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by dr alek nikolic

introduction

Hyperpigmentation is one of the commonest skin concerns and will affect over 40% of us, usually starting in the 30s and 40s. Hyperpigmentation, also known as pigmentation, presents as visible marks on the skin, which tend to be a deeper tone or colour.

Dr Alek shares his professional expertise on what causes hyperpigmentation, how to prevent it and how to manage and treat dark marks.

what is hyperpigmentation?

To understand hyperpigmentation, let’s take a closer look at how the skin normally produces pigment or colour.

The main function of pigment in the skin is to provide a natural defence against the sun’s UV rays. It is vital for our skin’s health and is the reason we tan with sun or UV exposure.

In the skin are cells known as melanocytes whose primary function is to produce pigment that, in turn, determines our skin colour or tone. Very simply, without these pigment producing cells (melanocytes) everyone’s skins would be pale white with tinges of pink caused by the blood flow through capillaries and veins.

The main function of the pigment in our skins is to provide us with a natural defence against the sun’s UV rays. So, having pigment or melanin is a vital structure and necessity for our skin’s health.

People with albinism have little or no melanin, their skin appears white or pale pink and they are at great risk of UV damage, including skin cancer. Similarly, fair-skinned people produce very little melanin, whilst darker-skinned people produce more melanin.

Usually, melanin is fairly evenly distributed throughout the skin, but sometimes people have spots or patches of skin with more melanin. Examples include freckles, age spots (lentigines) and melasma.

Melanin or pigment is produced by specialised cells known as melanocytes which are scattered among the other skin cells in the top layer of the skin, known as the epidermis. After pigment or melanin is produced, it spreads into other nearby skin cells. A normal and natural response of melanin or pigment stimulation in the skin can be seen with some sun or UV exposure. This is the reason why we tan, and our skin’s tone can change from a lighter colour to a darker colour which in turn provides our skin with a natural protection from the sun.

The cascade of events that takes place during pigment formation is extremely complex and involves multiple processes and pathways.

“A scientist could spend a lifetime on the study of the melanocyte and not fully understand it.”

– Dr Pugliese.

However, the mainstay of melanin or pigment formation depends on an enzyme tyrosinase converting tyrosine to DOPA and DOPA into melanin. DOPA is an amino acid and is a precursor to pigmentation. Understanding this cycle, helps understand why certain treatments work, as they typically work on the enzyme tyrosinase.

figure 1.

Pigmentation-article-graph-no-borders

what causes hyperpigmentation?

There are numerous causes for hyperpigmentation but all relate to an over-stimulation of the production of pigment in the skin. When the pigment producing cells are over-stimulated there is excessive production of pigment which shows up as the darker marks or patches in the skin, or what is known as hyperpigmentation.

typical causes of hyperpigmentation include:

1. excess sun exposure or UV damage

When the skin is exposed to the sun, melanin or pigment is produced to provide natural protection against UV rays. If we over-expose or burn the skin, there is an overproduction and deposit of melanin which can lead to hyperpigmentation. These may develop as freckles, age spots, liver spots, solar keratosis (flat or raised lesions) or dark non confluent patches (dark patches that have not merged together) or dark confluent patches, that are typically larger than freckles.

2. hormonal changes

Hormonal fluctuations, especially increases in oestrogen and progesterone that can occur with pregnancy or the contraceptive pill, can lead to an overstimulation of pigment formation. This is often referred to as melasma or chloasma (the mask of pregnancy). Melasma generally appears as large, dark brown confluent patches above the lips, on the cheeks and forehead.

3. inflammatory skin conditions

Inflammation tends to produce a healing response within the skin. When we experience a burn, an acne lesion, or a rash, the skin and inflammatory cells released to aid the healing of the skin tend to also trigger the pigment producing cells or melanocytes. This results in a dark patch or area that remains for a period after the initial inflammatory lesion has healed and disappeared. Occasionally it may remain permanently and will require treatment to lighten or resolve the dark pigmentation left behind.

4. skin treatments or trauma

Trauma such as a cut or laceration has a similar response to inflammatory skin conditions. This does not happen every time, but in some of us we will experience a deposit of pigment where the cut or laceration took place.
Similarly, skin treatments such as lasers; medium or deep chemical peels, Dermapen rarely, and even dermal fillers, can cause an overstimulation of the pigment producing cells which leads to hyperpigmentation.

