Pigmentation: Abnormal Pigmentation
Birthmarks and other skin pigmentation (coloration) disorders affect many people. Some of the most common problems are listed below. If you think you have one of these pigmentation abnormalities, be sure to see a physician or dermatologist to receive an official diagnosis.
As might be expected, these abnormal skin colorations will appear at birth or just a few weeks after birth. While most birthmarks are non-cancerous, certain birthmarks, described below, can pose health risks.
Nevus of Ota. This birthmark is marked by bluish or grayish discoloration of the face and sometimes the white part of the eye (sclera). The discoloration is caused by increased amounts of the pigment (melanin) and the cells that produce this pigment (melanocytes) in and around the eyes. Patients with this type of birthmark are at a higher risk of developing a melanoma cancer of their eye or central nervous system. In addition, they may develop glaucoma (increased pressures in their eyes). For this reason, they should have regular examinations by a neurologist as well as an ophthalmologist. Potential treatments for this skin discoloration include topical (applied on the skin) bleaching agents, such as hydroquinone, and laser treatments.
Mongolian spots. These birthmarks appear bruised or bluish in color and usually develop on the back or buttocks of babies. This discoloration usually disappears by age 4 and does not need to be treated.
Café-au-lait spots (French for “coffee with milk”). These are light brown-to-dark brown flat spots with smooth or irregular borders. About 10% of the general population has 1 or 2 of these spots, and do not have another disorder that is related to it. However, 6 or more of these spots that are greater than 0.5 cm in diameter can be associated with the genetic disorder neurofibromatosis. These birthmarks may be treated with a laser for cosmetic purposes
Nevi (moles). These spots may be flesh-colored to light-to-dark brown. They may be flat or raised. Although most moles are benign (non-cancerous) and will not cause any problems, some may change and become a skin cancer called a melanoma. For this reason, moles should be watched for bleeding, pain, itch, color, shape, symmetry, even borders, and size changes. A way to check these moles is ABCDE:
- A for asymmetry. If you divide your mole in half, both sides should look the same.
- B for border. The border of your mole should be even.
- C for color. Your mole should be one color. Your mole should not have a variety of colors, especially colors like red or blue.
- D for diameter. Moles less than 0.6 cm in diameter are usually benign. If your mole increases in size, especially if it is greater than 0.6 cm, you should have it checked.
- E for evolving or elevation. If your mole was flat but is now elevated (raised), or if you notice bleeding, crusting, pain, or itching, this should be checked out.
If any of these features change, you should have your moles examined. If you have a personal or family history of melanoma, you should have a regular examination of your moles by a dermatologist.
Vascular birthmarks (from blood vessels)
Macular stains. Macular stains appear anywhere on the body as mild red marks, but they are not elevated. They are the most common type of vascular birthmark. They can come in two forms: “angel kisses,” which may appear on the forehead and eyelids and usually disappear after age two; or “stork bites,” which will appear on the back of the neck and can last into the adult years. Because these marks are often mild and always harmless, they do not need to be treated.
Hemangioma. Hemangiomas are growths that are made up of many tiny blood vessels bunched together. Some hemangiomas are more serious. They are more common in females and premature babies. This birthmark is usually just a small mark on the face, trunk, or extremities (arms and legs). However, in some children, hemangiomas can be large and grow rapidly through the first year of life.
There are 2 types of hemangiomas: strawberry (or superficial), which are slightly raised and can appear anywhere on the body; or cavernous (deep), which are deeper birthmarks marked by a bluish color. Fortunately, most hemangiomas will go away on their own: 50% get better by age 5, 70% by age 7, and 90% by age 9.
If the hemangioma is small and not causing any problems, it can be watched to see if it gets better. Reasons to treat a hemangioma include problems with functions (such as sight, eating, hearing, or defecation), ulceration, bleeding, or pain.
