So often when looking at skin damage or skin disorders, hyperpigmentation, dark spots, age spots, sun damage, and excessive melanin production is a main focus. Let’s look at the opposite of hyperpigmentation: hypopigmentation.
WHAT IS HYPOPIGMENTATION?
Hypopigmentation, or depigmentation of the skin, manifests as patches of skin that are lighter than the overall skin tone. Melanin is a chemical that the body produces to give skin its coloring. When the skin is not producing enough melanin, white patches form. Understanding what is causing this condition is important when determining treatment.
In most cases, the loss of melanin is partial, although some can experience a total loss of melanin. Hypopigmentation is typically caused by trauma to the skin. Genetic conditions, as well as severe environmental conditions, can cause a disruption in melanin production. Not all cases of hypopigmentation result from trauma, but most do. Anyone can be affected by this skin condition, though it is more common in darker complexions.
Again, hypopigmentation is usually the result of some sort of trauma. Examples include acne, cuts, scrapes, lesions, infections (like chickenpox), burns, and blisters. Procedure related trauma could cause hypopigmentation. If chemical peels, cryotherapthy, microdermabrasion, dermabrasion, or laser treatments are administered incorrectly, they can cause trauma, resulting in white patches.
INFLAMMATORY DISEASE-RELATED HYPOPIGMENTATION
Inflammatory skin diseases can be a culprit of hypopigmentation. Seborrheic dermatitis is a skin disease where the skin is covered in red scaly patches. The skin tends to be oilier with this condition. Irritant contact dermatitis is when the skin is injured by friction, overexposure to water, environmental factors like cold, or chemicals such as detergents and solvents. It is typically confined to the area that was directly exposed to the irritant, but with prolonged exposure it can spread. Allergic contact dermatitis is just that, an allergic reaction. It is not commonly caused by an internal source, like food.
Atopic dermatitis is a form of eczema that causes dry, scaly rashes that can be uncomfortable and itchy. Chronic cases of atopic dermatitis can create changes in skin color.
Vitiligo is a disease where melanocytes are actually destroyed. The cause of vitiligo is unknown, making treatment of this condition difficult. Experts believe it is an autoimmune disorder, where the body’s immune system mistakenly attacks certain cells within the body. Most people develop the disease before the age of 40. It has a genetic component and has been linked to thyroid dysfunction. There is no known way to prevent or cure vitiligo.
Albinism is a disorder that is caused by an absence of the enzyme tyrosinase, which produces melanin. In place of this enzyme is a gene that inhibits the production of melanin. Due to the total lack of melanin, people with this disease are more prone to contract skin cancer. Albinism is inherited and genetic. In some people, melanin production can increase with age. Albinism not only affects the skin in a dramatic way but can also affect a person’s vision. One in 70 people are thought to carry this gene. Because this disease is genetic, there is no cure.
Pityriasis alba is a common skin condition in children. It can create ill-defined scaly patches. When these lesions subside, it leaves a hypopigmented area that will slowly return to normal. It commonly occurs on the face, most notably the cheeks.
Tinea versicolor is caused by yeast living on the skin. When this yeast (sometimes labeled as a fungal infection) gets out of control, it will cause tinea versicolor. It is very common in subtropical and tropical areas of the world. People who live in tropical areas may have this condition year round. The spots can be lighter than the surrounding skin and appear anywhere on the body. They are much more noticeable when a person is tan. They tend to disappear when the temperature drops and reappear in spring and summer, when the air is humid and hot. Some causes of the yeast overgrowth are excessive sweating, hot, humid air, oily skin, and a weakened immune system.
Other skin conditions that can cause hypopigmentation include leprosy, leucism, Angelman syndrome, and idiopathic guttate hypomelanosis.
REDUCING THE RISK
Unfortunately, there is no way to completely prevent hypopigmentation. But, through preventative measures, the risk can be reduced. Clients should be encouraged to take good care of their skin on a daily basis, by cleansing, exfoliating, and moisturizing. Bruises, cuts, and scrapes should always be treated with care. Leaving acne to heal properly will diminish the chance of any type of scarring. Emphasize that clients must not pick. An SPF of 30 or higher should be used daily. If there is a risk of genetic hypopigmentation, clients should seek proper treatment at first sight.
While there are many types of hypopigmentation, recognizing it can be tricky. When doing a client consultation, ask detailed questions beyond the intake form. For example, when the client writes what they would like to improve about their skin, if light or white spots are bothersome, ask more questions. Do they sunbath regularly? When did the light patches first appear? Have they ever seen a doctor for this specific condition? And, what types of deep peels or laser treatments have they had in the past? Knowing more will help determine the best treatment options. If unsure, say so. Some forms of hypopigmentation are incurable; if you misdiagnose what a client may have, you could make it worse.
Now, there are treatment options for some of the skin disorders that cause hypopigmentation. Corticosteroid creams are the first try at treating vitiligo. Since vitiligo is not well understood, the results can be unpredictable. It may or may not work, but under close supervision it can improve the condition. Skin lighteners have also been used to unify the lighter skin. If the client has this as a goal, using products with ingredients such as kojic acid, azelaic acid, or bearberry extract can be effective. Ultraviolet therapy and phototherapy are effective against vitiligo. It treats the depigmented areas with a narrowband UVB light. Laser treatments can cause hypopigmentation, but have cured it, as well. The type of laser treatment needed will depend on the cause. Antifungal creams can be effective against tinea versicolor. There have been suggestions that those experiencing hypopigmentation should discontinue the use of benzoyl peroxide and any type of strong cortisone.
Hypopigmentation is very common and widely accepted. Many clients learn to just live with it. There is beauty in all of us and our flaws make us unique. Still, understanding what hypopigmentation is, its causes, how to identify it, and methods for treatment and reducing the risk of developing it can all be instrumental in interacting with clients who may suffer from the condition.
Courtney La Marine has been a licensed aesthetician since 2006 and continues to grow and learn in the skin care industry every day. She is based in Denver, Colorado and owns Clove Studios. She has worked with many skin care and wax lines as head of education. Working with top resort spas and destination hotels has allowed her create a unique approach to how skin care is presented to clients. Not only does La Marine have a skin care studio in Denver, she also takes clients in Uvita, Costa Rica, and researches new ingredients for a fresh take on skin care. La Marine is a result-driven professional who loves what she does, creates unique treatments for each client, and wants to give clients the skin they deserve. Staying current with new trends, innovative ingredients, and the latest technologies are of the upmost importance to her.
As if our pregnant clients don’t have enough changes happening during pregnancy – it is unlikely their skin is going to let them sail through the next several months without any surprises. Many women notice their freckles and moles may look darker, as well as odd shaped gray-brown, tan, or dark brown patches appearing on places like the forehead, upper lip, cheeks, chin, and bridge of nose. Pigmentation can also occur on the forearms and neck, if exposed to the sun.
Rather than the desired pregnancy glow, many experience “pregnancy mask,” more commonly known as melasma. While this is a common problem during pregnancy, it can be embarrassing and frustrating.
WHY DOES MELASMA OCCUR DURING PREGNANCY?
During pregnancy, melasma is referred to as chloasma – a female skin disorder connected to hormone changes. Extensive hormonal changes are flooding a woman’s body in preparation for a baby. Cholasma is connected to the elevation of progesterone and estrogen hormones, which in turn causes increased melanin production.
Affecting a whopping 50% to 70% of women, the exact cause is not clear. Many factors have been cited in scientific literature, including excessive sunlight (ultraviolet rays), genetics, stress, thyroid disease, and certain drugs. And, as mentioned, progesterone and estrogen are also associated with the condition, which means oral contraceptives, hormone therapy, and, of course, pregnancy can trigger melasma.
HOW CAN WE HELP?
So, how can professionals help pregnant clients during this exciting but vulnerable time? Arm them with knowledge about prevention.
Mid to high SPF sunscreen needs to be worn religiously, even while in the car. The ingredients oxybenzone and avobenzone should be avoided because of possible hormone disruption.1,2 Zinc and titanium dioxide-based sunscreens should be suggested instead. To prevent against melasma, a sunscreen that blocks not only the sun’s rays, but also its light and heat is needed. Choosing a non-chemical, blocking sunscreen stops different wavelengths and light from coming through.
Wearing sunglasses with polarized protection should also be recommended. Ultraviolet rays stimulate the pituitary gland through the retina of the eyes, simulating more melanocytes.3 All wavelengths of sunlight can jumpstart melasma, explains Dr. Lance Setterfield in The Concise Guide to Microneedling.
Use natural tyrosinase inhibitors and lighteners to help prevent and correct hyperpigmentation. These ingredients will also help post-pregnancy to speed up lightening. Look for hydroquinone-free alternatives like:
It is best to avoid salicylic acid, hydroquinone, and retinoids during pregnancy and while breastfeeding because there has not been substantial studies on their effects during pregnancy.
Facial waxing should be approached with caution on pregnant clients. This can increase the risk of pigmentation in general. There is especially increased risk with sun exposure.
Pregnant clients should also take precautions from overheating. It has been found that temperature regulates how much melanin our bodies produce. Heat from the sun, cooking, saunas, hot flashes, and even blow dryers can trigger pigmentation.
OFFER PREGNANCY-SAFE FACIAL TREATMENTS
Don’t let pregnancy scare you away from treating this group of well deserving clients. Instead, get creative with your backbar full of skin lightening ingredients listed above and give them a treatment that is going to give them the pregnancy glow they deserve.
For these treatments to be successful, it is crucial for clients to follow your suggested homecare and tips on how to keep their melanocytes calm and happy. Here are a few facial ideas for pregnant clients.
Deep Cleansing: For problematic skin, try a deep cleansing treatment. This generally includes exfoliation, extraction of blemishes, and massage, followed by a healing clay or charcoal mask. Have a hydra-infusion machine? This would be a great add-on to this service.
Oxygen Facials: This facial introduces ingredients into the skin through a pressurized stream of steam. Incorporate hyaluronic acid for skin-plumping vitamins, botanical extracts, and antioxidants. This treatment is great for expecting moms with dull or dry skin.
Exfoliating Facial: Our expecting clients can tend to be more sensitive during this time. Take this into consideration and bypass exfoliation with microdermabrasion. Instead, get those cells turned over with gentle facial scrubs and pregnancy-safe alpha hydroxy acids like glycolic, mandelic, or lactic acids.
With melasma being one of the most difficult conditions to treat, be careful not to make any promises to your client about being able to completely eliminate it. Still, reassure them that the majority of cases lighten or resolve themselves within six to 12 months after giving birth.
“Hormones continuously trigger these dark spots,” explains Amy Takken with Masterpiece Skin Restoration.5 So, your client will get the best results if you delay treatment until after pregnancy and breastfeeding. Those prone to melasma and hyperpigmentation will always be more likely to have recurrences throughout their life. Because of this, melanin suppressants must be used daily, all year-round, during and after pregnancy. These recommendations along with treatments from you, their aesthetician, will make a huge difference.
1 Shanehsaz, Siavash M. “Efficacy of licorice extracts in the treatment of melasma: Randomized, double-blinded and placebocontrolled clinical trial.” Journal of Cosmetology & Trichology. https://www.omicsonline.org/proceedings/efficacy-of-licorice-extracts-in-the-treatment-of-melasma-randomized-doubleblinded-and-placebocontrolled-clinical-trial-61454.html.
2 Yang, Changwon, Whasun Lim, Fuller W. Bazer, and Gwonhwa Song. “Avobenzone suppresses proliferative activity of human trophoblast cells and induces apoptosis mediated by mitochondrial disruption.” Reproductive Toxicology 81 (2018): 50-57.
3 Lanning, Cassandra. “The Story of the Melanocyte.” The Renegade Esthetician. 2016. https://www.therenegadeesthetician.com/single-post/2016/05/23/The-Story-of-the-Melanocyte.
4 Setterfield, Lance. The Concise Guide to Dermal Needling. Expanded Medical Edition. Victoria, BC: Acacia Dermacare, 2013. https://www.needlingguide.com/product/the-concise-guide-to-dermal-needling.
