Category Archives: Articles

Skin Hyperpigmentation: A Brief Summary

Skin Hyperpigmentation: A Brief Summary

* by Lama Alkahtani

Hyperpigmentation occurs when there is darkening of an area of skin in the body; it is caused by an increase in dermal and epidermal melanin production and retention.

Hyperpigmentation takes on different forms and could affect an area of the face, arm, neck or back in a diffuse or localized manner. Hyperpigmentation is present in a number of different diseases and conditions. These include some of the following:


  • Patchy Pigmentation also known as chloasma.
  • Could be due to an increase in hormonal exposure as in the case of pregnancy, OCP use, hormonal therapy or an endocrine disease. Increased sun exposure and phototoxic drugs seem to play an important part in Melasma.
  • Key diagnostic features include a characteristic brown to grey hyperpigmentation, typically affects the centrofacial, malar and mandibular areas. 
  • Investigations include skin biopsies and wood lamp examination.
  • Skin biopsies from patients with melasma show an increase in the number of melanocytes and melanin-laden macrophages (melanophages). In addition, later-stage melanocytes may show greater numbers of melanocytes containing melanosomes. Solar elastosis is increased by 83% in patients with melasma, linking back to the important role of cumulative sun exposure in this disease.
  • Management depends on the state of the patient. If the patient is pregnant, first-line therapy includes azelaic acid and sun protection. For non-pregnant patients, management includes azelaic acid, chemical peels, laser therapy cryotherapy, dermabrasion plus sun protection.

 Addison’s disease

  • Adrenal insufficiency causes an increase in the production of ACTH hormone due to the negative feedback on the pituitary gland resulting in an increase in the production of melanin as a result of an increase in the levels of melanocyte stimulating hormone (MSH).
  • Hyperpigmentation is usually seen in high-pressure areas in the body like the elbows and knees. Mucocutaneous hyperpigmentation is noted particularly in the buccal mucosa. Some extent of hyperpigmentation does occur in the hands on the palmar creases and nail beds. In contrast, other skin findings may include vitiligo! (due to the autoimmune association). 


    Cutaneous drug reaction.

    • Certain drugs like tetracycline, amiodarone along with other drugs can cause hyperpigmentation.
    • Tetracycline an antibiotic can cause blue-grey discoloration of exposed skin, teeth discoloration and discoloration of previous scars.
    • Amiodarone can cause blue-grey discoloration of exposed skin, it can also cause yellow discoloration of the eyes.

Post-inflammatory hyperpigmentation.

*Medical student

King Saud University

Riyadh, Saudi Arabia






Do dietary choices have an effect on acne? A search for the illusive answer!

Do dietary choices have an effect on acne? A search for the illusive answer!

*By: Ibrahim Bahabri

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Topics in medicine tend to be shrouded in varying amounts of dissension. Hardly any healthcare provider would dispute that smoking is not beneficial to an individual’s overall health, however, the link of diet and acne remains a much more controversial issue. Although there is yet to be a clear answer in this field, a physician should be familiar with the most recent evidence regarding this topic.

  • A shared limitation:

A recurring issue with most of the studies mentioned in this article, is that the results are self-reported, making them susceptible to inaccurate reporting as people tend to be poor assessors of the ingredients in foods that they consume and the exact amounts.

  • A Rekindling of debate:

It was the general consensus around the mid-2000s that diet has little to no effect on acne based on the systematic reviews at the time (1,2). The search for a diet-acne link was reinvigorated in part because of studies showing acne to have a remarkably lower prevalence (sometimes to the point of being non-existent) among non-westernized populations of different ethnicities and in different areas (3), even in comparison to their ethnically matching more westernized/rural counterparts (4), such as the Canadian Inuits, the Kitavan Islanders of Papua New Guinea, the Aché people of eastern Paraguay and the Dogon of Mali, pointing to a possible environmental trigger to acne, with many of the researchers speculating that diet might be that trigger.

