Causes, Diagnosis, and Treatment of Hyperpigmentation

Hyperpigmentation is one of the leading skin conditions causing a person to seek treatment and has been a growing concern for several decades. It affects both men and women, no matter their skin type or background. The good news is treatment is possible, with an understanding of the causes, common disorders, and treatment options.

Skin pigment is controlled by many factors. The most obvious are genetics and race, but it also depends on the unique biological makeup of the intercellular layer of skin of each individual. Blood flow, skin thickness, and the presence of veins, capillaries, lipids, and proteins all affect the colour of one’s skin.

Skin colour and other characteristics can change over time due to ageing, environmental factors, hormones, diet, exposure to sunlight, and even stress. This is why skin conditions like hyperpigmentation tend to develop or worsen as people go through life.

Pigment Genesis

Hyperpigmentation presents as dark reddish or brown areas of the skin that are caused by the over-production of pigment. The brown pigment is produced through melanogenesis. In this process, the thyroid hormone tyrosine is converted into dihydroxyphenylalanine (DOPA) through oxidation by the enzyme tyrosinase. DOPA is then converted into dopaquinone, which is a catalyst for melanin synthesis.

Melanin synthesis takes place within the melanosomes, which are the cellular subunit organelle granules located in the stratum spinosum layers of the epidermis. The melanin then moves up to the surface layers of the epidermis where it results in a visible colour of skin.

There are two types of melanin created in melanogenesis: eumelanin and pheomelanin. Eumelanin is very effective at protecting the skin from UV radiation from the sun. It absorbs the energy and the free radicals on the skin and protects the skin’s cellular integrity. Pheomelanin, on the other hand, actually worsens the effects of UV exposure and can increase the production of free radicals.

The Fitzpatrick Scale

The Fitzpatrick scale is used to classify a patient’s skin type in a uniform way. It was developed by dermatologist Thomas Fitzpatrick of Harvard Medical School in 1975, as a way to understand skin colour and predict the skin’s reaction to sun exposure.

It is also useful in determining how a patient’s skin will react to different facial treatments and procedures. Knowing a bit about different skin types is extremely useful in determining the best way to treat a particular case of hyperpigmentation.

According to the Fitzpatrick scale, there are six different skin types, which vary from very fair (type I) to very dark (type VI). Type III is the most common in the world, and types IV, V, and VI are common for people of African descent, whose skin is generally less sensitive to harsh sunlight.

Skin colour differs greatly among people of different ethnicities. The distribution of melanosomes is usually proportional in all skin types, but hyperpigmentation is more common for those with darker skin.

This is because darker skin involves larger melanocytes, so it is more susceptible to damage from the sun, even though it is less sensitive to sunlight. Lighter skin has smaller groups of melanocytes and is better at slowing tyrosinase reactions caused by UV energy. With larger melanocytes, darker skin is less effective at stopping that tyrosinase action that produces brown pigment.

What are the most common Hyperpigmentation Disorders?

Many things can cause hyperpigmentation, but exposure to UV radiation is the most common. It can worsen pre-existing conditions and trigger the condition to develop in the first place. Common forms of hyperpigmentation are lentigos, melisma, and post-inflammatory hyperpigmentation.

Solar lentigos are commonly referred to as liver or age spots. They develop over time and are more common in the older population (usually 50 years of age or older), but they are not technically caused by ageing itself.

They are caused by chronic sun exposure and appear on parts of the body that receive the most sun exposure over time. Liver spots pose a risk that goes beyond appearance – they could be signs of skin cancer, such as melanoma or basal cell carcinoma.

Hyperpigmentation can also be a side effect of pregnancy or women who have melisma or chloasma. These hormone fluctuations result in a higher sensitivity to sunlight, and even a small amount of sun exposure can result in hyperpigmentation in the exposed area.

Melasma appears as dark patches of skin on the forehead, nose, cheeks, and chin. Sometimes this will clear up on its own a few months after pregnancy, though often patients will have to get skin-lightening treatments to deal with it.

Melasma can be emotionally damaging for the women who have it, so the demand for treatments is increasing. The best way to prevent melasma in the first place is to avoid sun exposure as much as possible and wear sunscreen with a minimum of 30 SPF.

Post-inflammatory hyperpigmentation can worsen dyschromia or abnormal pigment alteration. It can develop from conditions such as acne, allergic reactions, eczema, or an injury that causes trauma to the skin.