5 Takken, Amy. “Melasma Treatment | 11 Things That Really Work!” Masterpiece Skin Restoration. 2019. https://masterpieceskinrestoration.com/blog/melasma-treatment.
6 “Melasma.” American Academy of Dermatology Association. https://www.aad.org/public/diseases/color-problems/melasma.
7 “Unmasking the causes and treatments of melasma.” Harvard Health Publishing. 2018. https://www.health.harvard.edu/womens-health/unmasking-the-causes-and-treatments-of-melasma.
8 Draelos, Z., A. Dahl, M. Yatskayer, N. Chen, Y. Krol, C. Oresajo. “Dyspigmentation, skin physiology, and a novel approach to skin lightening.” Journal of Cosmetic Dermatology 12, 4 (2013): 247-53. https://www.ncbi.nlm.nih.gov/pubmed/24305422.
9 Lyford, Willis Hughes. “Melasma Treatment & Management.” Medscape. 2018. https://emedicine.medscape.com/article/1068640-treatment.
Jessica White Slorah is a licensed master aesthetician who practices solo and is the owner of illume Skin Care in Holladay, Utah. She was voted Favorite Licensed Master Aesthetician in DERMASCOPE’s 2019 Aestheticians’ Choice Awards.
Hyperpigmentation is the result of an over-proliferation of melanin within a specific area or region of the body. Another name for hyperpigmentation is dyschromia, which refers to the condition related to the darkening of the skin. Ultraviolet radiation is the most well-known extrinsic factor that regulates melanogenesis, which is the skin’s response to protect from the harmful rays of the sun. Hyperpigmentation, or dyschromia, is a very common skin condition that occurs in women and men on different areas of the face and body and occurs especially in individuals with darker skin tones.
Determining the causes, types, and severity of hyperpigmentation increases the potential for long-term, successful treatment of this problematic skin disorder. One of the best ways to detect skin dyschromia types is with the use of a Wood’s Lamp or diagnostic tool, as the florescent light magnifies areas of abnormal cell development. Until it is illuminated in the diagnostic tool, clients may never see for themselves the degree of sun damage or hormonal pigmentation occurring in their skin. This powerful tool gives professionals the ability to look behind, or through, epidermal layers, revealing more about the skin’s true condition than traditional magnifying lamp analysis. When using a diagnostic tool, ask the client to lift their hair away from the face to allow inspection of the hairline out to the ears, as well.
FITZPATRICK CLASSIFICATION SCALE
In the aesthetic industry, skin color is classified on the Fitzpatrick classification scale, which was developed in 1975 by Harvard Medical School dermatologist, Thomas Fitzpatrick, M.D., PhD. This scale classifies a person’s complexion and their tolerance of sunlight and is comprised of a grading system from I to VI, with very pale skin at number I and people with darker skin tones (Hispanics, Latinos, Africans, African-Americans, Caribbeans, Native Americans, Pacific Islanders, East Indians, Pakistanis, Eskimos, and Asians) ranging from III to VI.
Finding effective treatment for hyperpigmentation for clients with a higher Fitzpatrick’s grade is one of the more common complaints. Many aestheticians are hesitant to treat skin of color because of their higher risk of an inflammatory response. However, it is possible to utilize all of the popular modalities for treating hyperpigmentation on clients with darker skin, with an understanding of the causes of hyperpigmentation in ethnic skin and consideration of how to treat it without creating it.
Along with hyperpigmentation, professionals may also see a loss of pigment in a diagnostic tool that appear as white spots, which could be vitiligo, an auto-immune disorder. It is also possible to see scars where pigment cells are completely lost and look abnormally white, such as in the case of CO2 laser resurfacing or where dermabrasion has been performed on the skin. Disruption to normal melanogenesis can also create the opposite effect: the loss of skin color, or hypopigmentation. Hypopigmenation is caused by melanin depletion or a decrease in the amino acid tyrosine.
TYPES AND CAUSES OF HYPERPIGMENTATION
Hyperpigmentation is usually seen as either flat or raised, brown to black spots, freckles, moles, and macules and presents itself in three major categories.
Post-Inflammatory Hyperpigmentation (PIH)
PIH occurs as a result of an injury response in the skin, as in the case of an acne lesion that breaks the skin or leaves a demarcation that takes a period of time to fade on its own. Genetic inflammatory conditions, such as psoriasis, eczema, and lichen planus, may result in PIH. Allergic reactions, trauma to the skin from surgery, and incorrect use of microdermabrasion, lasers, and chemical peels that stimulate inflammation-causing melanocytes to produce more pigment in the skin may also lead to a post-inflammatory response.
Burns, friction, and even certain professional skin care products and treatments may be the cause of PIH, as well. The positive side to PIH is that it generally responds well to treatment, which helps to resolve or fade it over time. Strict compliance to sun protection of the traumatized area must be observed.
Visual indicators of melasma, a hormonally-induced pigmentation, include light to dark brown, symmetrical patches with defined edges. Up to 90 percent of women with dark hair and skin may encounter some degree of pigmentation during pregnancy. Considered to be one of the earliest signs of pregnancy, it is also known as the mask of pregnancy or chloasma. Melasma generally occurs on the forehead, temples, cheeks, nose, upper lip, and chin and sometimes on the neck. Its pattern is sometimes referred to as a butterfly mask. This discoloration is usually due to pregnancy, birth control pills, changes in estrogen, estradiol, and progesterone levels, thyroid dysfunction, and, to some extent, hormonal imbalance caused by heightened stress.
Patches of melanin may be an indication of a hormonal imbalance, inducing a buildup of pigment in the dermal-epidermal junction. In some individuals, melasma may be a condition that develops from the combination of birth control pills exacerbated by exposure to the sun. While melasma affects all races, it occurs most often in Fitzpatrick skin types III, IV, and V (brown or olive skin tones).
Ultraviolet light can damage skin, producing burns, premature skin aging, hyperpigmentation, wrinkling, abnormal cell development, and skin cancer. Just about everyone has, at some point, been caught out in the sun unprepared and suffered a sunburn. For those who grew up when a tan was in fashion and very little was known about the actual, long-term, damaging effects of the sun, deliberate, repeat, unprotected sun exposure may have taken place. Many do not begin to see the visible, long-term effects until they wake up one morning and wonder where the discoloration, keratosis, and wrinkles suddenly came from. Excessive exposure to sun rays is the most common reason people develop hyperpigmentation. If a client has developed hyperpigmentation in their early 30s, remember that the process began while in their teens.
Freckles are an inherited characteristic of hyperpigmentation. Also known as sunspots, freckles are small, flat, brown marks arising on the face and other sun-exposed areas that become darker with continuous sun exposure. They are most often seen in fair-skinned individuals, especially those with red hair, but they sometimes affect darker skin types, as well. The medical term for this type of freckle is ephilis (plural ephilides). The color of ephilides is due to localized accumulations of melanin diffused into the surrounding keratinocytes. Ephilides do not produce much melanin during the winter months, but produce more when exposed to the sun. Ephilides are more prominent in summer, but fade considerably or disappear in winter as the keratinocytes are replaced by new cells. As the individual ages, this type of freckle generally fades naturally and becomes less noticeable.
Solar lentigines, commonly known as liver or age spots, are found on 90 percent of light-skinned individuals over the age of 60. However, they are not directly caused by the aging process, but rather by ultraviolet exposure. A solar lentigo (plural solar lentigines), also known as a sun-induced senile lentigo, is a dark, hyperpigmented lesion caused by natural or artificial ultraviolet light. Solar lentigines may be single or multiple and are benign growths with no risk for the development of skin cancer. Solar lentigines are caused by a sudden and remarkable increase in pigment cells located in the superficial layers of the skin. Lesions sometimes develop into highly irregular shapes, their color might change, or they may gain in thickness.
IDENTIFYING SKIN CANCER
When performing a skin analysis and identifying hyperpigmented lesions, it is critically important to also be able to identify the different types of skin cancer. Skin care professionals do not diagnose, but can make recommendations to clients about abnormal cell growths that may be observed and encourage them to have these checked out by a dermatologist.
It is estimated that approximately 9,500 people in the United States are diagnosed with skin cancer every day. Since more than 5.4 million cases of non-melanoma skin cancer occur in over 3.3 million people each year, it makes sense to always be on the lookout for abnormal cellular changes in clients’ skin and to make them aware of what is observed.
Moles, brown spots, and growths on the skin are usually harmless, but not always. Anyone who has more than a hundred moles is at a greater risk for melanoma. The first signs of skin cancer can appear in one or more atypical moles. That is why it is so important to examine the skin regularly and be able to recognize any changes in moles on the face and body.
Hyperpigmentation is a very difficult skin condition to treat because of the variables involved and may take several months of intensive in-clinic and homecare treatments to see significant lightening results. With a consistent treatment regimen, the gradual fading of discolored areas will be noticeable.
Exfoliating enzymes, acids, chemical peels, and treatments, such as dermaplaning and microdermabrasion, help to remove already existing, abnormal pigmented cells, which aids in the lightening of darker lesions.
Many of the ingredients that are used to treat hyperpigmentation work by creating an exfoliation and can be irritating to the skin. Over-irritation of darker skin can actually make hyperpigmentation worse because it triggers the melanin response mechanism. This does not mean that professionals cannot use these ingredients on darker skin, but rather than use a lower percentage of the active ingredient and gradually, over time, increase that percentage so that the skin itself becomes conditioned and does not hyper-react.
Analyzing and reviewing a complete medical history, as well as a client’s past cosmetic history, will help in determining if there is any predisposition of sensitivity. This information is imperative in helping to choose the appropriate peel treatment. Inhibiting pigment production before a professional treatment will also help to reduce a possible inflammatory response. Product ingredients or medicines that are tyrosinase inhibitors help to slow down melanocyte cell activity and prevent the over-production of pigment. Tyrosinase is the copper-containing enzyme present in plant and animal tissues that catalyzes the production of melanin and is found inside melanosomes.
Fading skin discoloration can be very challenging. Bound to be a long-term effort, a client’s cooperation in taking responsibility of their skin care homework, as well as the application of sun protection, is mandatory if professionals are going to promise results. Daily application of sunscreen is essential in the treatment of hyperpigmented skin issues. It is also imperative to address the importance of suppressing the further production of melanin to prevent a reoccurrence. All it takes is one sun exposure and clients can repigment quickly. Recommend a physical sunscreen with ingredients such as zinc oxide or titanium dioxide, which reflect the light and are less likely to cause irritation of the skin, after a professional peel treatment as opposed to a chemical sunscreen.
Master aesthetician Lyn Ross founded Institut’ DERMed Spa, one of the most respected names in the skin care industry, in 1989. The Institut’ DERMed Spa is a 3,000-square-foot facility located in Atlanta, Georgia., with 11 treatment rooms offering the latest medi-clinical aesthetic technologies to assure quality solutions that provide the ultimate in relaxation and results for skin health and beauty. Ross was an originator of the cosmeceutical product and treatment concept Institut’ DERMed Clinical Skincare, which is now widely dispensed in prestigious salon spas, medical spas, and physicians’ offices. Ross founded the Institut’ DERMed college of Advanced Aesthetics in 1995 after years of providing patient support for the medical community to teach aestheticians, nurses, and physicians the specialized skin care and makeup techniques she developed working side by side with doctors to help patients recover after surgery.
The key to treating all types of pigmentation is early intervention. If nothing is done and the excess melanin leaches into the dermis, it becomes dermal pigmentation. The deeper the pigment, the more difficult it is to treat. It is important to be honest and realistic about what results clients can expect from clinical treatments and what level of commitment to homecare is required to maintain the results. The topical and clinical treatments are basically the same (progressive, not aggressive), except the results will vary due to the cause, the healing ability of the skin, and heredity. Let’s get started…
Determine The Cause
There are five main instances that trigger the formation of hyperpigmentation:
Medications and Medical Conditions
Hyperpigmentation due to medication is fairly common (10 to 20 percent) and is called medication-induced pigmentation (MIP). Hyperpigmentation can be the direct result of the medication or can result from the combination of the drug with a triggering effect – usually the sun. Some medications cause an allergic reaction, which appear as red swollen patches that sometimes blister. With each dose of medication, the lesion reoccurs in the same place and new lesions may form. These lesions can leave a dark spot that will slowly fade to a brown or purple color. When a medication causes hyperpigmentation without the sun, it usually appears on the face, often around the mouth area, although it can affect other parts of the body, as well.
