Michelle Rodrigues

Background: The 2015 core domain set (CDS) for vitiligo defines outcomes for clinical trials, comprising three essential and four recommended outcome domains/domain items. Periodic reassessment is required to ensure its continued relevance. Objectives: To evaluate the content validity (relevance, comprehensiveness and comprehensibility) of the 2015 vitiligo CDS to inform a consensus-based update as part of a core outcome set, including core outcomes and core measurement instruments. Methods: A roundtable discussion and three surveys reassessed the 2015 vitiligo CDS regarding relevance (≥ 70% agreement for ‘essential’), comprehensiveness (identification of missing domain items) and comprehensibility (clarity of terminology and descriptions). Results: Fifty-three patients with vitiligo (group 1) and 37 experts (36 dermatologists and 1 researcher; group 2) participated. Two previously essential domains (‘Repigmentation’ and ‘Side effects/harms’) were re-endorsed as essential by both groups. ‘Maintenance of gained repigmentation’ was rated essential by patients only. Among previously recommended domains, ‘Quality of life’ was considered essential by both groups, whereas ‘Cosmetic acceptability of repigmentation’ and ‘Cessation of spreading of vitiligo’ were rated essential by patients only. ‘Tolerability/burden of treatment’ was not considered essential by either group. Frequently suggested missing items (outcomes and contextual factors) included psychological impact, treatment session duration, overall treatment duration, treatment costs, patient education and evaluation of associated auto­immune diseases. Proposed updates included refining domain terminology (e.g. vitiligo-specific/health-related quality of life; replacing ‘harms’ with ‘adverse events’) and addressing feasibility-related timeframes. Conclusions: While the 2015 vitiligo CDS retains content validity for several domains, meaningful updates are warranted. These findings will inform the development of a revised and updated CDS.

Vitiligo and melasma frequently coexist, creating a treatment dilemma, since agents effective for one condition can destabilize the other, and no consensus currently exists on safe management. We conducted a scoping literature review (through June 2023) on treatment of patients with concomitant vitiligo and melasma, followed by a two‐round international e‐Delphi survey (22 experts from 14 countries; consensus defined as ≥ 70% agreement) and a final online consensus meeting. Only one study supported the safe use of oral tranexamic acid for melasma in vitiligo patients. Expert consensus favored prioritizing vitiligo treatment, particularly when active, while incorporating patient's preferences. Targeted phototherapy is suitable for localized facial lesions of vitiligo, and non‐facial vitiligo can be treated alongside melasma after covering the face. Topical calcineurin inhibitors, ruxolitinib, tretinoin, corticosteroids, and oral tranexamic acid can be used. Lasers and chemical peels were recommended only with caution by experienced pigment specialists. Until there is enough scientific evidence, hydroquinone would be replaced by other safer cosmetic lightening agents (e.g., niacinamide, ascorbic acid, thiamidol, melasyl), which show comparable efficacy with less theoretical risk. This first international consensus offers practical, patient‐centered guidance for managing coexisting vitiligo and melasma, emphasizing individualized, disease‐activity‐based treatment sequencing. Trial Registration: PROSPERO reference number: RD42023395586 Significance . Depigmenting agents used for melasma inhibit melanogenesis, a mechanism that can further compromise the already‐stressed melanocyte populations characteristic of vitiligo. This consensus gives clinicians an expert‐informed pathway through a common but understudied comorbidity. It also identifies a clear research gap: controlled, mechanistic comparisons of hydroquinone against newer tyrosinase inhibitors specifically in vitiligo‐prone skin are still lacking.

Background: Melasma and post‐inflammatory hyperpigmentation (PIH) are common dermatologic conditions disproportionately affecting individuals with darker skin phototypes, carrying substantial psychosocial burden and reduced quality of life. Emerging evidence increasingly implicates visible light (VL), particularly high energy visible (HEV) light, as a significant but underappreciated driver of disease appearance and progression. Aims and Methods: This narrative review integrates mechanistic and clinical evidence to examine VL's pathogenic role in melasma and PIH, synthesising data on opsin‐mediated melanocyte activation, clinical trial outcomes of VL protective interventions and patient adherence barriers to photoprotection strategies. Results and Discussion: HEV (400–450 nm) activates opsin‐3 on melanocytes, triggering calcium‐dependent signaling that increases melanogenesis in a wavelength‐specific manner. Clinical studies confirm that blue‐violet light induces dose‐dependent hyperpigmentation whereas red light produces none. Notably, pigmentation induced by high‐energy visible (HEV) light can be substantial and persist over time. Protection against VL significantly enhances melasma treatment outcomes: melasma patients using iron oxide–containing sunscreen achieved 15% greater Melasma Area and Severity Index (MASI) improvement, 28% greater lightening on colorimetry and 4% greater histologic reduction in melanin than patients using an otherwise similar UV‐only sunscreen. VL also seems to be involved in PIH, as suggested by a suction blister PIH model in which light‐blocked sites healed without hyperpigmentation by Day 29, unlike ambient light‐exposed sites that showed colorimetric and histologic darkening. Adherence to photoprotection in general remains suboptimal. Fewer than two‐thirds of patients with hyperpigmentation use sunscreen and fewer than 10% reapply appropriately, with worse habits observed in skin of color, the population at greatest risk. Shade incompatibility of tinted formulations represents a key additional barrier to the use of VL‐specific photoprotection. Conclusion: This review establishes VL as a clinically significant driver of melasma and PIH pathogenesis. Standardising VL photoprotection metrics and integrating these into sunscreen development is essential. Incorporating VL protective strategies into treatment recommendations is critical to improving outcomes, particularly in darker skin individuals where disease burden is greatest and treatment most challenging.

