HYPERPIGMENTATION - PEARLS OF WISDOM
Hyperpigmentation disorders are one of the most common cosmetic concerns encountered daily in clinical practice. Whilst visually unappealing, these conditions can be treated with gradual improvement being noticed over time. As common as these conditions are, experience in treatment modalities is essential. Fads are also quite common place with regards to treating hyperpigmentation disorders. Empowerment and education geared towards the consumer is therefore essential so your time and money are directed towards what will give you value and peace of mind.
By far, the most common hyperpigmentation disorder we treat is Melasma. It occurs more commonly in females than males and is precipitated by hormones and UV exposure from sunlight and light sources. Females using oral contraceptive pills and hormone replacement therapy following menopause are at particular risk. Sun exposure is the main factor leading to a cascade of inflammation and pigment production by pigment-producing cells, known as melanocytes. The avoidance of sun protection methods leads to gradual worsening of the condition of the skin. Epidermal melasma is far easier to treat whereas dermal melasma, following long term exposure without treatment or sun protection, extends deeper and is more resistant to treatment methods.
Another very common hyperpigmentation disorder is post-inflammatory hyperpigmentation. This can occur following inappropriate procedures which essentially burn the skin e.g. laser and chemical peelings or following severe acne which leads to scarring. More often than not, early recognition of precipitating factors and treatment thereof leads to fairly quick resolution. Basic principles still apply and the main instigator again is extended inflammation leading to pigment formation.
Ideally, treatment needs to be tailored to the type of skin being treated and the severity of the hyperpigmentation. 4 basic principles of treatment are highlighted below, all of which are essential in any treatment process.
Sun protection: High factor sun protection forms an essential part of treatment as protection from precipitating factors will prevent worsening. No patient should ever consider undergoing treatment without this basic essential. A finish according to the skin type of the patient can always be selected for optimum comfort. Of course, reapplication is essential through the day for higher protection. As a rule, make up and foundation products do not provide an adequate protection factor alone.
Antioxidants: Antioxidants also form an essential part in preparation for treatment and maintenance. Inflammation as a trigger results in the production of free radicals which damage DNA. Pigment is thereby produced as a defense to these free radicals and in the long term prevents more dangerous sequelae such as skin cancers. Antioxidants work to clear free radicals thereby reducing the risk of DNA damage and preventing pigment formation all together. Examples of strong antioxidants include vitamin C and ferulic acid.
Tyrosinase inhibitors: Treatment of hyperpigmentation also involves the use of Tyrosinase inhibitors. Tyrosinase is an enzyme that works along the pathway of pigment formation at a molecular level until melanin is produced. Use of tyrosinase inhibitors prevents excessive pigment formation by blocking the action of this enzyme along all steps. Examples of strong tyrosinase inhibitors include arbutin, phytic acid, liqourice extract and hydroquinone.
Exfoliation: Exfoliation is also an essential step in treatment, the preferred method of which is chemical exfoliation by means of appropriate active ingredients. Cell turn over refers to the production and elimination of skin cells. Increasing cell turn over will allow newer, fresher cells to come up to the surface of the skin faster and exfoliation will allow removal of a build up of dead, pigmented cells. Examples of ingredients which increase cell turn over and exfoliate include retinol and glycolic acid.
Many patients have a more compromised skin as compared to others and will therefore require more care and attention so as to avoid any instance of adverse reactions whilst on treatment. Careful follow up to assess response to treatment is therefore essential. The intensity of treatment can therefore be tapered up or down according to how the skin responds. No patient should undergo any treatment or procedure without the skin being adequately prepared with active ingredients first. A sufficient response in terms of; pigment production, hydration and exfoliation of the skin are essential as this will equate to the best possible response to treatment and adequate healing of the skin.
Dermaceutic offer a comprehensive collection of active cosmeceutical products and professional treatments to target any pigmentation concern. Depending on the experience of the treating practitioner, these ingredients can be combined with other treatments and used in a stepwise approach to achieve the best possible result with the least likelihood of adverse reactions.
Below are my personal guidelines for treating pigmentation, including a basic reference as to how these products perform on the skin:
Foamer 15 – Exfoliation
C25 Cream – Antioxidants
Sun Ceutic 50+ - Antioxidants, sun protection
TriVita C30 – Antioxidants
Night time treatments in ascending order of intensity – tyrosinase inhibitors, antioxidants, exfoliation. Light Ceutic -> Yellow Cream -> Mela Cream.
Compounded prescription cream (Dermabase) – this is a physician specific compounded cream for very severe dermal melasma. It is used as per the discretion of the treating doctor. It can either be used as a last resort if little or no improvement has been observed using conventional methods or as an initial method in very severe cases requiring shock treatment and immediate bleaching effect. Use has to be monitored and stopped once sufficient improvement is noted to avoid side effects and maintain a good result for a long time.
This collection contains all the essential ingredients at the optimum concentrations to target all pigmentation concerns. The appropriateness of each product again can be tailored to the skin being treated and the treating practitioner.
The hero treatment for pigmentation from Dermaceutic is the Mela Forte peel treatment. This is a 2 step peeling procedure with various intensities according to the skin being treated and the severity of the hyperpigmentation. The skin would need to be adequately prepared prior to this procedure in order to obtain the best possible result.
Fads: The “Glutathione IV”
The use of glutathione commercially has increased dramatically over the past few years. One has to understand what glutathione is and how it functions in order to make an informed treatment choice. Glutathione is an antioxidant which is produced by our livers in response to “oxidative stress” i.e. damage to the body which results in the production of free radicals. An example of this would be oxygen deprivation after intense exercise. It thereby functions to prevent free radical damage. Due to the high dose of this antioxidant given in treatments, a side effect noted in research instances has been that of altered pigment formation. This is essentially due to its antioxidant function, however, on its own, glutathione will not lighten the skin or treat hyperpigmentation. The reason for this is essentially explained in the treatment steps explained above which highlights the importance of a multifactorial approach to treatment. Furthermore, as with any drug or supplement, overdose will result in side effects some of which include liver and kidney damage and allergic reactions.