Being in the sun when taking certain medications can result in phototoxic and photoallergic reactions. Many clients do not realize that medication can cause hyperpigmentation. Ask clients every visit if they started new medications. If starting a new medication coincides with their new hyperpigmentation, advise the client to check with their medical provider as soon as possible to see if they can use a different medication. Many clients use contraception, which mimics the hormones of pregnancy by maintaining a constant level of estrogen and progesterone so that ovulation stops. These hormones can trigger hyperpigmentation. Usually, when the contraception medication is discontinued, the hyperpigmentation may fade away, but not always. Medications that treat menopause can also cause hyperpigmentation. While trying to fade it, wearing and reapplying sunscreen is mandatory because the dark spots that are a result of medication will get darker with sun exposure.
The main drugs implicated in causing skin pigmentation are nonsteroidal anti-inflammatory drugs, antimalarials, amiodarone, cytotoxic drugs, tetracyclines, heavy metals, and psychotropic drugs. Drugs.com is a good resource to check to see if medications might cause hyperpigmentation or photosensitivity (which could lead to hyperpigmentation). Even over-the-counter medications can cause hyperpigmentation. Be aware that diurectics and painkillers can also cause hyperpigmentation because they contain hormones that trigger melanin production in the skin.
Certain medical conditions can also result in hyperpigmentation of the skin. These include Addison’s disease, hyperthyroidism, and hemochromatosis.
Skin Care Treatments and Protocols
Skin can be more sensitive to the sun because of topical skin care products and procedures that heat up or remove the outer layer of skin. Procedures include waxing, peels, IPL, laser, microdermabrasion, and more. Alpha and beta hydroxy acids, retinol, and benzoyl peroxide are some of the topicals that can make skin more sensitive to the sun and may result in hyperpigmentation. For some people, some ingredients in sunscreens can cause phototoxic or photoallergic reactions such as para-aminobenzoic acid, cinnamates, benzophenones, and salicylates.
Essential oils, citrus fruits, and fragrances can be photosensitizing, as well. It is best to not expose skin to sun for 12 hours after application of an essential oil. If a reaction occurs, clients should get out of the sun and bathe the affected area with a carrier oil or full-fat milk. Most fragrances do not have an ingredient list (proprietary), so it is hard to know if they contain troublesome ingredients. Some known photosensitizing ingredients that are in fragrances include furocoumarins, phenylacetaldehyde, musk ambrette, and 6-methylcoumarin.
Inflammation Resulting from an Injury or Repeated Rubbing or Friction
Post-inflammatory hyperpigmentation (PIH) results from inflammatory skin conditions – such as acne, folliculitis, lichen planus, herpes zoster, dermatitis, or eczema – trauma, chemicals, skin products, or even an inflammatory procedure (laser, cauterization, and others). PIH is often called a stain and tends to appear pink on lighter skin tones and brown on darker skin tones. It can take a very long time to heal and sometimes never heals completely.
Physical injury to the skin can also leave behind dark marks after healing. These include scratches, burns, and pimples – especially those that have been squeezed. Repeated friction on the skin day after day in the same spot can cause darkening of the skin in the affected area. Treatment and homecare should focus on healing and brightening ingredients.
Melasma is easy to identify, since it presents as brown patches found in a characteristic, almost symmetrical, pattern on the face, usually on the forehead, cheeks, bridge of nose, chin, or upper lip. There is no definitive reason as to why women develop melasma. It tends to occur in women who are pregnant or using contraception and who live in sunny climates. However, it may occur in the absence of these factors and is sometimes seen in men.
Melasma is a puzzle that no one has completely figured out. It is thought to be estrogen driven, but postmenopausal women given progesterone develop melasma, while those given only estrogen do not. Since melasma develops because of internal hormonal changes, it is much harder to treat. Often what works for one person does not work for another. There is no cure for melasma, but it can be managed. Skin lighteners such as hydroquinone can help control the amount of melanin that is being produced. Skin brighteners such as vitamin C can help lessen the appearance of melasma.
When treating skin for hyperpigmentation, remember that the melanocytes responded to injury (or perceived injury) by making more melanin, so it is important to be progressive and not aggressive. Being too aggressive with treatments can do just the opposite of what a professional is trying to achieve. If the skin has been injured, allow healing time. Start with a homecare regimen of healing products, slowly adding brightening, lightening, peels, retinoids, and so forth. The same is true for treatments: be progressive, not aggressive.
The closer to the surface of the skin the hyperpigmentation is located, the easier it will be to eliminate. Clinical treatments for hyperpigmentation are listed below in order of the least aggressive to the most aggressive. They can be used on their own or sometimes in combination with each other:
Enzymes are among the most gentle ways to remove the outside layer of the skin. Since the upper layer of the skin is mostly dead skin cells that contain keratin protein, the enzymes work by specifically breaking down or digesting the keratin protein, resulting in smooth skin.
Dermaplaning is a beneficial exfoliation treatment for all skin colors, with no down time. A sterile blade is used to gently remove peach fuzz and dead skin cells (along with hyperpigmentation in them) from the epidermis. This buildup of dead skin and hair can make skin look dull and flaky and can even cause breakouts because of clogged pores and hair follicles. Removing this buildup will also help lightening and brightening products penetrate better so they can work faster.
Microdermabrasion uses a machine to rapidly exfoliate the outer layers of skin and a suction to accumulate them from the skin. There are two main types of microdermabrasion techniques: crystal and diamond tip. Microdermabrasion should not be painful and there is no recovery time. Once the pink subsides, skin is left smoother and softer. Just like enzymes and dermaplaning, microdermabrasion treatments can improve the appearance of skin discoloration, though the results will not be as effective for deeper pigmentation problems.
Microneedling is a great treatment for just about every skin condition and every skin color, unlike lasers, chemical peels, and IPL. Lasers and chemical peels are ablative because they remove tissue to start collagen production. Microneedling simply creates micro-injuries (tiny vertical channels) without heat and without removing layers of skin. The recovery time is usually a couple of hours, although a client’s face may look and feel very sunburned for a day or so. Microneedling will not thin the skin like microdermabrasion and ablative treatments.
Microdermabrasion only treats surface skin, while microneedling is able to go very deep into the skin – up to two millimeters – to stimulate new skin growth and reduce scars. With IPL and lasers, dark spots often get darker before improvement is made, but this is not so with microneedling. Microneedling releases growth factors, which cause beautiful, new skin to form with lessened or no brown spots, wrinkles, or stretch marks. A stamped method of microneedling causes the least amount of damage to the skin, as there is no dragging of the needles through the skin and the needles go in straight up and down, unlike a roller. For optimum results, immediately after microneedling, apply serums containing ingredients such as hyaluronic acid and stem cells.
Chemical peels use acids to treat the desired area of skin by irritation that leads to desquamation or burning. The type of acid, as well as the percentage, pH, and formulation, determines if it is a light, medium, or deep peel. Training is required, as improperly preparing the skin, failure to inform the client of expected results, downtime, and possible reactions, and improper homecare can result in worsened pigmentation and scarring.
Light peel solutions might use alpha hydroxy acids, such as lactic and glycolic, beta hydroxy acids (salicylic acid), or fruit acids at 30 percent with a pH of 3. Peeling may not be visible with light peels. Light peels can be repeated every four weeks and are useful for creating cell turnover for a more radiant look, while evening out skin texture and fading discoloration (melasma, sun damage, hyperpigmentation).
Medium peel solutions include 30 to 40 percent TCA, 70 percent glycolic acid, and Jessners solution (salicylic acid, resorcinol, and lactic acid). This peel destroys the top layer of skin, triggering an inflammatory response from the skin layers that sit below. Skin has a natural intuition to heal itself. As the dermis heals, new collagen forms and the old collagen tightens. Any problems on the layers removed (like actinic keratosis, hyperpigmentation, scarring, and lines) are gone. Recovery time can take several weeks and clients must adhere to strict sun avoidance, sunscreen, and no picking. The deeper the peel, the more possible the risks, such as redness, irritation, blistering, scars, and even increased hyperpigmentation.
Deep peels are only done by medical personnel in a surgical setting under general anesthesia. Solutions include deep TCA and Phenol solutions. They reduce the appearance of hyperpigmentation by removing the epidermis. Recovery time can be up to three months. Skin is sore and will ooze and scab. People with darker skin often see a definite line between treated and untreated areas. These peels are helpful for deep wrinkles, severe acne scars, hyperpigmentation from the sun, and pre-cancerous growths.
IPL therapy is also known as a photofacial. IPL treatments are similar to laser treatments in that they both use light energy to heat and destroy their targets. Lasers use a single wavelength (color) of light that can only treat one condition. IPL uses a broad spectrum of bright lights with a filter placed in front of it to censor out certain wavelengths not consumed by pigment and blood vessels. The light energy penetrates just below the skin’s surface to reach its target in either the melanin or the blood vessels. If the pigmentation is deeper, it will not be affected. Also, the heat of the IPL can darken some skins. Many clients see significant improvement within two to three weeks after their IPL treatment, as skin looks clearer and younger. IPL provides gradual, natural improvement with excellent long-term results. Skin looks clearer, younger, and healthier as sun damage, fine lines, pore size, freckling, and irregular pigmentation are minimized.
A laser peel uses targeted beams of light to rejuvenate the skin and reduce hyperpigmentation by heating up and destroying elements in skin to ensure that new skin cells grow back tighter and more toned. They are usually done by medical personnel under general anesthesia. There are two types of lasers: ablative and nonablative. Ablative lasers are the most intense and they work by vaporizing the outer layers of skin (including hyperpigmentation). This causes the skin to heal and restructure. The results are visibly younger-looking skin that can last for one to five years. These procedures are painful, require more recovery time (anywhere from two weeks to three months), and pose a higher degree of risk including redness, swelling, acne, infection, skin color changes, and scarring.
Nonablative lasers are far less invasive than ablative treatments. They work by heating up the targeted tissue deeper in the skin, without actually destroying it. This process stimulates collagen production to fill in unwanted skin imperfections, such as fine lines or wrinkles, and tighten the skin.
Because nonablative lasers do not resurface the skin as invasively as ablative lasers, multiple treatment sessions would be necessary to achieve results, but they will not be as dramatic as the results achieved with ablative lasers. However, clients benefit from almost no down time and the risk of undesirable side effects is greatly reduced. Some risks associated with nonablative lasers include mild redness and swelling, blisters or scars, infection, and skin color changes. Heat can also cause changes in skin color for some people.
Clinical treatments are wasteful and dangerous unless the skin is being protected by a broad-spectrum sunscreen of at least 30 daily, reapplied as needed. There are many wonderful topical products that can be used to lighten or brighten hyperpigmentation spots, including skin lighteners, retinoids, AHAs and BHAs, vitamin C, and skin brighteners.
What is a skin lightener? The FDA considers skin lightening a drug effect and currently only allows use of hydroquinone as a skin bleaching agent in over-the-counter drug and cosmetic combinations (up to 2 percent). Hydroquinone is approved for reducing the look of brown spots, dark spots, and freckles that result from sun exposure and from other triggers. Doctors can prescribe hydroquinone up to 8 percent. Hydroquinone should not be used for a long period of time, as prolonged use may cause cancer and can actually cause more bruise-like pigmentation called onchronosis. Onchronosis can also sometimes appear on darker skin after exposure to phenol or resorcinol.
