Pigmentation

What causes pigmentation?

Pigmentation is a generic term referring to areas where skin is darker than surrounding skin. One of the most common triggers of pigmentation is inflammation. It very common to see an increase in pigmentation for example after a flare of acne or eczema. It depends on the skin type to the response to inflammation, broadly darker skin tones are more likely to pigment with inflammation, lighter skin tones often develop post inflammatory erythema (redness). As soon as I start to treat acne in those at higher risk of unwanted pigmentation, I always discuss use of high factor sun creams and skin brightening topicals such as vitamin C and azelaic acid. If someone has acne the key to reducing pigmentation is to get the acne under control and reduce the inflammation. Photodamage is a common cause of pigmentation causing textural change with the loss of collagen and elastin often with areas of both hypo and hyperpigmentation e.g. solar lentigines. Hormones such as oestrogen with UV light combine to cause so-called melasma. (see below for description)

What are the most common types of pigmentation?

1. UV: As we age unwanted changes in skin pigmentation are common in all skin types. Skin dyspigmentation can be one of the main signs of skin ageing in those with darker skin tones.  Exposure to UV damages our skin particularly in areas of high sun exposure such as the face and hands where we often see clumps of pigmentation- commonly called age spots. We often see loss of pigment as a result of sun damage too.
   It is not only UV exposure that can cause pigmentation issues there have been several studies demonstrating the effects of pollution and increased skin pigmentation.
2. Inflammation: When are skin becomes inflamed substances are released that have an effect on the production of the pigment in skin called melanin. This is called post -inflammatory pigmentation.
3. Hormones: It is thought acombination of hormones and UV exposure mainly cause the specific type of pigmentation referred to as melasma. The pigment is usually facial, nearly always symmetrical and tends to affect the upper cheeks, forehead, upper lip, nose and chin. Less commonly it can affect other areas such as the neck and forearms.

Which is more likely to trigger pigmentation in women over 40, hormones or sun damage?

I think both. After the age of forty we start to reap what we sow… years of sun exposure start to show in the form of unwanted pigmentation, sunspots and textural change. Also, oestrogen is an antioxidant and with reducing levels there is less protection against external aggressors such as UV and pollution. This really is a time to start thinking about protection. I recommend layering vitamin C serum and a broad-spectrum high factor sun cream daily throughout the year.  

Can you still experience pigmentation through hormones alone if you’ve always been sensible in the sun? 

Hormonally driven pigmentation or melasma can absolutely affect those who have always been sensible in the sun. Melasma is commonly associated with pregnancy and exposure to hormones such as with the oral contraceptive pill, HRT etc. Removing the hormonal trigger will help, but clearing the melasma once established can be difficult, particularly if it is deeper in the skin. It mostly affects women, and rarely can be triggered by thyroid issues or certain drugs e.g. anti-epileptics

Firstly, I would wish to assess the depth of the pigmentation as this is crucial to assess appropriate treatments. Topical treatments such as hydroquinone, and retinoids often in combination with other treatments such as vitamin C, Kojic and azelaic acid are well established in the treatment of melasma. It is always advisable to start with these pigment suppressing topicals for several weeks before starting any clinic treatments such as peels, micro-needling or laser as these in themselves can cause post inflammatory pigmentation.

Ongoing treatments to reduce recurrence would always include a high factor sun cream, preferably with a physical block such as zinc oxide. I also advise topical vitamin C, I like SkinCeutical’s Ce Ferulic. Vitamin C helps to block an enzyme that is important in the production of melanin and has antioxidant properties to protect against UV and pollution that can both contribute to unwanted skin pigmentation.

Will cosmetic products ever really be able to get rid of pigmentation for good? Will it always come back?

If there is significant pigmentation, it is likely that prescription treatments may need to be used to try and treat and suppress the pigmentation. Ongoing suppression is key, and I advise looking for the following topical ingredients in skin care. Firstly, topical retinoids can help to increase skin turnover, and this will help to fade pigmentation. Vitamin C works as an antioxidant to protect against the free radical damage from sun exposure that can cause pigmentation. Vitamin C also suppresses an enzyme that is important in the formation of pigmentation, that is why it’s so successful at brightening skin. Liquorice is well known for its skin brightening qualities as is niacinamide, which also reduces inflammation for example in an acne skin. Alpha arbutin is a potent tyrosinase inhibitor, whilst topical tranexamic acid reduces melanin synthesis and its transport to the top layer of the skin. If the cause of pigmentation is post inflammatory such as eczema or acne, these conditions need to be treated to switch off the inflammation causing the ongoing pigmentation

How can you stop pigmentation from returning?