Cutaneous aging is a complex biological process that follows a distinct trajectory in skin of color (Fitzpatrick skin types III–VI) compared with lighter skin types. While increased epidermal melanin provides partial photoprotection and often delays the development of rhytides, skin of color is disproportionately affected by pigmentary sequelae of aging, including mottled hyperpigmentation, solar lentigines, melasma, and post-inflammatory hyperpigmentation. These differences are further complicated by gaps in skin of color-specific clinical training, as well as heterogeneity across ethnic subtypes, cultural practices, and social determinants, making management of aging in skin of color uniquely challenging. In this narrative review, we summarize contemporary evidence on the clinical and histologic features of skin of color, key mechanisms underlying intrinsic aging and photoaging, and practical strategies to address common aging concerns in this population. We highlight that long-wavelength UVA (UVA1) and visible light can induce oxidative stress and persistent pigmentation, and that conventional sunscreens may inadequately protect against these wavelengths. Accordingly, broad-spectrum photoprotection, particularly formulations that provide visible-light coverage (e.g., tinted sunscreens with iron oxides), should be emphasized as a cornerstone intervention. We also review topical agents (including retinoids and pigment modulators), oral antioxidants, and procedural therapies, underscoring the need for cautious selection and technique given the higher propensity for post-inflammatory hyperpigmentation and scarring. These strategies are underpinned by the need for individualized counseling, culturally responsive education, and improved skin of color-specific training for dermatologists globally.

This cross‐sectional survey assessed patient acceptability, perceptions and concerns regarding ambient artificial intelligence (AI) scribes in an outpatient dermatology clinic. Most patients reported comfort with AI scribe use (82.1%) despite limited prior exposure, although over half expressed concerns. These findings highlight the need for transparent, patient‐centred implementation strategies and tailored discussions addressing patient concerns.

Background: Fractional CO ₂ laser is an effective treatment for skin rejuvenation, although pigmentary complications remain a clinical consideration. Newer generation fractional CO ₂ laser systems include pulse modes such as HighPulse (HP), which deliver high energy over a shortened dwell time, reducing the duration of energy delivery per microbeam with the aim of limiting thermal diffusion beyond the ablation zone. Methods: We conducted a single‐center retrospective study of 38 patients (Fitzpatrick skin phototypes I–IV) treated with fractional CO ₂ laser using HP mode for facial rejuvenation. Pain scores and adverse events were recorded, stratified by skin type and anesthetic use. Results: Mean pain score was 4.8, with no statistically significant difference between patients who received topical anesthetic (LMX4) and those who did not. Pain scores did not differ significantly across skin phototypes I–IV. Erythema occurred in 50% of patients and edema in 24%, all of which were transient. No cases of blistering, post‐inflammatory hyperpigmentation, or scarring were documented in routine clinical records, although the true incidence may be underestimated. Erythema rates did not differ significantly by anesthetic use. Conclusions: In this preliminary cohort, the HP fractional laser was associated with transient short‐term adverse effects and no documented pigmentary complications among patients with Fitzpatrick skin types I–IV. These findings are descriptive and are not generalizable to Fitzpatrick phototypes V–VI, which were not represented.

Background: Refractory vitiligo encompasses disease unresponsive to conventional medical therapies and phototherapy, presenting a significant clinical challenge. Treatment resistance stems from multiple interconnected mechanisms. While JAK inhibitors represented a paradigm shift by targeting interferon‐γ‐driven pathophysiology, substantial limitations persist. This review aims to evaluate emerging therapeutic strategies beyond JAK inhibitors that address the multifaceted pathophysiology of refractory vitiligo. Methods: This review covers a broad range of studies, including in vitro and in vivo research, with a focus on therapeutic advancements beyond JAK inhibitors for refractory vitiligo. Results: Strategic targeting of immune memory through IL‐15/CD122 blockade, chemokine pathways via CXCL10 and CXCR3 antagonism, epigenetic regulation through BET protein inhibition, and melanocyte regeneration via mTOR modulation, prostaglandin therapy, melanocortin receptor activation, and Wnt pathway agonists represents a paradigm shift from single‐pathway interventions. While most of these novel agents remain in preclinical or early‐phase clinical trials, their mechanistically diverse approaches collectively offer a comprehensive therapeutic framework that addresses both persistent immune‐mediated melanocyte destruction and regenerative insufficiency. Conclusions: Among emerging therapies, IL‐15/CD122 blockade shows particular promise by targeting tissue‐resident memory T cells to potentially achieve durable repigmentation. Concurrently, afamelanotide, now in Phase III trials, offers a complementary regenerative approach by stimulating melanocyte proliferation through melanocortin receptor activation. Together, these mechanistically distinct strategies may overcome the immune memory and stem cell depletion that characterizes treatment‐refractory disease. These advances offer exciting new possibilities for patients with refractory vitiligo.