Retinoids are derived from vitamin A (prescription or over-the-counter). Retinoids have a small molecular structure, allowing them to penetrate deep into the skin. Benefits include increased collagen production, clearer skin, and fewer wrinkles. It is best to use retinoids at night. They can be irritating, so they must be added to a skin care regimen gradually. It is important to be careful about mixing retinoids with other beneficial, but irritating, ingredients, including vitamin C, benzoyl peroxide, and AHAs and BHAs. It is important to consider the sensitivity level of each individual’s skin. These ingredients may be contraindications when performing peels, waxing, laser, and so forth and a broad-spectrum sunscreen is a must. Hydrating and moisturizing the skin is especially important for barrier repair when using irritating, exfoliating, and brightening products.
At home, AHAs (with an acid content of 10 percent or less) work well for mild hyperpigmentation. Higher concentrations can increase risk of side effects. BHAs, including salicylic acid in concentrations of two percent or less, are also effective homecare products that can help with hyperpigmentation. AHAs and BHAs both smooth skin’s outer surface and speed up cell turnover. AHAs dissolve the intercellular bonds to speed up the natural shedding process of skin, helping to get rid of cells that can clog pores and follicles. The main difference between AHAs and BHAs is oil solubility. AHAs are water soluble only, while BHAs are oil soluble. BHAs also have antibacterial and anti-inflammatory properties, making them also effective for treating acne-prone skin and blackheads. Anti-inflammatory properties also make BHAs less irritating and better for sensitive skin. AHAs and BHAs make skin more sensitive to the sun, so a broad-spectrum sunscreen is a must. A combination of AHA and BHA homecare products is ideal for most skin types. It is best to use them at night.
For the morning homecare regimen, include vitamin C to help lighten pigmentation and protect skin from age-causing free readicals. Vitamin C is powerful as an antiaging nutrient in that it stimulates collagen production to improve firmness and elasticity while visibly tightening saggy skin and diminishing the appearance of fine lines and wrinkles. Topical vitamin C will improve the brightness, tone, and texture of skin.
Other topical treatments that help lessen the appearance of hyperpigmentation are called skin brighteners. Skin brighteners generally take longer than hydroquinone to produce visible results, so patience is key. The spots did not get there overnight, so fading them will be a process, as well. Using a product with a combination of brighteners to attack the hyperpigmentation in various ways is best. Clients usually prefer a complex of skin brighteners in a single serum. Whitonyl, B-White, Luminesse, niaciamide, licorice extract, and kojic acid are a few ingredients with proven results to consider.
Consider Skin Tone
Patience is important when trying to fade hyperpigmentation. A one-size-fits-all treatment approach to hyperpigmentation will fail. Light, medium, and dark skin tones can use some of the same therapies, but darker skin tones need more time for the treatment to work. While fair skin responds well to most hyperpigmentation procedures, the following might be off limits if a client tans easily or has darker skin: high-beam lasers and IPL therapy. Medium skin tones may do better with chemical peels and microdermabrasion. Darker skin tones might benefit more from over-the-counter lightening creams, lower-strength chemical peels, low intensity laser treatments, and more sessions.
In summary, it is complicated and must be dealt with on a case by case basis. Attacking hyperpigmentation progressively, not aggressively, is important; aggressive may result in more hyperpigmentation. When it comes to homecare, only introduce one new treatment product at a time and evaluate how the skin responds. Combining homecare lighteners or brighteners with clinical treatments will achieve the best results on hyperpigmented skin.
Pigmentation is a complex condition that concerns many clients. In fact, complaints about pigmentation from clients often exceed that of aging. Yet, if this is the case, why are treatments for this condition failing? It is a multi-faceted question and the reasons can be numerous, so reviewing the pigmentation process called melanogenesis will aid in exploring the answers.
The melanocyte is the name of the cell responsible for the formation of pigment that colors skin, hair, and eyes. It is formed during the embryonic stage in the neural crest. As the fetus develops, the melanocytes migrate away from the neural crest, traveling through the body to the areas where pigment is usually found (the skin, hair, and eyes). Over 120 genes are involved in this cell movement and, hence, the potential for 120 reasons something could go wrong.
Melanocytes are genetically programmed before leaving the neural crest with a blueprint that predetermines the color of skin, hair, and eyes. Research highlights some reasons why skin conditions associated with pigmentation are so challenging to treat. There is no stem cell resource of melanocytes. Once the melanocyte has left the neural crest there is no return and no further development of this cell after birth. By the age of 18, the few regeneration cycles of the melanocyte have been completed. From the age of 35, 10 to 20 percent of functioning melanocytes are lost every 10 years. Melanocytes will eventually settle in the lowest region of the epidermis (basal layer), just above the dermal-epidermal junction that separates the epidermis from the dermis. Here, about one in every 10 cells is a melanocyte, with a ratio of one melanocyte to 30 keratinocytes (the leading cell of the epidermis).The melanocyte is a dendritic cell that is long-lived and slow cycling. This long lifecycle makes them highly susceptible to oxidative stress, leading to lipid peroxidation and, ultimately, mitochondria DNA damage due to its long but slow cycling lifecycle.
The melanocyte produces and distributes the pigment melanin, which is responsible for the color of skin with two pigments: eumelanin, the dark brown pigment, and pheomelanin, the red pigment. Melanin is an extremely complex polymer and there may be very minute differences between the melanin of different people and within races.
Skin has a different color in different areas. This is because there are more melanocytes in darker areas, such as the neck, versus lighter areas, like the face. However, within these areas, the concentration of about 1,000 to 2,000 melanocytes per cubic millimeter is the same for all race groups.
So, whether a client has light or dark skin, they will still have about the same number of melanocytes, but with a different balance of eumelanin and pheomelanin pigment granules inherited from the family gene pool.
There are some significant differences between lighter and darker skins. The most significant is that the melanocyte dendrite in darker skins is longer in length. This length enables the melanocyte to deposit pigment higher in the upper spinosum layer, affording earlier and greater protection from the hot, sunny climates in the countries from which many darker skin tones originate. The opposite is found in lighter skin and, here, the shorter dendrites place the pigment more horizontally through the spinosum layer. The melanosomes themselves and pigment granules are also smaller in lighter skin.
The melanocyte stands fourth in line of skin barrier defense, preceded by the antimicrobial barrier (previously referred to as the acid mantle), permeability layer (previously referred to as the corneocytes and multilamellar structure), Langerhans cell, and melanocyte.Individuals with a gene called melanocortin-1 receptor (red hair in the family gene pool) may have a high percentage of red pigment pheomelanin and this is reflected by a very short burn time. Redheads are known to have a greater risk of melanoma.
The melanocortin-1 receptor gene determines skin’s tanning potential, but, make no mistake, it does not mean that those with fair skin cannot tan. The skin will attempt to protect itself, but tan, in this case, comes with the risk of pigmentation, loss of pigmentation, and permanent damage to the melanocyte.The formation of melanosomes and melanin pigment is a process that requires much energy by the melanocyte mitochondria creating many radicals.
This oxidative process is controlled by built-in cellular defense, antioxidant super dismutase oxide, sometimes known as superoxide dismutase. Sadly, this built-in defense system declines with cellular age or may be lost due to mitochondria DNA damage or cellular senescence. The creation of the red pigment pheomelanin causes even more oxidative stress than the formation of the brown pigment eumelanin.
Thus, it is important to note that repeated unprotected sun exposure or sunburn may cause the pheomelanin to become altered in such a way as to allow it to become converted into a free radical, generating the superoxide anion, which can damage nearby skin cells, including the mitochondria DNA of melanocytes and keratinocyte stem cells. This is called intra-cellular oxidative stress.
Next, professionals must understand the steps involved in the formation of the melanin pigment. It is a complex process, but this article will attempt to keep it simple and relevant.
Exposure to ultraviolet radiation through the retina of the eye begins the melanin production process. Ultraviolet radiation stimulates the pituitary gland to form a protein called proopiomelanocortin, the precursor to the melanin stimulating hormone. The melanin stimulating hormone first adheres to the specific receptor protein within the cell membrane of the keratinocyte. The keratinocyte will then communicate with the melanocyte to turn on a melanin stimulating hormone receptor. When a molecule of melanin stimulating hormone binds to a receptor, a series of events occur; in this instance, it will be the first step in the formation of the melanosome that will eventually carry the pigment granules eumelanin and pheomelanin.
The enzyme tyrosinase plays a key role in melanin synthesis as a catalyst to the amino acid tyrosine and the formation of a pre-melanosome within the melanocyte. Within the melanosome, pigment granules of melanin are synthesized.Tyrosine converts to dopa-quinone and then to eumelanin and – combining dopa-quinone with cysteine – makes pheomelanin the red pigment. It is during the formation of the pheomelanin that large amounts of energy are used and radicals created aggravate oxidative stress within the melanocyte cell. Melanin pigment granules are formed within the melanosome. Melanosomes are small oval pods with thread-like structures within them. The melanin pigment granule is deposited on these threads in varying concentration, depending on the individual genetic code. (For example, five brown and eight red pigment granules.) The melanin pigment granules inside the melanosome at this time remain almost colorless until after the transfer to the keratinocyte.
The melanosomes pass down through the dendrites, maturing as they move. Once they reach the end of the dendrite, they will be transferred to the keratinocyte by a receptor called PAR-2 by phagocytosis, where they are dispersed into the cytoplasm, eventually settling over the nucleus. Here, they play an essential role in cell defense by protecting the nucleus DNA of the cell. In lighter skin, this process occurs mostly around the lower spinosum layer. Once the melanosome has been transferred into the cytoplasm of the keratinocyte, it becomes darker and visible as skin color. This is called immediate pigment darkening.
The keratinocyte cell will then continue its journey upward to the stratum corneum. All things going well, the keratinocyte will desquamate. The use of tanning beds or high levels of sun exposure will speed up melanogenesis. This results in increased melanosome transfer to the keratinocyte and an increase in turnover of the keratinocytes to pick up the melanosomes. Keep in mind, increased oxidative stress from the heat and light spectrum of ultraviolet radiation, including increased mitochondria energy, and resulting oxidative stress may result in reduced cellular energy and production.
DETERMINING A TREATMENT PLAN
If all pigment gets passed to the keratinocyte and all keratinocytes desquamate, why does pigmentation exist? There are more cells and systems involved in the color story of skin. Aside from the melanocyte (the cell of main discussion here), note that the keratinocyte, the innate immune system, circulatory system, and adaptive immune system all contribute to color.
The main reason professionals are not getting the best results for clients struggling with pigmentation is because they do not take the time to think through the process well enough to determine the best homecare and in-clinic treatment program for the individual in front of them.If the skin barrier is not functioning well to start with, then the results obtained will be limited at best. Skin health is equally as important as choosing the treatment modality. It is also vital to provide treatments in the right season to prevent an even higher risk of pigmentation for clients.The answers, of course, lie in an in-depth consultation process. Professionals must ask themselves many questions, too. Here are some of the questions to think about when a client presents with pigmentation.
Why Would There Be an Abnormal Increase in Pigment-Carrying Melanosomes?
Pregnancy or medications, such as oral contraceptive, in-vitro fertilization medication, or progesterone-based medication, cause the pituitary gland to make too much melanin-stimulating hormone. When this happens, the melanin stimulating hormone is continuously adhering to the receptors of the keratinocyte and, in turn, the melanocyte creates uncontrolled manufacturing of melanosomes. This uncontrolled release of the melanin-stimulating hormone is called the melanin stimulating hormone cascade and will be reflected in the butterfly pattern of pigmentation that is commonly seen in the center of the face and across the upper lip and forehead. Here is a before and after an image of good results with no clinical treatments as an intervention. It was accomplished over 18 months with appropriate skin care only. This illustrates the importance of improving cellular health.
What Would Stop the Keratinocyte from Picking Up Melanosomes?
The keratinocyte cell membrane is not viable or flexible enough to practice the phagocytosis method of picking up the melanosomes that have been transferred to the keratinocyte through a receptor called PAR-2. Essential fatty acid deficiency is often a leading cause here and if the keratinocyte is not viable or flexible, the melanocyte may also be in a compromised state.
Where Will the Melanosome Fall if Not Picked Up by a Keratinocyte?