5. medication

Hyperpigmentation can be induced by a wide variety of medication, the most common of which includes: non-steroidal anti-inflammatory drugs (NSAIDs) such as Aspirin, Voltaren, Ibuprofen; antimalarial drugs such as chloroquine and hydroxychloroquine; epilepsy treatments such as phenytoin; certain antipsychotic drugs; antibiotics such as tetracyclines; and heavy metals.

6. genetics

Some rare hereditary disorders can predispose you to developing hyperpigmentation, such as Incontinentia pigmenti and pigmentary mosaicism. Treatments for this are difficult, considering it is genetically determined.

how to prevent hyperpigmentation

Prevention is usually better than cure. There are several steps that can help prevent hyperpigmentation and the most obvious is sun avoidance. However, this is almost impossible as we are exposed to the sun throughout the day - driving and stepping out of the car, exercising outdoors or watching our children’s sport, UV reflection off surfaces such as glass, white sandy beaches and even walls, visiting friends for an afternoon get-together.

6 steps to prevent sun damage:

  1. Do not actively tan.
  2. Be aware of other sources of UV exposure e.g. watching sport, outdoor exercise, reflections off water, glass and white sand etc
  3. Wear a sunscreen that contains zinc oxide and/or titanium dioxide with a SPF 30 or higher. Apply several times daily. The most important product in your skincare regime is sunscreen.
  4. Use sun avoidance techniques as much as possible. This includes wearing a wide brim hat that will allow as much coverage and blockage of the suns UV rays as possible. Remember a cap only stops direct sun from its front peak and still allows the UV rays to reach your face and neck from the sides and the back of the cap. One should also consider using an umbrella especially in situations where UV exposure for more than 10 minutes is unavoidable.
  5. Find a mineral makeup suitable for your skin which contains mineral ingredients that block the sun’s UV rays.
  6. Add a vitamin C based serum to your morning skincare routine, such as sk.in gloss. Vitamin C provides a natural increase in your skin’s SPF and also helps to boost the effectiveness of your sunscreen’s SPF.

how to manage hyperpigmentation

Firstly, the best way to manage hyperpigmentation once it has developed, is to follow the prevention steps listed above. This is paramount in the success of managing hyperpigmentation. No matter which treatment protocol we follow, if we continue to expose our skin to UV rays and do not use protective measures, the treatment success is greatly diminished. Secondly, to consider a treatment protocol that will suit your lifestyle and budget.

treating hyperpigmentation

Treating hyperpigmentation is difficult for a number of reasons:

  • It is impossible to completely avoid the sun’s UV rays so there will always be some pigment stimulation in our skin.
  • Studies have shown that our pigment producing cells, the melanocytes, have small extruding cellular ‘tentacles’ known as dendrites that act as memory cells. So even when we remove the main pigmented lesion with ongoing UV exposure these memory cells become activated and the pigment is produced again.

However, with a good treatment protocol and ongoing continuous use of a sunscreen and other sun ‘avoidance’ approaches, we can definitely soften and even prevent hyperpigmentation formation.

The best approach to treating hyperpigmentation would be to consider a combined treatment regime. I typically recommend that my patients consider a good skincare topical regime and consider an in-office medical treatment. If, however, budget is a concern, then a good targeted topical regime will make a difference, but it will not be as effective as when combining our treatment approach.

In-office medical treatments include chemical peels, Dermapen (or needling devices) and lasers such as IPL and fractional lasers.

topical skincare for hyperpigmentation

The basis of any skincare regime for hyperpigmentation is SPF protection, chemical exfoliation (increasing cellular turnover and removing the dead outer layer of skin cells) and targeting the pigment - either by lightening existing hyperpigmentation in the skin and / or preventing hyperpigmentation formation in the first place.

