14 Apr Hyperpigmentation of the Skin – Treatment Strategies
Hyperpigmentation simply described is a focal area or patch of darker pigmentation on any area of the skin. Special cells in the skin called melanocytes naturally produce melanin – the pigment which your body uses to create skin and hair color. The production of melanin is under very sophisticated and tight control but is influenced by a wide variety of biological and physiological factors. When there are too many melanocytes attracted to a given area, or if they are overactive, overproduction of melanin occurs and hyperpigmentation results.
Understanding what hyperpigmentation is may be simple but it is far from a simple problem. A full medical history and physical examination must be the foundation for any treatment plan for hyperpigmentation problems. A working diagnosis is also extremely important for developing the best strategies. Not all hyperpigmentation is the same. Hyperpigmentation can be associated with certain medical problems and conditions. Different forms of hyperpigmentation will respond better to different types of treatment. Always consult with your physician expert in cosmetic skin care.
Without question, every treatment plan will include minimizing sun exposure. Sun (UV radiation) avoidance, sun protection and sunblock will always represent the simplest and most critically important part of any plan for the treatment of hyperpigmentation.That’s because nothing stimulates melanocytes and melanin production more than UV radiation exposure. And pigment stimulation is the last thing we want when we are treating hyperpigmentation!
Resurfacing techniques – topical home use “peeling” agents (e.g. alpha-hydroxy acids, lactic acid, retinoids), office microdermabrasion, office chemical peels (e.g. glycolics, trichloracetic acid or TCA) – are commonly employed in most treatment plans dealing with hyperpigmentation. Resurfacing eliminates dead or dying pigmented surface skin cells (keratinocytes) allowing the less pigmented, fresher, new skin cells to be revealed at the surface. Resurfacing also stimulates cellular growth and turnover from the deeper levels of the skin, further assisting the skin in its shedding of pigmentation and the pigmented keratinocytes contributing to the hyperpigmentation. Certain types of lasers can also be used along these lines. But be careful – laser therapies can also cause hyperpigmentation! A series of 5 to 6 in-office chemical peels performed weekly, combined with a customized at-home regimen of topical agents can be quite helpful. Our skin care center’s aestheticians have found that a series of once a week Obagi Blue Peel Radiance® (glycolic, lactic, and salicylic acid) peels in combination with the use of the Obagi-C® Rx (vitamin C, hydroquinone) system at home can be very successful. A series of in-office microdermabrasion treatments are an alternative option to the office peels.
Below is a list of some currently available topical agents (brighteners, lighteners, whiteners) which are often used in the war against hyperpigmentation. You will find that many of these compounds are combined within a single product. Combinations of methods and the use of multiple ingredient topical agents seem to work better than any single mode therapy or single topical agent. However, no single agent seems to work as well on hyperpigmentation as hydroquinone does alone.
Alpha lipoic acid– Weakly inhibits melanin production.
Aleosin– Derived from the Aloe Vera plant. Weakly inhibits melanin production.
Emblica fruit– Weakly inhibits melanin deposition.
Licorice extract– Active ingredient is glabridin (also known as glycyrrhiza) which decreases melanin production.
Daisy flower (Bellis perennis) extract– Decreases melanin production.
Willow bark extract– A beta-hydroxy acid; a resurfacing (peeling) agent which helps to shed dead skin cells, remove surface pigment/pigmented keratinocytes, and reveal brighter, fresher layers underneath.
Acetyl Hexapeptide– Decreases melanin production.
Pelvetia canaliculata extract– Derived from seaweed. Decreases melanin production. Blocks UV radiation damage to DNA.
Watermelon fruit extract– Blocks UV radiation damage to DNA.
Kojic acid– Derived from mushrooms/fungi. Also a byproduct created during the manufacturing of Japanese rice wine (sake). Decreases melanin production. Also decreases number of dendrites (the connecting bridges melanocytes use to inject melanin pigment into the skin cells around them).
Azeleic acid– Found in barley and other grains. Primarily used as an anti-acne agent but has the “side effect” of decreasing melanin production.
Hydroquinone– Works by decreasing/blocking melanin production and by decreasing the number of viable melanocytes in a given area. Well known as a major component in photographic developer for film and paper! The only actual “bleaching” agent recognized by the FDA. Available as less than 2% concentration as OTC, up to 4% concentration or more as prescription. In 2006, the FDA revoked its previous approval of hydroquinone as an OTC pending further study because of concerns regarding its absorption and potential carcinogenicity. Ochronosis – the appearance of bluish/black skin discoloration spots – is another concern and a recognized potential unwelcome side effect that may be seen with long-term use. Final FDA decision on all this is still pending. Irritation reactions are very common and occur in ~25% of patients starting use of hydroquinone – a small spot test area should be tried first. True allergy to hydroquinone is rare. Hydroquinone treatment makes the skin more sensitive to sunlight and all other potentially irritating skin agents/treatments. Precaution should be taken accordingly.
Arbutin (Bearberry)– A “natural” form derivative of hydroquinone. Decreases melanin production.
Beta carotene– Decreases melanin production.
Gluconic acid– Binds copper (micronutrient needed for melanin synthesis) leading to decreased melanin production.
Paper mulberry (Mulberry extract)– Derived from an Asian tree root. Decreases melanin production.
Ascorbic acid (vitamin C)– Decreases melanin production. Can be irritating to the skin.
Norwegian kelp– Decreases dendritic transport of melanin.
N-acetyl glucosamine (NAG)– Decreases melanin production.
Niacinamide– Decreases dendritic transport of melanin.
UPA (undecylenoyl phenylalanine)– Decreases melanin production.
Steroids– Decrease irritation/inflammation of the skin, limit irritation from other products used in combination therapy (e.g. hydroquinone), also decreases melanin production.
Retinoids– A family of resurfacing (peeling) agents which are vitamin a derivatives. Retinoids help to shed dead skin cells, remove surface pigment and pigmented keratinocytes, and reveal brighter, fresher layers underneath. Streamlines “easier” absorption of other agents into the skin when used in combination therapy. Decreases melanin production. Increases skin cell turnover and promotes growth of plump, new skin cells up from the deeper layers further forcing the elimination of the older, pigmented cells which are contributing to the hyperpigmentation. Probably the most widely used: Retin-A®.
By Lyle M. Back, MD