Knowledge about the skin’s structure reveals that the keratinocyte mother cell and melanocytes are attached to the basal lamina of the dermal-epidermal junction by keratin filaments called hemidesmosomes. This junction is permeable and also referred to as the dermo- junction. The dermo-junction is made of sinusoidal connective tissue because it is filled with holes, pockets, and channels that allow the movement of fluids and immune cells (like the Langerhans) to move through from the dermis to epidermis. The epidermal side of this junction is called the basal lamina and is where the melanosome would rest if not picked up by the ascending keratinocyte. If this is ongoing, then a large amount of pigment could accumulate into this junction. All of the accumulated pigment that was in the junction will be released into the dermis as a result if or when the dermal-epidermal junction collapses. This is called dermal pigmentation.
What Will Be the Result if the Spinosum Layer Were Not Viable Enough for the Even Dispersion of Pigment?
There will an accumulation of pigment into smaller areas, which may reflect as pigmentation.
What Will Be the Results if the Melanocyte to Keratinocyte Ratio Were Not the Normal 1 to 30?
The melanocyte is programmed to make a specific number of melanosomes relative to the strength and length of sun exposure it has experienced. These melanosomes should be released across to 30 keratinocytes for pickup. If the melanocytes dendrites are not long enough to reach 30 keratinocytes or there is a lesser number of keratinocytes to pick up the melanosomes, it is likely that the 30 cells worth of melanosomes will be released out to fewer keratinocytes. It would reflect in a heavy deposition of pigment into a very small area with many melanosomes spilling into the dermal-epidermal junction.
The world is full of mixed ethnicities and there are many hidden dangers. Hair and eye color as an indication to establish phototype is now misleading. The melanocortin-1 receptor gene (redhead gene) can be hidden as a result of mixed ethnicity and this means that the client’s risk for skin cancer may not be obvious.
The answers lie in the consultation and sensible questions should cover information gathering about genetic heritage, tanning ability, redhead gene, and sunbed usage.
Powerful treatment modalities are available today, but they are not without risk and just because a modality is available does not make it the right choice for all clients with pigmentation-related skin conditions. It is the professional’s obligation to say no when a client carries too high a risk. Professionals should recommend treatment at a future date if the client is seeking treatment in a high-risk time, such as summer; professionals can minimize risk by delaying treatment. Professionals must say no when a client might be non-compliant with the necessary homecare protocols to perform safe and effective treatments.
Above all, it is a privilege to educate clients and give them every opportunity for fully informed consent.
1 Barrett-Hill, Florence. “Understanding Dermal Pigmentation.” Pastiche. Jul 20, 2017. http://www.pastiche-training.com/flosaid/understanding-dermal-pigmentation
2 Fernandes, Des. “The Melanocyte and the colour of skin.” https://emaniocreativecom.ipage.com/files/product-information/white-papers/skin- conditions/THE-MELANOCYTE-AND-COLOUR-OF-SKIN.pdf
3 “The A-Z Of Understanding Pigmentation.” Pastiche. https://www.pastiche-training.com/a-z-pigmentation.
4 Barrett-Hill, Florence. “Photosensitivity.” beautymag Online. http://www.beautymagonline.com/beauty-articles-2/934-photo-allergy-2W.
5 Barrett-Hill, Florence. “The Power of The Consultation.” Beautymag Online. http://www.beautymagonline.com/beauty-articles/1199-the-power-of-the-consultation.
6 “MC1R gene.” U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MC1R.
7 Schenkel, Laila Cigana, and Marica Bakovic. “Formation and Regulation of Mitochondrial Membranes.” International Journal of Cell Biology. 2014. https://www.hindawi.com/journals/ijcb/2014/709828.
8 “Mitochondria and Golgi Apparatus.” Organelles. https://introducingorganelles.weebly.com/mitochondria-and-golgi-apparatus.html.
9 “How This Normal Body Process Can Contribute to More Than 60 Diseases.” MERCOLA. https://articles.mercola.com/sites/articles/archive/2011/05/16/all-about-antioxidants.aspx
10 “Mitochondrial DNA.” U.S. National Library of Medicine. https://ghr.nlm.nih.gov/primer/basics/mtdna.
11 Agarwal, Sanjiv and R.S. Sohal. “Relationship between susceptibility to protein oxidation, aging, and maximum life span potential of different species.” Experimental Gerontology 31, no. 3 (1996): 365–72.
12 Bolognia, Jean L. and Seth J. Orlow. “Melanocyte Biology.” In Dermatology, edited by Jean L. Bolognia, Julie V. Schaffer, and Lorenzo Cerroni, Page 44. Elsevier Limited, 2007.
13 Prota, Giuseppe. Melanins and Melanogenesis. Elsevier Limited, 1992.
14 “Red-hair gene tied to melanoma.” keratin.com. Mar 2004.
15 Pawelek, John M. “Ultraviolet light and pigmentation of the skin.” Cosmetic & Toiletries 107 (1992).
16 “Note for Guidance on Photo-safety Testing.” The European Agency for the Evaluation of Medicinal Products. London, 2002.
17 “Some substances which cause photosensitivity.” National Occupational Health & Safety Commission. www.geocities.com/fragranceallergy.
18 Lyford, Willis Hughes. “Melasma.” Medscape. Oct 26, 2018. www.emedicine.com/DERM/topic260.htm.
19 Laumann, Anne Elizabeth. “Anetoderma.” Medscape. Apr 6, 2017. www.emedicine.com/DERM/topic221htm.
20 Scruggs, Jessica M. “Ephelides (Freckles).” Medscape. https://img.medscape.com/pi/iphone/medscapeapp/html/A1119293-business.html.
21 Jaku, Jeannette Rachel. “Poikiloderma of Civatte.” Medscape. Apr 28, 2017. www.emedicine.com/derm/topic603.htm.
22 Alikhan, Ali. “Berloque Dermatitis.” Medscape. Dec 21, 2018. www.emedicine.com/derm/topic52.htm.
23 Schwartz, Robert A.“Postinflammatory Hyperpigmentation.” Medscape. May 4, 2018. www.emedicine.com/derm/topic876.htm.
René Serbon, corneotherapy expert, industry educator, and speaker, gives skin care professionals a true point of difference in the industry. How? By handing them the ultimate drawing card: knowledge about the skin wrapped in savvy business strategy. Her keynotes and in-depth trainings educate on skin anatomy, physiology, and how to match cosmetic chemistry to specific skin conditions and by helping clinic owners and solo aestheticians blow the roof off their in-clinic results and business growth by 30 percent a year or more. Serbon is CIDESCO and CIBTAC certified, one of the world’s few Pastiche educators, and proudly serves on the International Association of Applied Corneotherapy (IAC) educational board. She personally swapped grooming services for corrective skin care the day she opened her appointment book and saw 10 hours of back to back waxing, hence her motto: “There’s life after waxing.”
Summer is fast approaching. For aestheticians, that usually means the second phase of brightening season. Since suppressing skin activity actually makes skin more photosensitive, the fall is the best time for clients to complete a brightening series before the sun really starts to beat down. However, a new generation of ingredients are making it safe to address pigmentation concerns year-round.
By now, most clients have learned that the lightening ingredient hydroquinone is toxic and can lead to adverse reactions. While proven as an effective lightener, this carcinogen is known to cause skin irritation, pose pregnancy risks, target the kidney, and even cause a bluing of the skin known as ochronosis when overused. In addition, recent studies show that hydroquinone contributes to environmental pollution, as it depletes microbial activity in soil, throwing off the planet’s microbiome.
Arbutin, hydroquinone’s tree-hugging cousin, has long been used as a dark spot treatment. The standard cocktail for serious pigmentary issues involves a combination of arbutin, licorice, vitamin C in the form of magnesium ascorbyl phosphate (MAP), a chemical peel series incorporating kojic, lactic and/or mandelic acid, and oral glutathione supplements for good measure. With recent regulations from the European Union, however, arbutin can no longer be used at the percentage that garners the best results. So, what is a freckled (or just blotchy) face to do?
The following is a range of patented brightener ingredients that suppress melanin production without the negative side effects.
Manufacturers are adding these ingredients to serums, creams, makeup and even chemical peels. Whatever the mode of attack, the primary point to remember is that melanin is a friend. It is a powerful antioxidant that congregates together to protect DNA at the nuclei of cells. So, choose wisely and always layer an antioxidant serum and mineral-based sunscreen to prevent further sun damage.
Aliesh Pierce, L.E., is the author of the textbook “Treating Diverse Pigmentation (Milady 2012).” Before making the transition to skin care, Pierce was a freelance makeup artist. She worked almost a decade in the fashion industry. Her makeup and skin care careers collided when she was commissioned by Volwerk to expand the range of products offered by direct sales brand Jafra Cosmetics International. After launching the new products, Pierce went on to become the director of education for Veria International and DMK Skin Revision. Pierce continues to create content for various brands. Through her online beauty portal AskAliesh.com, she features emerging brands via ingredient reviews, skin care articles, and makeup tutorials. The member-based education division of Ask Aliesh is due to launch Spring 2019.
From moles to melasma, there are various forms of hyperpigmentation for which clients seek treatment. Some are treated best under the care of an aesthetician; others require a dermatologist. And, sometimes, the two working together can lead to the greatest healing. Knowing the difference in these cases is vital.
Requests for treatment of brown spots and irregular hyperpigmentation occur daily in skin care practices. To best serve these requests, a working knowledge of the spectrum of skin conditions that cause brown spots and hyperpigmentation, along with the array of treatment options for each condition, is vital for skin care professionals. Certain brown spots and pigmented areas respond well to interventions within the spectrum of an aesthetician’s services; others do best with a more invasive medical approach. Many real-world clinical situations with brown spots and irregular pigmentation fare best with a combination of an aesthetician’s and a dermatologist’s services in tandem, ideally as part of an organized plan.
There are four distinct types of brown spots and pigmentary disorders commonly seen in practice by aestheticians and dermatologists – moles, seborrheic keratoses, sunspots, and melasma. The management of each type is somewhat different. The two most important types of pigmented conditions for the aesthetician are sunspots and melasma, as these conditions can be successfully managed with non-invasive treatment in many cases. Aestheticians benefit from understanding the triggers and developmental pathways of sunspots and melasma, as this understanding helps guide treatment options which must be considered in the context of the risks, benefits, and limitations of each option. It is best to have a working knowledge of both procedural interventions and topical care for these conditions. As for topical care, there is a vast array of brightening products on the market with ongoing ingredient innovation. It is helpful to look at these ingredients in terms of mechanism of action, side effects, efficacy, and popularity, as a broad understanding of topical treatment options can help guide therapy in practice.
When considering the vast array of pigmented skin spots seen in clinical settings, melanocytes are almost always involved. Melanocytes are a distinct type of skin cell found at the base of the epidermis. While keratinocytes occupy the majority of the epidermis and are most responsible for epidermal growth and function, it is melanocytes that produce the sun-shielding pigment melanin. Melanin colors the skin and produces the brown pigment found in moles, seborrheic keratoses, sun spots, melasma, and healthy skin of all shades.
Two of the four common brown skin growths are best treated in the medical setting. These two – moles (called nevi) and seborrheic keratoses (SKs) – invariably require medical intervention for successful treatment. Moles and SKs are extremely common; aestheticians who recognize these growths will help their clients best by referring concerns about SKs and moles to trusted medical community colleagues.
Moles are flat and/or raised areas of variable pigmentation that can be present at birth but, more commonly, develop in the first 30 years of life. Moles consist of dense groupings of pigment producing cells called melanocytes. Over the years, moles may slowly raise up from the skin’s surface while becoming lighter. Some are bothered by the appearance of one or more of their moles. Not all moles, however, are good candidates for cosmetic removal. The experience, judgment, and artistic talent of a skilled dermatologist helps guide good outcomes. Moles may be removed by scalpel shaving or full thickness skin excision with suturing. Moles do not lighten or flatten in response to creams and non-invasive interventions.
