Hyperpigmentation is one of the most common reasons for a dermatological consultation, particularly in patients with darker skin tones.
It is characterised by the darkening or increase in the natural colour of the skin (ie. dark marks), usually due to an increased deposition of melanin in the epidermis and/or dermis.
Hyperpigmentation and the role of skin phototype
You are generally less likely to develop hyperpigmentation the lighter or paler your skin is. However, lighter skin types can also develop lighter marks known as hypopigmentation. Most patients with noticeable uneven facial pigmentation tend to be Skin Phototype III or higher.
Many believe that if you have a darker skin type IV (or higher) your risk for pigmentation is less. The truth is actually the opposite: Darker skin types are more at risk for hyperpigmentation, especially post-inflammatory hyperpigmentation (PIH) than skin type I or II. This means that additional caution should be exercised when treating darker skin types, especially with chemical peels and lasers. For instance, in Asian skin phototypes, no pigmentation may be present, yet a strong thermal or chemical insult can result in marked skin response i.e. inflammation and blotchy hyperpigmentation.
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Types of hyperpigmentation & treatment options
Crucial to winning the hyperpigmentation game is correctly identifying the sub-type of the condition you have. This will ultimately determine the course of treatment you will need to follow.
Freckles
These are small, flat-coloured spots of melanin, also known as ephelides. They are generally a genetic trait and are most often found in individuals with fair skin. The spots usually develop on sun-exposed areas, especially after repeated exposure and they vary in colour – they may be red, light-brown, brown, or black.
Key treatment advice
Freckles usually fade in the wintertime, however, they tend to come back darker during summer. Skincare products and IPL can help lighten freckles, but if one is not meticulous about daily use of the correct sunscreen they may become darker.
Solar Lentigines
These are large, irregular, flat brown patches on sun-exposed areas that are caused by a lifetime of sun exposure. Unlike freckles, these harmless age spots do not fade in winter and are common on the face, the “V” of your neck, the backs of your hands, and your forearms.
Key treatment advice
Your sun tanning days are over – avoid the sun at all costs. Skincare products can improve the appearance of the darker marks and it is relatively easy to treat smaller lentigines by freezing them with liquid nitrogen (cryotherapy). It is important that this treatment is done with skill, as over-freezing can leave white marks at the site of the sunspot. For multiple larger solar lentigines especially on the face, IPL and TCA peels are very effective treatments.
Hormonally-induced hyperpigmentation will manifest itself as melasma, also known as the ‘mask of pregnancy’. This name points to its frequent occurrence during pregnancy or when oestrogen-containing oral contraceptives are used, as it mainly affects women of childbearing age.
Melasma may be permanent or disappear and reappear with subsequent pregnancies or use of the oral contraceptive pill.
Melasma is more prevalent in women with darker skin tones. It is thought that oestrogen and UV light are the biggest culprits in this condition. Some scientists say UV exposure seems to be a requirement for melasma to develop as it is most commonly seen in areas that are exposed to sunlight, cheeks, upper lip, chin and forehead in a symmetrical pattern. It is seen as irregularly shaped patches of hyperpigmentation (ranging from light to dark brown).
In melasma, most of the excess pigment is initially found in the epidermis but may drop down into the dermis and thus make it more difficult to treat. Most clients have mixed melasma, i.e. epidermal and dermal.
Unfortunately, since melanin may reside in both the dermis and epidermis, it is very difficult to treat. Similar patterns of pigmentation have also been noted in men, but maybe in fact due to photo-sensitising agents. You can become photosensitive to medications, diseases and medical conditions. Some skincare ingredients such as Retinol, and Glycolic Acid may cause irritant contact dermatitis making pigmentation worse.
Key treatment advice
Hormonally-induced pigmentation is difficult to treat (once it is noticed) as hormones have a physiological influence 24 hours a day. If caught in the early stages, it is preventable with sunscreen. Hormonally-related melasma can spontaneously disappear when hormones return to normal, though it is harder for darker skin to revert back and because UV is a known contributor to melasma, educating sufferers on the importance of sun avoidance and using a high factor, broad-spectrum sunscreen every day, is crucial.
PIH stems from the melanocyte’s exaggerated response to injury. This is where areas of the skin darken after inflammation or when trauma occurs as a result of increased or abnormal distribution of melanin in the tissues (e.g. think of a burn or acne and the dark mark it leaves behind). The area of PIH could be as small as a pimple or a larger patch following skin injury. The darker the skin the more noticeable the PIH will be.
Following an injury, the excess pigment is situated in the dermis. With time the body will slowly clear this pigment but with the correct topical treatment, this process will be accelerated.
Key treatment advice
It’s important to realise that since inflammation is a trigger for PIH, we have to be cautious with over-treating the areas of hyperpigmentation. Note any areas of underlying erythema. Thermal or chemical treatments such as laser and IPL could further inflame the area and worsen PIH.
What other treatments will help my Hyperpigmentation?
Chemical peels that have been specially formulated to treat pigmentation. These peels should be performed by a Dermatologist or an experienced skin therapist. If an incorrectly indicated harsh peel is applied to the face it can leave Post-Inflammatory Hyperpigmentation, which means the peel will make the pigmentation worse. Sun freckles can be lightened and reduced with regular peels.
Intense Pulsed Light (IPL) is recommended for Superficial Hyperpigmentation – sun freckles respond extremely well to this treatment. It cannot be used to treat Melasma.
Cryotherapy (Liquid Nitrogen) is another treatment for solar lentigines but not for Melasma.
Dermapen Micro-Needling can help break up and reduce more superficial hyperpigmentation.
Non-ablative fractional Laser (eg. Clear & Brilliant Laser) can help for the superficial or mixed forms of melasma, but not for deep dermal melasma.
Will my Hyperpigmentation ever go away?
Unfortunately in many patients especially with Melasma, it tends to be a chronic condition. Many treatments will improve and lighten the hyperpigmentation, but often the patients will have to use some form of treatment for many years.
What is the most important advice you can give someone with Hyperpigmentation?
Epidermal or superficial forms of hyperpigmentation can resolve quite easily with sun avoidance: seek shade, wear protective clothing and hats, and be meticulous about using a high factor broad-spectrum sunscreen every day and re-applying when outdoors every 2 hours or after swimming or sweating.
Your maintenance treatment is just as important as your initial treatment.
Fine-tune your personalised treatment game plan with an experienced physician or skin therapist who can offer you a comprehensive routine to target and treat hyperpigmentation as well as other skin concerns.