If necessary, hemangiomas can be treated in different ways, each of which carries its own risks. Corticosteroid medication can be injected or taken orally (by mouth). Risks of corticosteroid medication include high blood pressure, high blood sugar, poor growth, or cataracts. Certain hemangiomas can also be treated with lasers to stop them from growing, and heal them. Rare risks associated with laser treatment include ulceration and scarring. In addition, both topical and oral beta blocker medication has been used to treat hemangiomas, but these medications also carry their own risks that should be carefully discussed with your dermatologist. In rare cases, a hemangioma can be removed with surgery.
Port wine stains. A port wine stain appears as a flat pink, red, or purple mark on the face, trunk, arms, or legs, and lasts a lifetime. Port wine stains are caused by abnormal development of blood vessels (capillaries). Over time, the port wine stain may become raised and thickened. Port wine stains on eyelids are thought to pose an increased risk of glaucoma. Physicians have tried many ways to treat port wine stains, including radiation, tattooing, freezing, dermabrasion, or sclerotherapy. Laser therapy is currently the treatment of choice, as it is the only method that destroys capillaries in the skin without causing damage to the rest of the skin. Port wine stains may be seen in certain medical disorders, such as Sturge-Weber Syndrome, whose symptoms include port wine stains on the face, vision problems, convulsions, intellectual disabilties, and perhaps even paralysis; and Klippel-Trenaunay Syndrome, in which a limb has port wine stains, varicose veins, and/or too much bone and soft tissue growth. Both of these syndromes are very rare.
Skin pigmentation disorders
Albinism. Albinism, an inherited disorder, is caused by the absence of the pigment melanin, and results in no pigmentation in the skin, hair, or eyes. Albinos have an abnormal gene that restricts the production of melanin. There is no cure for albinism. People who have this disorder should use a sunscreen at all times because they are much more likely to get sun damage and skin cancer. Albinism can occur in any race, but is most common in Caucasians. In addition, almost all patients with albinism have problems with their eyes, such as decreased vision or abnormal eye movement, and should be seen by an ophthalmologist.
Melasma. Melasma (also known as chloasma) is marked by tan or brown patches that may appear on the forehead, cheeks, upper lip, nose, and chin. Although this condition is often called the "pregnancy mask," men can also develop it. It may also occur in women who are taking birth control pills or postmenopausal estrogen. Melasma may go away after pregnancy, but if it remains, it can be treated with certain prescription creams and some over-the-counter skin care products. In addition, lasers that target pigment can be helpful. Remember to consult your dermatologist for a proper diagnosis of this condition before you choose to treat it yourself. If you have melasma, use a sunscreen at all times because sunlight will make the condition worse.
Pigmentation alteration (change) as a result of skin damage (post-inflammatory hyper- or hyperpigmentation). If you have had a skin infection, blisters, burns, or other trauma to your skin, you may have a decrease or increase of pigmentation in the affected area. This type of alteration is usually not permanent, but may take up to several months to fade or get better. Cosmetics can be used to cover the area. In the case of hyperpigmentation (dark spots), prescription or over-the-counter lightening creams may help decrease the amount of time for the areas to fade. You should also wear sunscreen, as sunlight can prolong the darkness of the areas.
Vitiligo. Vitiligo is a condition where the body’s immune system attacks pigment cells (melanocytes), causing pigment loss. Other immune system diseases associated with vitiligo include diabetes, pernicious anemia, thyroid disease, and Addison’s disease. Vitiligo causes smooth, white skin patches, usually around the mouth and eyes, or on the back of the hands. In some people, these patches can appear all over the body. There is no cure for vitiligo, but there are several treatments, including: topical steroid preparations; topical immunomodulators; topical vitamin D analogs; dyes or psoralens (light-sensitive drugs) used in combination with ultraviolet A (UVA) light treatment; and, the Excimer laser, which delivers targeted ultraviolet B (UVB) light. All treatments may take 6 or more months to be effective.
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