SKs represent epidermal overgrowths that are usually brown and appear “stuck on” or warty. The tendency to develop these common growths is genetic. SKs tend to increase in size, thickness, and number over the years and are common on the face, neck, scalp, and back but can occur on any body surface. SKs are growths that must be physically destroyed for removal. Treatment can be challenging; undertreatment will allow focal persistence and regrowth, while overtreatment can permanently decrease pigmentation and potentially cause scarring. The treatment window between persistence and scarring can be narrow, so attention to detail is essential. SKs are frequently treated with liquid nitrogen spray. Scraping (curettage) with or without hyfrecation (electrodesiccation) is also popular and sometimes more effective. Small bumpy SKs, called DPN, are common among Filipinos and those of African descent. These are best treated with pinpoint hyfrecation, which can clear them perfectly.
Sun freckling, sunspots, and melasma are pigmented processes that, other than being darker, share overall look, feel, and texture of adjacent skin. These hyperpigmented conditions are typically of normal epidermal thickness and architecture, with the main variable being melanin content relative to surrounding areas. These conditions tend to be more amenable to improvement via intervention by an aesthetician. There are, however, subtle differences between sunspots and melasma that are important in practice.
Sunspots are darkened areas that occur in defined areas subject to significant cumulative sun exposure. They tend to have more concentrated pigmentation relative to surrounding skin than melasma. This makes fading with topical products somewhat more challenging and less gratifying than with melasma. Additionally, sunspots can evolve over time and develop increasing thickness due to slow, subtle epidermal overgrowth. In fact, over time, some sunspots evolve into SKs and require physical, medical intervention for removal. As a result, sunspots (unlike melasma) are frequently treated with superficial liquid nitrogen treatment by dermatologists, often with excellent results. Nevertheless, there is a big role for an aesthetician’s services and topical products to play in the management of sunspots, just as there is with melasma. Sunspots and melasma can be considered conceptually as similar forms of hyperpigmentation that respond comparably to therapeutic interventions.
Hyperpigmentation is a term used to describe areas of skin that have more pigmentation than is normal. These areas visibly contrast with the surrounding unaffected skin, leading to unevenness of color and/or tone. In young and middle-aged women, the most common cause of hyperpigmentation is melasma. Hyperpigmented patches develop primarily on the cheekbones, forehead, and upper lip and can also be on the nose, chin, lower cheeks, and lateral neck. Hyperpigmented patches typically have distinct edges with pigmentation in one or more layers of the skin. Hyperpigmentation may be confined to the epidermis or it may be present solely in the dermis. Generally, however, it is present in both outer layers of skin. The tendency to develop melasma is based in both genetic and hormonal components and is also frequently exacerbated by sun exposure.
The tendency to develop hyperpigmentation is genetically predetermined. Most of the genetic factors that contribute to this tendency are not fully identified, but people who have inherited baseline skin color in the light olive to dark olive range have increased susceptibility to melasma and those with fair complexions are most prone to freckles and, with sun and time, sunspots.
Melasma has been referred to as the “mask of pregnancy” because it often develops during pregnancy. Oral contraceptives can also trigger hyperpigmentation and it can also be seen in association with menopause, hormonal imbalance, certain medications, and ovarian disorders. Women develop melasma much more frequently than men and estrogen may contribute to its formation in predisposed people. Estrogen is not essential in the development of melasma, as it sometimes occurs in men.
The one key factor that is essential to the development of hyperpigmentation in predisposed persons is sun exposure. UVA and UVB rays from sunlight or tanning beds are contributory to the development of melasma, freckles, and sunspots. The visible light spectrum may also contribute to melasma hyperpigmentation in particularly susceptible persons.
Regardless of its triggers, hyperpigmentation on a cellular and molecular level results from increased production or retention of melanin within the skin. Melanin is produced by melanocytes and can be transferred to keratinocytes in the epidermis and melanophages within the dermis. The most popular ways to lighten dark spots topically is to decrease melanin production and/or decrease melanin transportation into the epidermis and dermis. Most popular topical brightening products work by blocking the formation of melanin. Melanin is a small, organic molecule and is created within melanocytes by modification of an amino acid, tyrosine. The enzyme called tyrosinase is essential in conversion of tyrosine into melanin.
Treatment of hyperpigmentation is challenging. Long-term success requires strict avoidance of sun exposure on hyperpigmentation-prone skin. One day of unprotected sun exposure can disrupt months of meticulous treatment. Effective broad-spectrum sun protection, sun avoidance, and sun protective clothing are essential for optimal treatment outcome.
Hyperpigmentation is managed with procedural, oral, and topical therapies, sometimes in combination. Procedural interventions tend to provide benefit by selectively destroying the melanin-producing machinery within melanocytes or by reducing retention of pigment containing keratinocytes through enhanced exfoliation and cellular turnover. Oral medications suppress melanin production by limiting ultraviolet damage and skin inflammation. Most topical brightening ingredients function by preventing melanin formation via inhibition of the tyrosinase enzyme.
Popular brightening procedures include chemical peels, lasers, light sources, and microneedling. Laser therapy and liquid nitrogen cryotherapy have been shown to be beneficial for sunspots. Melasma, on the other hand, may benefit from chemical peeling in conjunction with topical therapy but, when reviewed globally, the available evidence suggests that melasma does not respond predictably well to any currently available procedural intervention, possibly because melasma pigmentation can reside in both the epidermis and dermis. Still, hyperpigmentation procedures continue to be popular and may enhance the efficacy of topical therapies used in combination. Some professionals believe that microneedling may help melasma by allowing better penetration of brightening ingredients.
Oral therapies are newer adjunctive treatment options for hyperpigmentation. These agents are used prophylactically to prevent the development of new hyperpigmentation rather than as targeted treatment of existing dark spots. Polypodium leucotomos (PL) is a safe, well tolerated, and increasingly popular extract that decreases stimulation of melanin production by limiting damage from ultraviolet light exposure. Glutathione is another natural oral ingredient that has been shown to decrease hyperpigmentation over time, presumably by decreasing inflammation within the skin.
Topical therapies for hyperpigmentation remain popular; there is an ever-widening range of brightening products. Efficacy and tolerability vary. The most effective and popular brightening ingredient is hydroquinone, a synthetic ingredient. Hydroquinone is unstable in formulation. Both hydroquinone and the sulfite preservatives used to help preserve it frequently cause irritation. Hydroquinone has profound effects on melanin production due to multiple biochemical effects on melanocytes. Similar molecularly to hydroquinone, arbutin is a safe, natural, and stable ingredient that is slowly metabolized into hydroquinone within the skin for prolonged bioavailability and excellent tolerability. Arbutin has an excellent performance profile and continues to grow in popularity.
Retinoids including tretinoin and retinol are very popular in brightening products. Just as arbutin slowly converts to hydroquinone within the skin, retinol is metabolized into tretinoin within the skin for slow controlled tretinoin release. Nano-encapsulated retinol is more stable and tolerable than tretinoin. Retinoids brighten by inhibiting tyrosinase, limiting contact between melanocytes and keratinocytes, and increasing epidermal turnover.
Azelaic, kojic, glycolic, and ascorbic acids are the most commonly recommended natural acids for hyperpigmentation. Their relative efficacy appears to be in the order listed. Azelaic acid deactivates abnormal melanocytes and has the best combined tolerability and efficacy profile of these acids. Kojic acid has good efficacy, but tolerability varies. It works by preventing formation of the tyrosinase enzyme. Glycolic acid is the most popular brightening acid and brightens via inhibition of tyrosinase. While it is well tolerated at lower concentrations, efficacy is limited. Ascorbic acid is unstable in formulation and has uncertain efficacy.
Topical steroids are occasionally used in combination with other brightening agents. Their mechanism of action is unknown. While steroids can improve performance of other brightening agents, they are invariably harmful to the skin with prolonged use and are best used with caution or not at all.
The expansive list of newer brightening agents includes licorice extract, niacinamide, flavonoids – such as green tea extract – and a list of other ingredients too long to review here. Licorice extract inhibits tyrosinase. Niacinamide inhibits transfer of melanin from melanocytes to keratinocytes. Flavonoids are polyphenolic compounds common in botanical extracts. Flavonoids are typically anti-inflammatory, occasionally carcinopreventive, and contribute to brightening via undetermined pathways.
When it comes to formal FDA review of prescription-strength brightening products, only one, Tri-Luma, has received approval. Tri-Luma provides the most consistent and rapid results in the care of moderate to severe facial hyperpigmentation with good results frequently seen within eight weeks. Tri-Luma contains hydroquinone, fluocinolone acetonide (a topical steroid), and tretinoin (retinoid). Despite having a topical steroid (with all its long-term risks), Tri-Luma frequently causes irritation due to the high combined irritant potential of tretinoin, hydroquinone, and sodium metabisulfite, a preservative.
Countless non-FDA approved prescription lightening products containing hydroquinone in concentrations above two percent are available. Many are combined with other ingredients such as kojic acid, tretinoin, glycolic acid, or sunscreen. These products are slower and less efficacious than Tri-Luma, yet, typically suffer from the same hydroquinone-related issues of instability and irritability. Nevertheless, prescription topical hydroquinone therapy for hyperpigmentation remains routine and commonplace.
The lack of uniformly safe, effective, and pleasant prescription products to treat hyperpigmentation has helped stimulate a robust market for over-the-counter cosmeceutical brightening products. The best of these tend to combine high-concentration, nano-encapsulated retinol with high-concentration arbutin and flavonoid-rich botanical extracts (often with other brightening ingredients, as well) in formulations that are cosmetically elegant and attractively packaged. These over-the-counter products often perform well and, given their overlapping mechanisms of action, may, in some cases, match the efficacy attained by their less pleasant prescription alternatives over time.
Aestheticians and dermatologists are frequently called upon to evaluate and treat dark spots. In practice, dark spots come in four main subtypes – moles, seborrheic keratoses (SKs), sunspots or freckles, and melasma. Moles and SKs are best managed by dermatology medical professionals. Sunspots respond well to a combination of medical interventions including laser and liquid nitrogen cryotherapy, along with topical hyperpigmentation therapy. Melasma responds best to topical therapy and may benefit from adjuvant peeling and microneedling procedures. Oral agents may help long-term control of sunspots and melasma.
Topical therapeutic options are exploding. The workhorse prescription hyperpigmentation ingredient today is hydroquinone, a less than perfect compound. Over-the-counter options continue to make great strides in efficacy and elegance and are becoming increasingly reasonable options for long-term hyperpigmentation care.
Dr. Craig Kraffert is a board-certified dermatologist and president of Amarte, the luxury skin care and spa brand fusing Korean skin care innovation with modern Western dermatology. He is also the founder of dermstore.com and ReddingDerm, a multi-clinic dermatology practice in northern California and Oregon that specializes in both aesthetic and clinical dermatology.
A few years back, I received a laser hair removal treatment on my legs. The laser machine was defective, causing waves of excessive energy as it hit my skin. The heat sensation I usually experienced from my previous treatments was tolerable but, during this session, I noticed an uncomfortable amount of heat with each pulse. At that time, I should have told the aesthetician what I was experiencing but, instead, I chose to stay silent and continue the treatment until the full session was completed.
The day after my treatment, my legs were swollen and red where the laser hit the skin. Sensitive to the touch, my legs felt as though I had received a second-degree burn. I started treating my skin as I would have with a burn, taking a vinegar bath and rubbing a high-numbered, physical SPF on my legs, hoping the redness and pain would subside. I contacted the aesthetician and told her what I was experiencing, only to be told that she knew her machine was defective and needed to be serviced by the company. Her words did not bring me any solace.
A week later, the redness was gone, but a new form of discoloration appeared. Where the laser spots were once red, now they were a pale white. Thinking that it was part of the process, I decided to wait it out and let my skin cycle out this newly formed discoloration. A week turned into months, and months turned into a year. I was embarrassed to show my legs, covering them with makeup concealer, tights, pants, and anything that would hide my spotted legs.
Once a year had passed and the white spots had not disappeared through my various treatments at home, I saw my dermatologist. He was unhappy about why I received the discoloration and his only prescription was sunlight – having both UVA and UVB rays hitting my naked skin. He needed my legs to be exposed to natural sunlight without any sunscreen or tanning lotion until the white spots went away. A few more months had passed and any opportunity I had within those months I would sit in the sun, hoping for this prescription to heal my wounds.