i. SPF protection

A topical SPF, applied several times a day is an absolute necessity in preventing and treating pigmentation.
I recommend using a mineral SPF, such as zinc oxide and/or titanium dioxide because they are most effective and they are considered environmentally safe. Not all mineral sunscreens are considered safe for our coral reefs. It has been shown that mineral based sunscreen ingredients must be larger than 100 nanometre in size as this prevents the mineral from being absorbed by the coral reef. When choosing a mineral sunscreen look for products that indicate that the ingredients are not nano particles. This is often displayed as non-nano zinc oxide and/or non-nano titanium dioxide.
Minerals reflect harmful rays, preventing UV from entering the skin cells, which minimises pigment stimulation and helps prevent free radical damage. Free radicals can also lead to hyperpigmentation as they cause oxidative damage to the skin. These environmental stressors include pollution, smog and invisible light emitted by computer and phone screens.
Some sunscreens contain chemicals that work as UV absorbers. The concern with these is that the UV absorption leads to a build-up of energy within the skin. This may lead to genetic changes in the skin causing further harm and pigment formation. There are studies that show some chemical absorbers have a harmful effect on coral reefs. Avoid sunscreens that contain chemical absorber ingredients such as oxybenzone, benzophenone-1, benzophenone-8, OD-PABA, 4-methylbenzylidene camphor, and 3-benzylidene camphor.

ii. chemical exfoliation

There is a difference between granular (or mechanical exfoliation) and chemical exfoliation of the skin. I am a firm believer in chemical exfoliation versus granular.

The concern with granular exfoliation is two-fold:

  • The first is that these granules, unless they are naturally derived such as from bamboo, will be harmful to the environment. Plastic beads are not biodegradable.
  • Secondly, granular exfoliation tends to disrupt the natural pH balance and cause damage to the important outer skin barrier. This leads to inflammatory responses in the skin which in turn leads to sensitivity reactions, either an over or under production of sebum, and stimulation of inflammatory markers in the skin with possible pigment formation.

Chemical exfoliation uses mild acids in facial cleansers such as glycolic acid or salicylic acid. These acids have the ability to remove the outer dead layer, increase cellular turnover, and allow stimulation of new cell formation. Exfoliation is an important step in treating hyperpigmentation as this removes the more superficial layer of the pigment and allows for other topical ingredients to penetrate deeper into the skin. This in turn allows these ingredients to act and target the deeper parts of the pigment, for improved results.

serum ingredients that target hyperpigmentation

There is a large number of serums and ingredients that target and help to diminish the appearance of hyperpigmentation. The commonest ingredients used in these serums include arbutin, vitamin C, vitamin E, vitamin B3 (niacinamide), kojic acid, and vitamin A (retinoids). I will discuss each of these ingredients briefly.

arbutin

Arbutin is one of the most widely prescribed skin-lightening and de-pigmenting ingredients worldwide. Arbutin is a naturally occurring plant-derived compound found in the dried leaves of a number of different plant species including bearberry, blueberry, cranberry, and pear trees. Arbutin works by inhibiting tyrosinase activity which is the enzyme needed for the pigment formation process to be completed. It also inhibits the pigment cell from maturing, which ultimately slows down the pigment formation process and helps to lighten visible pigmentation.

vitamin c

Vitamin C is one of my ‘go-to’ ingredients when it comes to treating hyperpigmentation as it has a double action. Firstly, it works as an antioxidant which protects our skins from free radical environmental damage and from invisible light (monitors, screens, etc.); and secondly, it acts as an inhibitor of tyrosinase and stops multiple steps in the production of melanin. The most stable forms of topical vitamin with the greatest absorption, are water-based ascorbic acid and lipid-soluble vitamin C, such as magnesium ascorbyl phosphate and ascorbyl tetraisopalmitate. A study compared 5% ascorbic acid and 4% hydroquinone in 16 female patients with melasma and found 62.5% and 93% improvement respectively. Side-effects were present in 68.7% with hydroquinone versus 6.2% with ascorbic acid.

vitamin E

Vitamin E has been shown to have the ability to dramatically increase the skin’s photo-protective effects. Vitamin E prevents melanin or pigment formation by interfering with the normal membrane functions of melanin cells and inhibition of the tyrosinase enzyme.
Studies have shown that combining topical vitamin E and C will provide better results than using either vitamin E or vitamin C alone, topically.

vitamin B

Vitamin B3 works by inhibiting a number of enzymes that are needed to produce pigment in our skin cells. Clinical studies using 2% niacinamide, a form of vitamin B, have shown that it significantly reduces the total area of hyperpigmentation and increases skin lightness after 4 weeks of treatment.

kojic acid

Kojic acid is a naturally occurring ingredient derived from different fungi including acetobacter, aspergillus, and penicillium. It reduces hyperpigmentation by inhibiting the production of free tyrosinase and is also works as a potent antioxidant. In most topical formulations kojic acid is used in concentrations ranging from 1% to 4%.