Irritated and inflamed skin is more likely to react badly to hyperpigmentation treatment. It is crucial for your doctor to fully understand your unique case so they can prescribe the best treatment plan for you. The wrong treatment is at best ineffective, and at worse can actually exacerbate the condition and cause hyperpigmentation.

What could Cause Hyperpigmentation?

The number one cause of hyperpigmentation, as mentioned, is exposure to ultraviolet radiation from the sun. Cell damage from UV radiation causes actinic keratosis, precancerous patches of thick, crusty, and scaly skin. These are more likely to appear on light skin tones.

Other risk factors that damage cell health include air pollution, smoking, and some drugs and medicines. Smoking restricts oxygen flow to cells, essentially suffocating them and weakening their structural integrity. Damaged cells not only make the skin look worse, but they are also more sensitive to even more sun damage, which can lead to hyperpigmentation.

As mentioned above, hyperpigmentation can also be caused by hormone imbalance, such as during pregnancy. Irregular hormones during menopause, menstruation, ovulation, and extreme stress can also lead to hyperpigmentation. All of these conditions stimulate the tyrosine thyroid hormones, which then promote excessive melanin production and can eventually lead to hyperpigmentation.

Treatment Response Prediction

Different kinds of skin damage will respond differently to treatment. A tool used to determine the extent of the damage is a Wood’s lamp. This device reveals how deep the skin damage is.

The deeper the damage, the more difficult it is to treat. Epidermal damage, near the surface, responds much better to skin lightening treatments than deep dermal damage. Epidermal damage appears as dark areas under a Wood’s lamp, whereas deep, difficult-to-treat dermal damage is faint.

Skin Lightening Ingredients

Hydroquinone is derived from the resin bees collect from tree buds. It is a phenol, a chemical that is known to be safe and is commonly used in skin lightening treatments. It works by inhibiting tyrosine, the hormone that causes overproduction of melanin.

The highest dosage available over the counter is 2%, anything above that will require a prescription from a dermatologist. It works well in combination with other treatments such as 2% kojic acid or 5% alpha hydroxy acid, which amplify the effects of hydroquinone.

Kojic acid is the natural alternative to hydroquinone, and it is derived from fungi. It has a similar tyrosinase-blocking effect to hydroquinone, but it does come with risks for sensitive skin.

As with most skin treatments, the higher the intensity of the product, the more likely it is to be harsher and carry side effects of increased skin sensitivity. Shiitake mushrooms are a milder alternative with skin brightening effects, but the gentler nature of this natural treatment means it is less efficacious.

Azelaic acid is more subtle treatment compared to kojic acid. It is a dicarboxylic acid derived from wheat, rye, and barley. It doesn’t inhibit tyrosinase action as much as the previously described treatments, but it still suppressed melanocyte regeneration. It is high in antioxidants and is an anti-inflammatory agent, which is extremely useful for treating post-inflammatory hyperpigmentation.

There are several holistic options for skin lightening treatments, which work to restrict tyrosine activity and create an overall brightening effect on the skin. For epidermal pigmentation, anything that promotes exfoliation and cell turnover is very effective for an evening out the skin’s texture and tone.

A concentration of 5-10% alpha hydroxy acid (AHA) or beta hydroxy acid (BHA) works great to even the texture of skin suffering from post-inflammatory hyperpigmentation, such as is caused by acne scars. A concentration of 20-40% AHA will produce even better results, but should only be used if a skin specialist approves based on the sensitivity of the skin.

AHAs come in five kinds: glycolic acid, lactic acid, malic acid, citric acid, and tartaric acid. They all compliment each other and can be used in combination with each other to boost the results.

Glycolic acid comes from sugar cane, lactic acid is from milk, malic acid is derived from apples, citric acid from citrus fruit and tartaric acid comes from grapes. AHAs a popular treatment for skin brightening, and are widely used by both medical professionals and spas.

For those looking for a herbal treatment for hyperpigmentation, here are some options: Licorice, mulberry, arbutin, gotu kola, arginine, and vitamin K from dark leafy greens. Licorice root extract inhibits melanin production and thus results in lightened skin.

Mulberry contains betulinic acid, which is an anti-inflammatory and skin lightener. Arbutin can be found in an evergreen plant called bearberry, and is applied as topical skin lightener because it’s molecular structure means it is too large to actually penetrate the epidermis.