  • Dairy and acne:

Dairy is probably the most researched food group in relation to acne, with several epidemiological studies showing a link between dairy consumption and acne (5,6,7), in addition, a case-control study done 563 patients associated intake of more than 3 weekly portions of milk with moderate to severe acne (8). However, these studies failed to control for other dietary triggers and a randomized controlled trial is yet to be performed to examine this link.

This potential link might be attributed to the presence of mammalian hormones in dairy, this includes Estrogen (9), and Insulin like growth factor (IGF-1) (10).

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  • IGF-1 & High Glycemic Load (GL) foods:

High levels of IGF-1 have been linked to increased prevalence and severity of acne in post adolescent females (11), which is why Insulinogenic high GL foods are a recurring suspect, this would also explain the increased prevalence of acne in western societies with the higher amounts of processed foods. One Dietary trial comparing high and low GL diets found improvement in lesion counts and acne-related endocrine profile (IGF-1 and Free testosterone) in the lower GL group (12). More studies are needed to further examine this link. It is worth noting that chocolate, being an infamous comedogenic food according to popular belief, has not been demonstrated to have any effect on acne, and oily foods in general have very little in terms of evidence supporting comedogenicity (3).

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  • Foods to improve acne:

A few studies have suggested that fiber, Omega-3 fatty acids and zinc might have a positive effect in terms of acne reduction (13), but a strong link and recent evidence are lacking in this area as most of these studies are over 30 years old!

  • Conclusion:

As one expects in areas of great controversy, conclusive evidence is yet to come out regarding this topic. Dairy and high GL foods might be possible triggers, but the correlation remains to be fully established. The best recommendation we can give as physicians is to have the patient do a trial of removal of certain foods for a few weeks at a time and observe if that helps their condition.

*Medical Intern

King Saud University 

Riyadh, Saudi Arabia








Hair Loss: An Overview

Hair Loss; An Overview

By: Ghadah Alhammad*

Hair loss (Alopecia), is one of the most common complaints seen by dermatologists worldwide. It can be associated with a wide variety of medical conditions which can affect the scalp alone or the entire body. There are many types of hair loss with different patterns and causes, this article will be focused on three major types: alopecia areata, androgenic alopecia and telogen effluvium.

Alopecia Areata

Non-scarring sudden acute hair loss, with 75% self-recovery within 2-6 months. It can affect any hair-bearing area, ranging in severity from a solitary localized patch to involvement of the entire scalp “alopecia totalis” or the whole body “alopecia universals”. The etiology of alopecia areata is autoimmune in nature, however, family history and psychological factors also play a major role.

On examination, it manifests as well demarcated non-scarring hairless patch with pathognomonic short stubs called “exclamation point (!)”.

Treatment of alopecia areata is not necessary, as it is benign in many instances, and has high rates of spontaneous remissions. However, management options include; topical or systemic corticosteroids, immunotherapy, anthralin, minoxidil, PUVA and others.

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Androgenic Alopecia (Male and Female Pattern Hair Loss)

Non-scarring androgen dependent loss of scalp hair that can affect both men and women with different patterns. In men, it starts with gradual fronto- parietal recession that usually spares the temporal and occipital areas. However, in females, the frontal hairline is preserved and there is thinning only over the crown area. Androgenic alopecia is extremely common and it is caused by a combination of genetic and hormonal factors. There is no cure for androgenetic alopecia. However, medical treatment including minoxidil can improve the condition but should be used lifelong as discontinuation will result in losing all hair that has been restored. Hair transplant is also an option but should be combined with medical treatment even after transplantation.

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Telogen Effluvium

A common type of non-scarring alopecia where there is diffuse thinning of the hair, rather than defined bald patches. It is a reactive process caused by the body when it goes through a stressful event like; giving birth, crash dieting, major surgery, certain drugs, high fever, severe infection, iron and biotin deficiencies and many other causes. Hair thinning starts usually 3-4 months from the trigger and recovers spontaneously within 6 months. On examination, gentle hair pull test should yield at least two hairs with each pull. This gives a rough estimation of how much hair is being lost. Since it is a self-correcting condition, treatment is limited to reassurance and treating the reversible causes. 

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*Medical student

King Saud Universiy 

Riyadh, Saudi Arabia