Pigmentation (Part 2)

 

In the first part of our pigmentation series, you learned about what pigmentation is, what causes it, and the most common types of pigmentation. Here we deal with the front line treatments - topical skincare and chemical peels. Lights and lasers will be dealt with in Part 3 (coming soon!).


 
 

treatment principles

Treatments for hyperpigmentation generally focus on 5 things:

  1. Reducing melanin synthesis (usually tyrosinase inhibitors)

  2. Enhancing skin’s own protection measures (antioxidants, anti-inflammatories)

  3. Blocking melanosome transfer to melanocytes

  4. Degrading melanosomes (breaking up the pigment)

  5. Photoprotection measures

I know I sound like a broken record, but you are wasting your time with any pigmentation treatment unless you manage the major trigger: UV exposure. Sun exposure is the main risk factor for hyperpigmentation, triggering its appearance, worsening and persistence. No treatment plan is complete without a broad spectrum sunscreen with an SPF of at least 30. For example: high-factor sunscreen has been shown to reduce melasma severity by 50%, and reduces its impact during pregnancy in more than 90% of people. So you should be diligently seeking shade, using sun protection measures and wearing (and re-applying) sunscreen.

You may also need to consider stopping hormonal treatment. This is something you should discuss with your dermatologist when you develop a treatment plan.


(A) topical treatments

Topical agents are the first line of treatment for hyperpigmentation, with hydroquinone (in triple therapy with hydrocortisone and tretinoin) as the gold standard treatment. Topicals are also used in conjunction with peels, lights and lasers (on the advice of your dermatologist). Topical treatments generally focus on inhibiting tyrosinase, the enzyme that is critical for melanin synthesis or blocking melanosome transfer to skin cells. Adding in skin protective agents such as antioxidants and anti-inflammatories can also help reduce the UV damage that triggers pigmentation.

Available over-the-counter (OTC):

Click on each ingredient to link to products containing that ingredient:

Image credit | @paulaschoice

Image credit | @paulaschoice

  • Alpha-arbutin - Tyrosinase inhibitor. More potent than kojic acid. Look for 1-6% concentration.

  • Azelaic acid - Antioxidant, anti-inflammatory, anti-bacterial + tyrosinase inhibitor. Use 15-20% concentration twice daily. My favourite is from Paula’s Choice or Azclear

  • Kojic acid - Antioxidant + tyrosinase inhibitor. Most effective when combined with 5% glycolic acid. Look for 0.5-0.6% concentration.

  • Vitamin C (Ascorbic acid) - Antioxidant (but potent inhibitor of melanin production as a result). Use your favourite Vitamin C serum here - you all know my favourite!

  • Vitamin E (Tocopherol) - Tyrosinase inhibitor + depigmenting agent. More effective when used with Vitamin C (why I love the product I linked above).

  • Resorcinol - Antioxidant + tyrosinase inhibitor. Use in 0.5-1% concentration.

  • Niacinamide - blocks melanosome transfer to keratinocytes. Look for at least 2% concentration. More effective when used wth N-Acetyl Glucosamine (I like it in this product) or you can find it in these products too.

  • Tranexamic acid - see below

  • Other - Bioflavonoids, ellagic acid, alpha-lipoic acid, idebenone, phytic acid, pycnogenol, licorice extract, boswellia, mulberry extract, grape seed extract, and green tea - clinical trials on topical use for hyperpigmentation are lacking at this stage.

Prescription only:

  • Hydroquinone - the most potent tyrosinase inhibitor available. Suffers from controversy after being banned as a ‘cosmetic’ ingredient in Europe, the USA and Canada. But it’s not actually ‘banned’, just regulated as a drug rather than a cosmetic.

  • Tranexamic acid - Blocks melanosome transfer. Look for 0.4-3% concentration. Works better when taken orally (available on prescription only) but is also available in a topical OTC formulation

  • Corticosteroids - Usually used in conjunction with tretinoin and hydroquinone.

  • Retinoic acids - (active form of Vitamin A) - Tyrosinase inhibitor and increases epidermal turnover to remove pigment. Includes tretinoin, isotretinoin, adapalene and tazarotene.

Ed’s note: Adding in each of these topical ingredients would be a nightmare skin routine, and cost a fortune! To keep it simple I use a custom compounded prescription formula containing azelaic acid, tranexamic acid, kohl acid, hydrocortisone, tretinoin, hydroquinone. Contact me if you want more details. I also use Vitamin C+E, and niacinamide daily. If you prefer an OTC formulation that contains a number of big hitting depigmenting agents, then this one is worth a try.

 

 

(B) Peels

Chemical peels create an injury to a very specific skin depth, to remove skin cells and melanin deposits. Superficial peels can be a great adjunct to topical treatments for pigmentation - in fact, they are usually used in combination with targeted take-home products.

Superficial peels come in two types: (1) lighter peels designed to exfoliate the stratum corneum only, and (2) deeper (but still classed as superficial) peels exfoliate into epidermal-level melanin deposits, but don’t penetrate the dermis. Dermal peels like those performed with >20% trichloroacetic acid (TCA) or higher strength acids than those discussed below, need to be discussed with your dermatologist, so are not dealt with here.

A word of warning: approach even superficial peels carefully! If you have melasma, PIH or darker coloured skin, they should only be used under the care of a qualified professional to avoid inflammation that can result in the reoccurrence or worsening of pigmentation. They can also be a waste of money if you have dermal pigment deposits, so make sure you have undergone diagnosis with a Wood’s lamp and/or skin biopsy. You should also advise anyone approaching your face with peeling solution of your at-home skin routine, particularly if it involves retinol or retinoic acids.