Always use very high protection sun cream that will preferably protect against UVB/ UVA and the visible light spectrum. Traditional sun creams may protect against UVB and UVA but combinations of antioxidants in some sun creams will also protect against the free radical damage of exposure to visible light that can be a common cause of unwanted pigmentation. I like the new La Roche Posay sun cream UVMUNE 400 with its extra protection against UVA and the longer wavelength UVA -1. Longer wavelengths such as UVA-1 are often not protected against in many sun creams. Of note UVA-1 and pollution work synergistically to create sunspots and pigmentation. I also like Heliocare 360 for its broad protection

I believe that sun creams that contain physical blocks such as zinc oxide, titanium oxide and iron oxide are particularly good at protecting the skin against unwanted pigmentation. I like SkinCeuticals Mineral Radiance, it is an excellent physical block but has a universal tint that has a lovely light reflective tint. I also like colorscience’s mineral sun cream range that is matches all skin tones. Most importantly there is no substitute for a large wide brimmed hat and shade, dermatologists never sit facing the sun, backs are turned!

Ongoing use of pigment suppressing topicals such as retinoids, vitamin C, azelaic acid, niacinamide, liquorice, alpha arbutin and Tranexamic acid will also help.

I like SkinCeutical’s discolouration defence serum, which contains Tranexamic acid and niacinamide.

Use of AHA’s such as glycolic and lactic acid can help, but overuse can cause irritation and inflammation and in fact lead to further pigmentation, so caution needed here.

Again, keeping skin calm and hydrated and reducing inflammation e.g. acne and dermatitis will help to reduce post inflammatory pigmentation  

• What are the best ingredients to use for pigmentation in cosmetic products? See above retinoids, vitamin C, azelaic acid, niacinamide, liquorice, alpha arbutin and Tranexamic acid
• What are your thoughts on hydroquinone? Does anything work as well as this? I think that hydroquinone is an option if used under careful medical supervision and with a clear endpoint. It can be combined successfully with other pigment suppressants such as retinoids and antioxidants. The danger is when it is acquired outside of a medical clinic at higher, often unregulated concentrations and used for unlimited time periods. It should be used with caution. In the UK Hydroquinone must be prescribed by a doctor for supervised use
• What are the safer alternatives to hydroquinone? Why do people have reservations about it? The reservations with hydroquinone are mainly the skin irritation it can cause, the possibility of severe pigmentation when applied at higher concentration without UV protection and potential damage to a foetus so it is contraindicated in pregnancy. Most concerns relate to its unregulated use at high concentrations, but alternatives are being studied and used with some success.
• What are your thoughts on tranexamic acid for reducing the appearance of hyperpigmentation? There are studies that suggest oral and topical tranexamic acid can be an alternative to hydroquinone. There have also been some helpful studies comparing topical tranexamic acid 5% often use 2x a day with 2-4% hydroquinone, usually with favourable comparisons but less side effects. Interestingly when tranexamic acid is combined with fractional laser or micro-needling the results were even better. Alpha Arbutin found naturally on bearberry and mulberry plants is also seen as a safer alternative to hydroquinone with its suppressant effect on tyrosinase the important enzyme in the creation of the skin pigment melanin
• What can be done in-clinic to reduce the appearance of hyperpigmentation? (for each, how many sessions needed, and a rough idea of cost would be amazing) Firstly a careful assessment of pigmentation with an experienced skin specialist is needed to be clear of the cause, and in the case of melasma underlying triggers and depth of pigmentation. A careful assessment allows a clear management plan with an honest appraisal of likely outcomes from treatment, managing expectations is key. It is then important to suppress the process before treatment to reduce the risk of unwanted post procedure pigmentation. Treatment options include peels, I favour The Perfect Peel, a medium depth peel that is suitable for a range of skin tones. It may be a one-off treatment, but more than one may be required. The average cost is around £450. Combining micro-needling with topical anti-pigmentation treatments such as tranexamic acid, and antioxidants costs on average between £250 and £350 and usually 3-4 treatments will be required 4-6 weeks apart. For photodamage the broad band light (BBL) and IPL may be helpful which can be combined with fractional laser for quicker more effective results. Usually more than one treatment is needed, on average 3 treatments again 4-6 weeks apart. Costs per treatments are on average between £350 and £800 depending on combinations.

In summary: Getting the diagnosis of the cause pigmentation in the first place is key. A treatment for photodamage may be very different to that of melasma for example. Using the right daily skin care with ingredients will help to fade and suppress pigmentation is key for lasting results. Often in-clinic treatments or prescription topicals are needed . Once the pigmentation is under control ongoing skin protection with anti-oxidants, pigment suppressing skin care and the highest protection sun cream against UVA, UVB and longer wavelengths is going to be key to lasting results.