vitamin a

Retinoids are derivatives of vitamin A, and are used to treat various pigmentation disorders like melasma and post-inflammatory hyperpigmentation. It works by inhibiting the tyrosinase enzyme and causes pigment in the skin cells to disperse or breakdown. My recommended ingredients when it comes to Vitamin A is retinol or hydroxypinacolone retinoate (HPR). HPR, also known as granactive retinol, is a relatively new member of the vitamin A family. It is a retinoic acid ester which allows it to bind directly to the all-important retinoic acid receptors in the skin. Furthermore, it has been shown to be one of the most stable forms of vitamin A and also the least sensitising, allowing one to use higher concentrations with fewer side effects.

in-office medical treatments

dermapen

Micro-needling devices, such as Dermapen 4 which we use in our practice, is one of the most popular skin rejuvenation treatments worldwide and for good reason. As well as enhancing the look and feel of the skin, it can also treat and help reduce acne marks, improve fine lines and wrinkles, and reduce hyperpigmentation.

Needling devices work by promoting deep dermal collagen production and increased cellular turnover. Very simply, small needles penetrate the skin creating multiple fine fractional channels. These channels can carry up to 80% more topical nutrients, deeper into the skin which results in an increased production of collagen and elastin and a better targeting effect of topical ingredients. It is particularly effective for hyperpigmentation.

I recommend all hyperpigmentation patients undergoing Dermapen treatments to add retinol during treatment. After cleansing the skin, a layer of the retinol e.g. sk.in avenge HPR, is applied followed by a gliding agent. As the needles penetrate they force retinol into the deeper layers. This increased absorption and penetration allows for a superior inhibition of the tyrosinase enzyme and causes pigment to disperse or breakdown. The only downside is that ‘downtime’ is extended by several days as there will be visible peeling and dryness which tends to resolve within 5 to 7 days.

lasers

There are several types of laser treatments for hyperpigmentation, which work on the principal of emitting a specific light wavelength that targets dark marks.

Skin cells have the ability to absorb light and certain cells have a propensity to absorb certain light wavelengths to a greater degree than other wavelengths. It’s been established that hyperpigmented cells tend to mostly absorb wavelengths between 530 to 750 nm (nanometres). This technology has allowed the development of lasers specifically to target hyperpigmentation.

During this type of laser treatment, energy and heat builds up in the pigmented cells, destroying them. Over time, these cells are brought to the surface and are sloughed off, resulting in lightening or removal of the dark marks.

There are two types or classes of lasers that treat hyperpigmentation: Intense Pulse Light (IPL) which uses a xenon flash lamp as the energy source and fractional lasers which use a laser. The most widely used to treat hyperpigmentation is IPL.

IPL

IPL therapy is considered a non-ablative laser treatment as all IPL machines tend to focus their light energy in the deeper layers of the skin and does not affect the outer and top layers of the skin. The advantage of IPL over fractional lasers is that there is no to minimal downtime and people can return to work immediately after the treatment. With fractional lasers there will be some downtime experienced, including redness, inflammation and some mild scabbing.

The downside to an IPL is that results are not as dramatic as with the fractional laser and that multiple sessions will be required to achieve similar results. IPL treatment sessions usually take between 20 to 45 minutes depending on the size of area/s treated and the type of IPL used. To achieve best results, one would need to consider between four to six treatment sessions that are spaced every four to six weeks.

There are some potential side effects but generally these are rare and are dependent on the person operating the IPL machine:

  • Pain during treatment
  • A red inflamed skin immediately after the treatment that usually subsides within 1 to 2 hours
  • Some people experience swelling
  • You may experience a sunburn-like feel on the skin following the treatment. This also tends to subside within a few hours
  • If the energy setting is too high, or if cells absorb too much energy, a burn and scabbing can be seen
  • Inflammatory reactions or a burn may lead to further hyperpigmentation and even a loss of pigment known as hypopigmentation
  • It is important that men undergoing the treatment are informed hair loss may occur over the beard area

chemical peels

Chemical peels can be effective in treating hyperpigmentation. These acidic solutions come in three strengths or types - superficial, medium and deep. The strength of the peel is determined by the depth it reaches in the skin, the results achieved and the degree of downtime.

