Derm Dilemma
by Jordan Pilkington
MD Candidate , Class of 2025 , University of Arkansas for Medical Sciences , Little Rock , Ark .
This 60-year-old post-menopausal woman presents with mildly atrophic , mottled hyper- and hypopigmented patches with telangiectasias located symmetrically on the anterolateral neck . The immediate submental area is spared . The area is asymptomatic and has slowly developed over the past 2-3 years . The patient finds these changes cosmetically objectionable and is interested in treatment options .
What is an appropriate intervention for this patient ?
A . Use of intense pulsed light or pulsed dye laser therapy in addition to daily sunscreen .
B . Punch biopsy of the affected area in order to narrow the differential diagnosis , as the cutaneous changes are not distinctive enough to allow definitive diagnosis based upon clinical features alone .
C . Extended use of oral niacinamide 500mg BID . Niacinamide is a mildly anti-inflammatory form of vitamin B3 that has also been shown to be somewhat UV protective .
D . Serial use of microdermabrasion over the affected area .
E . Narrowband UVB ( 311nm ) light therapy twice weekly for approximately 3 months .
Answer : A
The clinical findings are highly characteristic of Poikiloderma of Civatte ( PC ). PC commonly occurs in middle-aged and older women , and develops symmetrically in areas of chronic sun exposure , particularly the anterolateral neck and “ V ” area of the upper chest . The submentum , shaded by the chin , is typically spared . PC is characterized by reticulated hyperpigmentation , hypopigmentation , and telangiectatic erythema , as well as mild epidermal and papillary dermal atrophy (“ poikiloderma ”). Chronic sun exposure along with lighter Fitzpatrick skin types , decreasing estrogen levels , and potentially photosensitizing toiletry products are precipitating factors , and there may be a genetic predisposition as well . PC is a clinical diagnosis , and skin biopsy is rarely necessary . PC differs from other chronic dyschromias in that it is often restricted to the anterolateral neck and upper chest .
PC is often considered unsightly by patients , but currently available treatment options are suboptimal . Photoprotective measures including daily sunscreen use may slow progression , and perfumed toiletries should be avoided in affected areas . Topical therapies include hydroquinone , retinoid , or alpha-hydroxy acid containing preparations . Pulsed dye laser , intense pulsed light therapy , and non-ablative fractional lasers remain the most potentially effective interventions .
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34 • The Journal of the Arkansas Medical Society www . ArkMed . org