The interval between a light superficial peel (just removes the stratum corneum) can be as little as one week. Superficial peels that remove skin cells into the deeper epidermis, can be repeated every 2-6 weeks, depending on the extent of peeling. All superficial peels require multiple applications (3-6) whereas dermal peels are usually a one-off.

These are the most common types of clinical peel available for depigmentation and your dermatologist can explain which one is most suitable for you after diagnosing your skin (these are NOT at-home peels):

 
 
  1. Glycolic acid (stratum corneum level only but can be epidermal with longer contact time) - uses alpha-hydroxy acid (AHAs) such as glycolic, lactic, malic, oxalic, tartaric, and citric acid derived from sugar cane, milk and fruit. Typically used at 20-70% concentration. This peel is generally painless, but some mild stinging may occur. You may have only very light peeling.

  2. Salicylic acid (stratum corneum level only) - uses beta-hydroxy acids (BHA, derived from the sweet birch, wintergreen leaves and willow tree bark) at 10-30% concentration. Often used for patients with darker skin tone, and in combination with other peeling agents (see Jessner’s peel below). You will experience intense burning initially which resolves quickly as the acid acts as an anesthetic. The peel will be on your skin for only 3-5 minutes. Skin will be red and tight, but you will experience only mild skin flaking for up to a week afterwards.

  3. Jessner’s solution (epidermal level peel) - 2-3 coats of a combination of resorcinol (14%), salicylic acid (14%) and lactic acid (14%) are applied (sometimes with added kojic acid). This peel is accompanied by intense burning. Skin will be red and tight and start to peel almost immediately. You will peel for up to a week afterwards.

  4. Tretinoin peel - 1-5% tretinoin is as effective as a Jessner or glycolic acid peel in treating melasma. It works, not by destroying skin, but by increasing cell turnover. This peel is painless but it turns skin light yellow and must remain on the skin for 6 hours. You also need to stay inside as the tretinoin is decomposed by UV light. You will be very red for a few days, but peeling is limited. This type of peel is commercially marketed as Cosmelan.

Ed’s note: if you’re susceptible to cold sores like me, you will need to take antiviral medication the night before and the day of your peel to prevent the peel reactivating the Herpes virus. Contact me if you want to know more about this.

 

Part 3 of this series deals with lights and lasers for pigmentation. Coming soon!


 

References

Bolognia JL and Orlow SJ, 2018, Melanocyte Biology, New York: Elsevier Ltd, Clinical Key.

Cario M, 2019, How hormones may modulate human skin pigmentation in melasma: an in vitro perspective. Exp Dermatol, Mar 18 [epub ahead of print].

Chaowattanapanit S, Silpa-Archa N, et al. 2017, Postinflammatory hyperpigmentation: a comprehensive overview: treatment options and prevention. J Am Acad Dermatol, 77(4): 607-621.

Chopra K, Calva D, et al. 2015, A Comprehensive Examination of Topographic Thickness of Skin in the Human Face. Aes Surg J, 35(8):1007-1013.

Dessinioti C, Lotti TM, et al. 2015. Melasma. In: Katsambas AD, Lotti TM, Dessinioti C, D’Erme AM (eds) European Handbook of Dermatological Treatments. Springer, Berlin, Heidelberg

Ebanks JP, Wickett R, et al. 2009, Mechanisms regulating skin pigmentation: the rise and fall of complexion coloration. Int J Mol Sci, 10(9): 4066-4087.

Fink B, Grammar K, et al. 2006, Visible skin color distribution plays a role in the percpeption of age, attractiveness, and health in female faces. Evol Hum Behav, 27(6):433-442.

Fink B, Matts PJ, et al. 2018, The effect of skin surface topography and skin colouration cues on perception of male facial age, health and attractiveness. Int J Cosmet Sci, 40(2):193-198.

Gillbro JM & and Olsson MJ, 2011, The melanogenesis and mechanisms of skin-lightening agents – existing and new approaches. Int J Cosmet Sci, 33:210–221.

Gordon J & Brieva J, 2012. Unilateral Dermatoheliosis. New Engl J Med, 366(16):e25-26.

Kaufman BP, Aman T, et al. 2018, Postinflammatory hyperpigmentation: epidemiology, clinical presentation, pathogenesis and treatment. Am J Clin Dermatol, 19(4):489-503.

O’Connor A, Lowe PM, et al. 2018, Chemical peels: a review of current practice. Australas J Dermatol, 59:171-181.

Rendon MI, Berson DS, et al. 2010, Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol, 3(7): 32-43.

Sarkar R, Arora P, et al. 2013, Cosmeceuticals for hyperpigmentation: what is available? J Cutan Aesthet Surg, 6(1): 4-11.

Sonthalia S, Jha AK, et al. 2017. Dermoscopy of melasma, Indian Dermatol Online J. 8(6):525–526.

Taylor SC, 2005, Photoaging and Pigmentary Changes of the Skin. Berlin: Springer, Springer Link.

Trivedi MK, Yang FC, et al. 2017, A review of laser and light therapy in melasma. Int J Womens Dermatol, 3(1):11–20.

Zubair R, Lyons AB, et al. 2018. What’s new in pigmentary disorders. Dermatol Clin, 37(2):175-181.