I noticed a small difference within my legs. The natural sunlight was starting to work; the spots were starting to lighten up from a pale white to a faint white. But, still, they were there, noticeably resting on my skin like a hypopigmented leopard’s coat. My hope of the spots disappearing seemed unattainable. I thought that there was nothing else I could do to treat the hypopigmentation and I would forever be discolored on my legs. That is when I took one more chance and found a red-light bed at a local tanning salon.
Red-light therapy was a tool that I would use in my facials to treat hyperpigmentation and found great results on my clients. I decided that there may be a possibility that it would work to help treat hypopigmentation. I went to the tanning salon – not to tan, but to bask under its red lights for 20 minutes each session. After eight sessions, my legs were back to their normal color. All the white spots had been filled in with healthy, new pigment of my natural skin tone. I no longer had to be embarrassed by my spotted legs – no longer had to find ways to cover up or mask the discoloration I received from one bad laser hair removal treatment. Almost two years had passed by that time – two years that I never want my skin to relive.
Hypopigmentation, I found through my own experience of having gone through it, was harder to find answers for treating than its counterpart, hyperpigmentation. The lack of melanin production in the skin – caused by vitiligo, a trauma to the skin through tears in its dermal layers, burns, blisters, or cancerous cell growths – leaves difficult ways to treat the damaged skin. There seems to be no topical agents that can be placed on the skin to treat hypopigmentation, unlike hyperpigmentation, where some product companies specifically create lines to treat too much melanin production within the skin.
I consider myself very lucky to have been able to find the right treatment that finally worked on my skin to bring back melanin production within the traumatized skin due to overly excessive heat during a defective laser treatment. I found the combination of natural sunlight with its UVA and UVB rays along with the red-light therapy was the correct treatment for my hypopigmented skin. I also found, personally experiencing both hypopigmentation and hyperpigmentation, both equally create an insecure feeling of being flawed. I have become more aware when treating clients with either pigmented concern but am no longer without answers when it comes to helping someone with hypopigmentation.
Amra Lear is a licensed massage therapist and aesthetician. She has been working in the spa industry for 16 years, working for two of the most prestigious spas in the world. Her clientele consists of stars, moguls, and people alike. She has been trained by Japanese shiatsu masters and the founders who pioneered such wonderful modalities such as ashiatsu, mother massage, and lulur. Skin is her ultimate passion. She has dedicated the last six years to research and education of biochemistry to better understand the biochemical response to products used on the skin.
Hyperpigmentation – one of the leading reasons individuals seek treatment from a skin care professional – has been a major skin concern for decades. It is a condition that affects men and women alike, regardless of background and skin type. Fortunately, with the right understanding of cause, common disorders, and available treatment options, there is hope for individuals facing the condition.
What makes one person’s skin pigment or color different from another? With the exception of genetics and cultural background, in the intercellular layers of the skin, there exists an entire universe of the biological makeup of what affects the appearance of someone’s skin color. The flow of blood and lymph, the presence of veins, capillaries, lipids, and proteins, the thickness of the skin itself, and everything else in between are all differentiating factors that enable skin color individualism. Over time, the characteristic qualities of the skin change. Some reasons include chronological aging, environmental impact, hormone fluctuations, nutrition, diet, sun exposure, and many other uncontrollable factors, like stress. As a result, pigmentation disorders inevitably develop or, if already present, worsen. Hyperpigmentation is among one of the most prominent skin concerns for men and women of all backgrounds.
Hyperpigmentation is the appearance of darkened areas of skin – typically brownish in tone, sometimes with a hint of red – caused by the hyperactivity or the excessive production of pigment. First, it is important to understand how the brown pigment is created from the beginning through a process known as melanogenesis. The thyroid hormone, tyrosine, is converted by the tyrosine enzyme, tyrosinase, into dihydroxyphenylalanine (DOPA) through oxidation, which, then, is converted to dopaquinone, the ultimate catalyst for melanin synthesis. The melanin generating process led by the melanocyte cells occurs within the melanosomes. Melanosomes are the cellular subunit organelle granules in the stratum basal leading into the stratum spinosum layers of the epidermis. The melanin then makes its way into the upper epidermis, carried by the keratinocyte cells, actuating visible skin color.
There are two different types of melanin generated through melanogenesis – eumelanin and pheomelanin. Eumelanin has significant skin protecting properties.
Eumelanin is critical as the skin’s primary shield against ultraviolet radiation from harmful solar rays. Eumelanin actively absorbs the ultraviolet impact on the skin along with the accompanying free radicals; hence, aggressively protecting cellular structure and well-being. Pheomelanin, on the contrary, exacerbates the skin-damaging side effects of sun exposure and actually increases the body’s production of free radicals.
A uniform way to assess, and determine, a client’s skin type is by the Fitzpatrick classification scale. The scale was developed by Harvard Medical School dermatologist Thomas Fitzpatrick in 1975 to gain an understanding of a person’s skin color and likely reaction to sun exposure. It is also particularly useful in assessing and anticipating how well skin will respond to certain kinds of facial treatments or procedures. Being knowledgeable about the different skin types offers a resourceful foundation to recommend the most appropriate and effective hyperpigmentation treatment. There are six skin types, according to the Fitzpatrick scale, from very fair skin – which is type I – to the darkest skin – type VI. Type III is the most common. Types IV to VI are typical among people of African descent, who tend to be less sensitive and susceptible to sunburn and sun exposure.
Across the world, skin color varies among different ethnicities. Generally, the distribution of the melanosomes is proportional in both light and dark skin; but, traditionally, hyperpigmentation is a much greater concern for darker skin types. Darker skin has larger melanocytes, whereas light skin has smaller-sized clusters of melanocytes. This means that lighter skin is better at blocking enzymatic pathways to slow tyrosinase action triggered by ultraviolet exposure. Dark skin, on the other hand, is more vulnerable to sun damage, despite the fact that it is less sensitive to the sun because there is greater tyrosinase stimulation.
COMMON HYPERPIGMENTATION DISORDERS
Several factors cause hyperpigmentation, but sun exposure is universal. It is directly responsible for worsening the condition of skin already predisposed to pigmentation, plus triggering the development of new conditions. Some of the most common forms of hyperpigmentation disorders include solar lentigos, melasma, and post-inflammatory hyperpigmentation.
Solar lentigos are also known as liver spots or age spots. Although solar lentigos develop over time and are usual among a mature demographic, typically 50 years or older, they are not actually caused by aging. Rather, chronic sun exposure is accountable for actinic photo-induced aging. The dark lesions are found throughout areas of skin that cumulatively had the most exposure to the sun over time. Essentially, skin that is better protected, such as the forearms or other areas usually covered, remain impervious. Age spots are not just an aesthetic concern; they raise serious health risks surrounding skin cancer, including melanoma and basal cell carcinoma. Proactively protecting skin before spots develop is essential.
Hyperpigmentation, unfortunately, is an undesirable side effect during pregnancy or among women of childbearing age who develop melasma, also referred to as “mask of pregnancy” or chloasma. Elicited by hormone fluctuations, melasma develops because the melanocyte-stimulating hormones are elevated. It is a chronic condition and, typically, people with melasma have considerably greater sensitivity to the sun. The slightest amount of unprotected sun exposure easily forces melanin to the surface of the skin.
The presence of dark patches on the forehead, nose, cheeks, and chin are melasma-defining. This type of hyperpigmentation can clear up on its own within a few months post-pregnancy, but it is likely skin lightening treatments will be necessary. The demand for treatment of melasma is quite large and strongly desired, particularly by women who are emotionally affected by the condition. The best precaution is to use sun protection with a minimum SPF of 30 and reapply it often.
Abnormal pigment alteration, also known as dyschromia, is worsened by a condition known as post-inflammatory hyperpigmentation. It develops from something as minor as post-acne blemishes, an allergic reaction, eczema, or even an injury-causing trauma to the skin. Skin that is irritated, or inflamed, is most susceptible to counter reacting because of hyperpigmentation treatment. Skin practitioners must carefully plan a suitable course of skin therapy for clients suffering from post-inflammatory hyperpigmentation. Inappropriate treatment can precipitate or induce hyperpigmentation.
To emphasize, the greatest culprit of hyperpigmentation is ultraviolet exposure that progressively provokes cellular sun damage. In turn, it causes actinic keratosis, which are patches that build up on sun-exposed areas of the body. The precancerous cells are thick, crusty, and scale-like. Actinic keratosis patches are most common in lighter skinned people.
Other external hyperpigmentation-causing forces are the impact of environmental air pollution, smoking, and the use of drugs or medications. These are factors that influence overall cell wellness. Smoking, in particular, deprives cells of oxygen, literally suffocating and destroying cellular structure and quality. Compromised health of cells worsens the appearance of the skin, but also it heightens skin sensitivity to the sun.
As previously discussed, hormone-fluctuations associated with pregnancy are one type of hormone-causing hyperpigmentation scenario. Other incidences where hormone imbalances can affect skin pigmentation is the drop in estrogen levels during menopause. Hormonal equilibrium is also shifted during menstruation, ovulation, and even during times of high stress. Any hormone stimulating events can ultimately influence the tyrosine thyroid hormones, which in turn would activate and increase melanin production, a precursor to hyperpigmentation
A Wood’s lamp is one useful tool that professionals can use to examine skin and sun related damage. It offers professionals a method to assess how deep the skin damage goes, which provides insight on whether skin will respond to certain kinds of skin lightening treatments. Typically, epidermal damage has a much better prognosis than when it is deeply dermal. Under a Wood’s light analysis, epidermal damage will appear much darker, while dermal will appear faint. If the predominant appearance is light, meaning greater dermal damage, the client may not experience optimal results with treatment. When the examination reveals mostly darker areas, signifying mostly epidermal damage, it is almost certain that the client will have successful treatment results.
Hydroquinone, naturally, is one of the constituents of propolis, the resin collected from tree buds by bees. Most likely, it is a phenol, a widely used chemical ingredient considered safe for skin lightening by the medical community. It has powerful tyrosine inhibiting action, which allows for effective hyperpigmentation lightening results. A two percent hydroquinone concentration is the highest available as an over-the-counter before requiring a prescription by a dermatologist. Hydroquinone efficacy can be amplified when combined with other skin lightening ingredients such as a two percent kojic acid or five percent alpha hydroxy acids.
Although hydroquinone is safe and one of the strongest skin care ingredients in the battle against pigmentation, there are mixed feelings about it. This is why Mother Nature has been very generous in sourcing other natural alternatives. A natural ingredient that is comparable to hydroquinone is kojic acid derived from fungi. It can potentially deliver a similar tyrosinase blocking effect. The down side is, as effective as kojic acid may be, it does accompany certain risk of skin sensitivities. One point to keep in mind is that, when investing in hyperpigmentation repairing therapy, the more intense a treatment or product, the higher probability there is that certain sensitivity may occur. Shiitake mushrooms are an ingredient option also part of the fungi family, but without the concern of any adverse reactions. They provide brightening and astringent benefits to the skin, but milder and gentler.
Azelaic acid is a dicarboxylic acid derived from grains like wheat, rye, and barley. In comparison to kojic acid, azelaic acid exhibits milder tyrosinase inhibiting action. It is an ingredient that hinders melanocyte regeneration, but through a more subtle approach. Azelaic acid is high in antioxidants and has anti-inflammatory properties that are valuable in treating post-inflammatory hyperpigmentation.
There are a handful of holistic, skin lightening ingredients on some scale, mostly working to inhibit tyrosine activity, to promote a topical brightening effect. Ingredients that boost cell turnover and exfoliation are great for enhancing and promoting an even skin texture and tone, especially when treating epidermal pigmentation. Hyperpigmentation associated with post-inflammation, such as acne blemishes, typically responds well to this type of retexturizing method, incorporating five to 10 percent alpha hydroxy acids (AHA) or salicylic acid – a beta hydroxy acid (BHA). A stronger result can be achieved with a 20 to 40 percent AHA concentration, as long as a specialist qualifies
There are five types of AHAs: glycolic acid, lactic acid, malic acid, citric acid, and tartaric acid. Each offers its own benefits, but when in combination, will enhance the results, as one AHA compliments the efficacy of the other. Glycolic acid is a derivative of sugar cane, lactic from sour milk, malic from apple, citric from lemons or other citrus fruits, and tartaric from grapes. Alpha hydroxy acids are a widely known and recognized set of ingredients among both medical and spa professionals. They are versatile and appropriate for a wide range of clients, offering them a popular, skin-brightening solution.
