PracticeUpdate: Dermatology - Winter 2018

EXPERT OPINION 23

scarring in the histologic description; the images in my copy of the article were not of the quality where I could make an accurate assessment. 8 As noted above, in other studies, scar- ring does not seem to be an important histologic feature of IGH. 5-FU, in addi- tion to other chemotherapeutic agents, has been known to cause hyperpig- mentation, possibly by upregulation of melanocyte-stimulating hormone. 9 Maybe it is not necessary to deliver the drug by microneedling – perhaps a trial of a reti- noid combined with topical 5-FU could be performed to determine if obviating proce- dural delivery of the drug could be of value. Think of Winston Churchill when your patient returns with their recalcitrant dis- orders seeking your help. I once asked a terribly pruritic patient why he kept sched- uling appointments when I did not help him at all. He said, “If anyone will figure it out, it’s you. Keep trying something new, and I’ll keep coming back.” Patients love phy- sicians who never, never give up. Disclaimer: First published on Dr. Warren Heymann’s Dermatology Insights and Inquiries website on January 22, 2018. Republished with permission. References 1. Juntongijin P, Laosakul K. Idiopathic guttate hypomelanosis: A review of its etiology, pathogenesis, findings, and treatments. Am J Clin Dermatol 2016;17(4):403-411. 2. Kim SK, Park JY, Hann SK, et al. Hypopigmented keratosis: Is it a hyperkeratotic variant of idiopathic guttate hypomelanosis? Clin Exp Dermatol 2013;38(5):526-529. 3. Kim SK, Kim EH, Kang HY, et al. Comprehensive understanding of idiopathic guttate hypomelanosis: Clinical and histopathological correlation. Int J Dermatol 2010;49(2):162-166. 4. Kakepis M, Havaki S, Katoulis A, et al. Idiopathic guttate hypomelanosis: An electron microscopy study. J Eur Acad Dermatol Venereol 2015;29(7):1435-1438. 5. Gordon JRS, Reed KE, Sebastian KR, Ahmed AM. Excimer light treatment for idiopathic guttate hypomelanosis: A pilot study. Dermatol Surg 2017;43(4):553-557. 6. Laosakul K, Juntongjin P. Efficacy of tip cryosurgery in the treatment of idiopathic guttae hypomelanosis (IGH): A randomized, controlled, evaluator-blinded study. J Dermatolog Treat 2017;28(3):271-275. 7. Arbache S, Roth D, Steiner D, et al. Activation of melanocytes in idiopathic guttate hypomelanosis after 5-fluorouracil infusion using a tattoo machine: Preliminary analysis of a randomized, split-body, single blinded, placebo controlled trial. J Am Acad Dermatol 2018;78(1):212-215. 8. Falabella R, Escobar C, Giraldo N, et al. On the pathogenesis of idiopathic guttate hypomelanosis. J Am Acad Dermatol 1987;16(1 Pt 1):35-44. 9. Co ML, Esteban M. Lingual hyperpigmentation after 5-fluoruracil chemotherapy. BMJ Case Rep 2017;2017. pii: bcr-2017-219806. www.practiceupdate.com/c/65949

" I once asked a terribly pruritic patient why he kept scheduling appointments when I did not help him at all. He said, “If anyone will figure it out, it’s you. Keep trying something new, and I’ll keep coming back.” Patients love physicians who never, never give up. "

This commentary was prompted by recent literature about successful treatments for IGH. Gordon et al performed a longitudinal, split-body controlled, single-blinded pilot study of 6 patients treated with the excimer laser for 12 weeks using a vitiligo protocol. Effectiveness was graded by the blinded observer scale through photographic com- parisons at the end of the study. Lesions that received the excimer treatment had significantly higher repigmentation com- pared with baseline and untreated lesions. 5 A single session of cryosurgery, admin- istered by cotton-tip application for 5 seconds, was administered to 43 lesions,

with 58 assigned as control. At the fourth month, 82% of the treated lesions sig- nificantly demonstrated more than 75% improvement compared with only 2% improvement in the control population. 6 Arbache et al utilized a microneedling technique to deliver 5-fluorouracil (5-FU) in 8 patients with IGH. They found that IGH repigmentation was statistically higher in those treated with 5-FU (75.3% repigmentation) versus placebo (33.8% repigmentation). Their rationale in using 5-FU was based on their prior work noting varying degrees of papillary dermal fibrosis. 7 I reviewed that article they were referring to – there was no mention of

VOL. 2 • NO. 3 • 2018