachial cutaneous dyschromatosis (ABCD) which presents as asymptomatic, gray-brown patches with an irregular geographical border, interspersed with hypopigmented macules on the dorsal aspect of the distal forearms, bilaterally

Dr. Govind Mittal discussed about acquired bilateral telangiectatic macules, which occur due to characteristic alterations of the macular capillary network and neurosensory atrophy. It is a rare disease of unknown etiology.

Another brainstorming session garnered much interest which focussed on evidence-based management of melasma, chaired by Dr. Manas Chatterjee and Dr. Trilokraj Tejasvi. Several distinguished speakers presented the recent updates on melasma:

Dr. Pooja Arora discussed about newer botanicals recently being tried for melasma. She concluded that all botanicals are at best adjunctive agents, never the first line treatment

Dr. Saumya Panda stressed on different newer mechanisms on melasma. Recently, the vascular mode of pathogenesis has garnered much attention

Dr. Rekha Seth discussed about facial hypermelanosis not responding to conventional treatment. She said many of these cases may be associated with hyperandrogenism. However, this view was debated by the chairpersons who opined that most of these cases are facial acanthosis nigricans

Dr. Indrashis Podder made a lucid presentation discussing the various systemic agents being used to treat melasma. He concluded that tranexamic acid is the most effective and safe systemic agent while there is no credible evidence favoring the use of systemic glutathione

Dr. Sonali Langar discussed about the different peeling agents; glycolic acid peels are most favored to start treatment. Combination peels are slightly better that single peels in the long run.

To summarize, Pigmentarycon 2017 was a grand success, the highlights being enthusiastic participation of delegates in workshops, academically enriching sessions, lively participation of residents in paper presentations and quizzes, packed halls, and phenomenal interactions [Figure 2]. The 4th Pigmentarycon will be held in 2019 in Kolkata with Dr Koushik Lahiri as Organizing Chair, Dr Abhishek De as Organizing Secretary, Dr Rashmi Sarkar as Scientific Chair, and Dr Sandipan Dhar as Scientific Advisor.

Figure 2

Core committee of Pigmentary Disorders Society

N.B. The information provided in the article, is a conference proceeding and not a peer-reviewed information.

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Conflicts of interest

There are no conflicts of interest.