Licorice, mulberry, arbutin, gotu kola, arginine, and even vitamin K derived from dark leaf greens offer a gentle, herbal approach to treating hyperpigmentation. Licorice root extract allows skin pigment to lighten by interfering with the melanin creating process. Mulberry contains active concentrations of betulinic acid, exhibiting anti-inflammatory, as well as skin lightening, results. It is recommended in inflamed skin, which is susceptible to pigmentation. Arbutin comes from the evergreen bearberry plant. It is too large of a molecule to penetrate the epidermis and cannot self-hydrolyze – meaning breakdown. This means that it works only topically as a mild skin lightener, but it is still effective enough to limit a certain level of melanin synthesis.
Vitamin C in the form of ascorbic acid is a beloved and powerful mainstream antioxidant. It interrupts tyrosine enzyme cycles, but is active when it is in a stable, non-oxidized form. When vitamin C is a product of magnesium ascorbyl phosphate, it is most effective. Extracts including arginine coming from wheat germ, vitamin K, soy, and gotu kola – an ancient Chinese medicine remedy – are another set of ingredients that demonstrate qualities that can improve skin discoloration. Soy and gotu kola are particularly suitable to offer options in treating stress- or hormone fluctuation-provoked hyperpigmentation, such as melasma. Luckily, the selection and variety of ingredients that work to repair hyperpigmentation-afflicted skin certainly do not come up short. Skin care products containing one or several of the ingredients discussed earlier synergistically work better to improve and even skin complexion.
Depending on the type and severity of the hyperpigmentation, a professional will need to first assess and determine an appropriate course of treatment. Factors of consideration must include the cause and depth of the hyperpigmentation. Managing a client’s expectations are necessary to assure a positive experience. There are some forms of pigmentation that can be resistant to treatment, including dermal, hormone, and post-inflammatory related. The easier and most responsive to treatment are epidermal and sun-damage caused pigmentation.
In many cases, when treating hyperpigmentation, before there is any visible improvement, the hyperpigmentation may initially become darker or worse. Many forms of treatment will likely accompany skin flaking or peeling. Regardless of the treatment, clients must stay protected from the sun and consider a necessary period of several weeks for full treatment results to take effect. With any treatment, regardless of the intensity, a proper and consistent homecare routine is critical to achieving and optimizing results. Wearing protective clothing, like a wide brim, hat is a good idea and using a broad-spectrum sun protection product of no less than SPF 30 is mandatory.
When weighing in on a spa or medical route, it is important to understand what is within an aesthetician’s scope of practice, based on the individual state regulations, and what types of procedures can be performed only within a medical practice. There are several treatment options for hyperpigmentation, including from the mildest – holistic brightening facials, microdermabrasion, chemical peels, and light therapy – to the most severe performed only under the supervision of a doctor – laser resurfacing. In the spa, an aesthetician can choose to incorporate a superficial peel, enzymes, and microdermabrasion to boost skin renewal. The exfoliating process alone promotes a brighter and even complexion. The key for any professional treating hyperpigmentation is patience; noticeable progress will be slow, but steady, especially with milder forms of treatment.
Facial spa treatments geared to gently, but gradually, improve hyperpigmentation must include a wide variety of holistic tyrosinase inhibiting ingredients, mentioned earlier, that suppress further melanin pigment production. A treatment protocol can implement one or multiple forms of exfoliation to force the outer layer of skin to shed chemically, enzymatically, or mechanically. This allows the proliferation of new skin cells. Microdermabrasion mechanically exfoliates the skin by sandblasting the outermost epidermal layer of skin. Enzymes, such as papaya- or pumpkin-derived, offer a non-chemical peeling exfoliation.
A light or superficial peel with AHAs, BHA, or a Jessner’s peel works to brighten and restore the skin, but it may cause some photosensitivity, so it is not ideal to perform during the most intense, sunny months of the year. Also, keeping in mind the Fitzpatrick scale, Jessner’s peels containing resorcinol may not be a great fit with darker skin types – IV or greater – as it can trigger post-inflammatory hyperpigmentation.
Incorporating an LED green light over a serum or a gentle transparent gel mask, which would allow the light to pass through and penetrate the skin, is another option to add to a facial that will help block melanin production. Overall, cumulative impact on the skin following each treatment session will generate the best results.
More intensified treatments will need to be done under the care of a physician. Medium-depth peels can be performed with trichloroacetic acid (TCA) of 10 to 40 percent or a combination of TCA with other AHAs or BHA. This type of peeling is effective in treating dyschromia, but if the client is not a candidate for this type of treatment, post-inflammatory hyperpigmentation or even scarring can develop. Lighter skin types – I-III (a select group of clients) – would be suitable for this type of treatment. The post-treatment recovery time is usually between six to 10 days, depending on the particular nature and components of the peel.
Treatments performed only in medical settings include intense pulse light (IPL) photo rejuvenation or the most aggressive treatment options, like deep peels and laser resurfacing. IPL therapy produces results with virtually no down-time by delivering an intense pulsing light down to the dermis to attack melanosome clusters. This forces the melanin to breakdown, or to surface, and ultimately shed away. A deep peel is usually a phenol-based peel that removes skin layers down to the dermis and has a demanding post recovery phase. Clients require rest time for the outer layer to regenerate and heal. Laser resurfacing is a procedure in which self-inflicted wounds enable new tissue generation. Today, fractional lasers are used most commonly. Fractional lasers treat the skin in a grid-like manner that allows for a shorter recovery time, since less of the area is directly impacted by the laser. The procedure is available as nonablative, for deeper dermal pigmentation, or ablative, where the laser dissolves surface cells. This modality of treatment is appropriate when looking to make a difference for the severe and resistant forms of hyperpigmentation.
Hyperpigmentation has been a major skin concern that is not particularly biased to skin color or background for decades. One of the outstanding reasons that people visit a licensed skin care professional is because they are looking for options for treating hyperpigmentation. The high demand for solutions and results has enabled the medical and beauty industry to continue to research and innovate more advanced forms of treatment. No less, the tried and tested, effective remedies continue to be utilized to treat and repair hyperpigmented skin. Although hyperpigmentation disorders can be challenging for professionals to completely remedy, in the majority of cases, with appropriate treatment, continued improvement is promising.
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Victoria Tabak, published beauty expert, two-state licensed aesthetician, spa consultant, educator, and CEO of Nature Pure Labs, has more than 19 years of experience in the beauty industry along with a master’s degree in business and a minor in chemistry. Throughout her career, she has shared her love and passion for skin wellness and making a difference in people’s lives. She has inspired many, supported women in business like herself, and influenced the growth and success of spa owners across the country.
Sun spots? Age spots? No matter what name is given to these little brown spots on the skin, they are all hyperpigmentation. The spots are the result of past sun damage – damage that has caused the skin to go into fight mode to protect itself. When skin senses the sun’s rays, it produces melanin to protect itself.
These dark spots are often called age spots because they become more prominent as a person ages. Years of unprotected sun exposure causes the melanin in some sections of the skin to become darker than surrounding tissue.
Historically, there was not a strong explanation for dark spots. They were blamed on age and swept under the rug. As the skin care industry has expanded over the years, the terms “sun spots” and “age spots” have been let go and these spotsare now categorized as hyperpigmentation. Scientists and product formulators have also discovered there are three main causes of hyperpigmentation.
The main function of melanin is to absorb the harmful rays of the sun. Too much sun exposure and the skin produces dark spots.
A very common form of dark spots is known as melasma – also referred to as “pregnancy mask” – and it is due to hormonal changes in the skin related to pregnancy.
Any trauma to the skin that causes a lesion has the potential to develop into a dark spot. Accidents of any sort can lead to these situations. Those with darker skin tones are more susceptible to lingering dark spots from trauma. Some examples include scratches, abrasions, lacerations, waxing burns, excessive extractions, razor bumps from ingrown hairs, and scars from acne blemishes.
Many spas and doctors can easily treat hyperpigmentation with skin care services and topical skin care products. There are two types of treatments for hyperpigmentation: exfoliation and skin lightening. Exfoliation, either manual or chemical, removes layers of skin to help remove the dark spots. There are also topical products that have skin bleaching, brightening, or lightening ingredients that also help to fade existing hyperpigmentation.
There are two primary methods for treating hyperpigmentation. One option is for clients to apply topical cosmeceutical products to their skin that contain specific skin-brightening ingredients. The other option is for clients to seek out professional skin care services that work to exfoliate the top layers of the skin.
The best course of action for any client seeking to treat hyperpigmentation is to combine professional skin care services that exfoliate the skin with brightening products in a home skin care routine. This combination will remove surface skin cells that are damaged while topical ingredients work to lighten the remaining damaged skin cells.
Dimethylmethoxy Chromanyl Palmitate
This ingredient, also known as chromabright, is known to have wonderful brightening benefits and is one of the safest brightening ingredients available.
The kojic acid that is produced from shiitake mushrooms has wonderful skin brightening effects.
This ingredient interrupts the chemical reaction in the skin that causes discoloration.
One of the most universal services in the skin care industry, peels can range from very mild enzyme peels to more advanced and powerful peels. There are many types of peels that help to remove dead skin cells, with some also acting as a skin brightener in the process.
This treatment is performed under physician supervision. Tiny needles on the tip of a wand, usually in the shape of a pen, are moved across the face, causing micro injuries. The treatment helps to increase cell turnover and improve collagen production.
This treatment involves a vacuum massage of the facial skin that is combined with either aluminum oxide crystals or a spinning, diamond-tipped head that is whisked across the skin, removing dead skin cells.
This physician-only service is one of many options. Laser resurfacing treatments are for tone, texture, and elasticity. These treatments can be very mild and only treat the very top layers of the skin, delivering noticeable results on a small scale – with virtually no down time
No matter the cause of a client’s hyperpigmentation, there are several options available for treatment. Professionals have access to an assortment of resources to help clients reduce, and virtually eliminate, troublesome dark spots. Every client has unique needs, so the products and services used to treat each person should be based on the client’s skin type, type of hyperpigmentation, and budget.
Ottmar Stubler is the president of PFB Vanish, a topical gel for the relief of irritation associated hair removal. He received his California aesthetics license in 1985 and practiced through 1996 in San Francisco. After establishing several wholesale distribution companies, Stubler formulated PFB Vanish in 1999. He remains an active educator within the industry. pfbvanish.com
Hyperpigmentation is a common, usually harmless condition in which patches of skin become darker in color than the normal surrounding skin, which occurs when an excess of melanin forms deposits in the skin.
A common form of hyperpigmentation is age (liver) spots. Sun damage is the leading cause of age spots, which are referred to by doctors as solar lentigines.
With pigmentation issues being one of the most frequently addressed concerns in professional skin care, it is important to understand that there is no longer a sole culprit of dark spots. Skin care professionals used to think that the most stubborn forms of hyperpigmentation were either sun damage related or hormonally induced, but new research suggests that there are numerous other sources and factors that play a role in skin discoloration. This information causes professionals to rethink how they treat every client because different ingredient technologies can help address their clients' specific concerns.
Hyperpigmentation is beginning to rival acne and wrinkles as a top reason people consult aestheticians. Although different types of hyperpigmentation may have different etiologies, the outcome is still a visible result of what happens when melanocytes – whether in normal numbers in the basal layer of the epidermis or those transferred to the dermis – repeatedly receive signs of distress or trauma, either to the skin or another system of the body.1 Instead of the melanin umbrella of pigment closing when the distress is over, the melanocytes continue to produce excessive melanin in an effort to protect the other cells and systems in the dermis; as a result, the umbrella remains open.