Extracts from an ancient Chinese remedy called gotu kola, arginine from wheat germ, vitamin K, and extracts from soy also work to decrease hyperpigmentation. They are especially useful for treating hyperpigmentation induced by hormone imbalance or stress, such as melasma.

Fortunately, most of the ingredients discussed all work together to boost each other’s effects and correct hyperpigmentation. There is certainly no shortage of treatment options containing one or more of these ingredients.

Spa Treatments vs. Medical Procedures

Before you can start treatment, you will need to consult a professional so they can assess your situation and decide the best course of action for your particular type of hyperpigmentation. They will consider the cause, type, and depth of the hyperpigmentation.

Be aware that some factors affect how well you will respond to treatment, and you should manage your expectations accordingly. Deep dermal, hormone-induced, and post-inflammatory hyperpigmentation are especially resistant to treatment. The easiest pigmentation problems to treat are surface-level and caused by exposure to sunlight.

Often times the condition appears to get worse when treatment starts. Treatment can also cause flaky or peeling skin. It’s important for anyone receiving skin treatment to stay out of the sun as much as possible and wear protective clothing and high SPF sunblock when sun exposure is necessary. The treatment will begin to take hold and show improvement only if the proper aftercare steps are taken.

It’s also important to note that some treatments can only be provided by certified medical practitioners. The gentler treatments such as microdermabrasion, brightening facials, chemical peels, and light therapy can be performed by an aesthetician at a spa.

The more intense treatments like laser resurfacing need to be performed by a trained doctor in a medical clinic. After a professional assessment of your condition, you will be better informed about what treatment is needed and where you can go to safely receive that treatment.

Other treatments for pigmentations at spas generally make use of a combination of the tyrosinase-inhibitors discussed above. These restrict further melanin production, and then an exfoliating technique is used to shed the outer layer of the skin and promote new skin cell growth.

Exfoliation can be chemical, enzymatic, or mechanical. Mechanical exfoliation includes microdermabrasion, which is sandblasting the top layer of the epidermis. Enzymes from papaya or pumpkins work as a non-chemical peel to exfoliate the top layer of skin.

A chemical peel using AHAs, BHA, or a Jessner’s peel is great for brightening the skin, but they make the skin very photosensitive so they are not recommended for use in the sunnier summer months of the year. Recalling the Fitzpatrick scale of skin classification, Jessner’s peels with resorcinol are not ideal for dark skin tones of IV or greater, as they risk triggering post-inflammatory hyperpigmentation.

Light therapy that uses green LED lights applied over a serum or gel mask also inhibits melanin production and can be used in combination with the above techniques.

The best results will likely come from combining multiple treatments.

Intense treatments require a doctor to perform in a medical clinic. Deeper chemical peels using 10-40% trichloroacetic acid (TCA) is used for the treatment of dyschromia, but it should be performed by a trained professional and only if the patient is a good candidate for this treatment.

Otherwise, it can cause scarring and post-inflammatory hyperpigmentation. This type of treatment works best for light skin tones, I through III on the Fitzpatrick scale. It can take six to ten days to recover from this kind of chemical peel.

Intense pulse light (IPL) photorejuvenation is a more aggressive treatment and should only be performed in a certified clinic, along with deep peels and laser resurfacing. IPL has a short recovery time and works by attacking melanosome clusters with short bursts of energy sent through the dermis.

This breaks down the melanin and it eventually disappears. A deep peel, or a phenol-based peel, strip layers of skin to the dermis and requires a longer recovery time for the skin to heal and the cells to regenerate.

In laser resurfacing, the wounds caused by the laser force new tissue to generate. Fractional lasers are the most common in use today, as they require less downtime post-procedure by spreading the impact of the laser over areas of the skin like a grid.

For deep dermal pigmentation, fractional laser treatment can be nonablative, but for epidermis pigmentation, it is ablative, in which it destroys the skin cells at the surface. This advantage makes it ideal for severe hyperpigmentation.

Hyperpigmentation affects people of skin types and tones

It is one of the most common reasons people seek out a skin care professional for treatment. Due to the high number of patients suffering from the condition and the continued demand for good results, the skin care industry is researching more solutions to the problem of hyperpigmentation.

However, the solutions discussed here are tested and proved to work well. Although hyperpigmentation is difficult to eradicate completely, with good treatment and aftercare practices, hyperpigmentation is a highly treatable condition.

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