PracticalDermatology

A New Option in Melasma

“The new kid on the block,” for melasma management is oral tranexamic acid, explains Seemal R. Desai, MD. In an interview for DermTube’s coverage of the American Academy of Dermatology Annual Meeting in Washington, DC last month, Dr. Desai addressed recent developments in management of the condition.

“We have case reports, we have large cohort studies and it’s great to talk about this option for melasma, especially for your recalcitrant patients. I will mention that this is FDA off label when treating this condition, it’s not FDA approved for melasma but it can be used orally for those patients who fail topical therapies, who fail rotational algorithms with chemical peels and second line topicals, especially cosmeceuticals and sunscreens.”

The usual dose is 250-500mg twice a day, Dr. Desai says. “Here in the US there’s really only one dose you can get. It’s 650mg. I split that in half and use 325mg in the morning and at night. These patients who get put on tranexamic acid are extensively counseled, I document extensively and I also have the patients sign a consent form, going over the risk of deep venous thrombosis and also to make sure they have no issues, such as thromboembolic phenomenon, coagulation disorders, are pregnant, nursing, smokers, on oral contraceptives,” among other factors. Patients are continued on therapy for several weeks; if improvement is not seen by about 12 to 16 weeks, treatment is discontinued.

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Dr. Desais also discussed the potential role for cysteamine in melasma care. The topical agent is currently being studied for pigmentation concerns, particularly melasma. “We have seen promising results, it’s a topical, it’s non-hydroquinone based, and I’m excited that there are going to be new options for topical treatment of melasma where we don’t necessarily have to rely on hydroquinone long term,” he says.

Finally, Dr. Desais says that multi-pronged approaches offer the best results. “I think the important thing to stress about melasma is that it’s a multimodal disease as we’ve discussed in the past and as we talked a lot about with the expert line up of speakers in a variety of sessions, including therapeutic hotline and melasma pathogenesis,” he says. “Chemical peels are the last thing I discussed, especially combination and sequential chemical peeling using agents like salicylic acid, mandelic acid and glycolic acid, oftentimes in conjunction with each other, to help those patients who have recalcitrant disease.”

Hair Loss in African American Patients: An Unmet Need

The epidemic of hair loss in African American women represents “a huge unmet need for dermatologists,” says Yolanda Lenzy, MD. She spoke at the AAD meeting about challenges and opportunities in managing hair loss.

Dr. Lenzy reviewed data showing that nearly half (47.6 percent) of approximately 6,000 African American women surveyed reported having hair loss at some point in their life. “What was surprising to us is that 80 percent of them stated that they have never seen a doctor to address this issue,” Dr. Lenzy says. “A lot of patients are dealing with hair loss and they don’t know that we, as dermatologists, can be there to help them with this issue.”

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Outreach efforts may help, Dr. Lenzy says. For example, she discussed educating hair stylists about early signs of hair loss and what warrants referral to a board certified dermatologist.

Many dermatologists may undertreat Central Centrifugal Cicatricial Alopecia (CCCA), Dr. Lenzy notes. “Many of us who treat a lot of these patients find that actually treating patients a little more aggressively with oral antibiotics—maybe like doxycycline for three months—actually does a great job at helping to decrease the inflammation.” Topical steroids and minoxidil can be used as a maintenance therapy.

Given that many patients get lost to follow up, Dr. Lenzy stressed “letting patients know that this is a life-long condition which can be managed when treated effectively.”

Recent genetic findings may yield new treatment options, Dr. Lenzy suggests. “Traditionally we thought CCCA was primarily brought on by patient’s hair care practices…Recently work out of South Africa has found that CCCA can be inherited in an autosomal dominant inheritance with partial penetrance. And that led to other studies, most recently a paper published in the New England Journal of Medicine by Amy McMichael and colleagues.” The team found that 35 percent of people with a specific mutation in the PADI3 gene had CCCA, compared to age and sex matched controls. “This is really exciting information helping us to know the pathogenesis of this condition that many of our patients suffer with.”

Considering PRP for African American Patients with Hair Loss

Platelet rich plasma or PRP is a treatment that Brooke A. Jackson, MD has been using with increased frequency to treat hair loss in her practice, following a full discussion of the patient’s diagnosis and the expectations from PRP treatment.

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“I like to explain PRP for my African American patients as CPR for your hair follicles,” Dr. Jackson says. “It is particularly challenging in patients who’ve got scarring alopecia, but it is absolutely something that is an addition to the armamentarium for treating a very tough problem.”

Dr. Jackson does not use microneedling prior to PRP application; instead she uses deep injections, down to bone, with Pro-Nox for analgesia. Patients undergo a series of three treatment sessions followed up with maintenance sessions once or twice per year.

Dr. Jackson notes that more research on the benefits of PRP would be welcome. “Most of these studies have been done in male pattern alopecia,” she observes. But she adds, “Having practiced medicine for a few years and treating a lot of these patients, I know that these patients are desperate, and other therapies have not been homeruns.”

Dr. Jackson also stresses the importance of arriving at an accurate diagnosis for hair loss patients and considering the multifactorial nature of hair loss disorders when devising a treatment plan.