superficial chemical peels  typically use alpha hydroxy acids (AHA) and beta hydroxy acids (BHA) such as glycolic acid, citric acid, mandelic acid and salicylic acid. They are formulated to remove the outer skin layer, known as the epidermis, and are aimed at treating superficial hyperpigmentation, fine lines and wrinkles and improving skin texture. There is little or no downtime required with these peels. You can typically return to work after the treatment, which has given them the name ‘lunchtime peels’. You may experience mild discomfort during the treatment, which usually lasts between 2 to 5 minutes.

medium depth chemical peels typically use trichloroacetic acid (TCA) solution (between 20% to 50%) or a 70% glycolic acid. These chemical peels tend to reach the upper layers of the dermis, the layer just below the epidermis, and are aimed at treating scarring, deeper wrinkles and hyperpigmentation. They can be painful and often some form of pain control will be required. Downtime can be 5 to 7 days during which time you may experience stinging, burning, heat and peeling and the skin sloughs off.

deep chemical peels typically use a stronger TCA solution (greater than 50%) or phenol acid to reach the deepest part of the skin. Downtime can take between 7 to 14 days during which time there may be pain, swelling, scabbing and even some crusting.  Deep chemical peels are extremely effective at treating deeper wrinkles, scarring and deep-seated hyperpigmentation.

superficial chemical peels are the most popular chemical peel treatments performed worldwide today. I will focus on a few of the ingredients used in superficial chemical peels in more detail below.

glycolic acid

Glycolic acid is one of the most popular and studied superficial peeling agents. It is an alphahydroxy acid (AHA) derived from sugar cane. Glycolic acid at concentrations of 20 to 50% has demonstrated excellent clinical efficacy in the treatment of superficial hyperpigmentation, mild-to-moderate intrinsic ageing changes, UV induced ageing and fine lines and wrinkles. Glycolic acid chemical peels are often considered a good starting choice for the treatment of melasma.

citric acid

Citric acid is an alphahydroxy acid (AHA) and a betahydroxy acid (BHA) and has shown to have a strong antioxidant activity against environmental free radical scavenging effects. In studies using concentrations of citric acid (ranging from 10% to 25%), visible improvements in skin includes a thickening of the skin due to increased collagen stimulation, lightening of hyperpigmentation and increasing the effect of glycolic acid.

sk.in ProPeel | glycolic-20 citric-30

sk.in ProPeel | glycolic-35 citric-30

sk.in ProPeel | glycolic-50 citric-30

lactic acid

Lactic acid has demonstrated when compared to standard glycolic acid peels, a comparable efficacy in the treatment of superficial hyperpigmentation. Because lactic acid has a lower pH than glycolic acid, a lower concentration is often used to achieve an equivalent depth of penetration when compared to glycolic acid which allows a favourable side effect profile and recovery time.

sk.in ProPeel | mandelic-20 lactic-35

kojic acid

Kojic acid has several cosmetic skin benefits as it acts as a powerful tyrosinase inhibitor (to inhibit melanin or pigment formation), skin whitening or depigmenting agent, anti-inflammatory, UV protector and as an antioxidant.

sk.in ProPeel | kojic-5

my recommended sk.in products for hyperpigmentation

sk.in has been formulated with powerful active ingredients to target specific skin concerns like hyperpigmentation.

My recommended sk.in regime for managing hyperpigmentation includes:

chemical exfoliation and targeting pigment by lightening existing pigmentation and preventing pigment formation.

It includes:

  • sk.in pure for a mild exfoliation
  • sk.in avenge | glyco-10 for an at-home chemical exfoliation treatment
  • sk.in gloss with lipid-soluble vitamin C to target and prevent hyperpigmentation
  • sk.in flash with granactive retinol vitamin A to target dark marks
  • sk.in avenge HPR can be added as an at-home treatment once a week for enhanced results

chemical exfoliation recommendations

The main goal of chemical exfoliation is to remove the outer dead layer of skin, to target the superficial pigmented lesions and to allow better penetration of the ingredients used to target the pigment in the skin. In the sk.in range of products we have topical exfoliation products that are indicated specifically for oily and acne prone skin types and for normal and combination skin types.

chemical exfoliation indicated for oily and/or acne skin:

sk.in pure

sk.in pure contains salicylic acid and pineapple and papaya enzymes that all help in exfoliating the skin.

the main benefits of salicylic acid:

there are three main benefits of salicylic acid:

  1. It is a comedolytic agent: used for people who suffer from oily and/or acne prone skin.
  2. It exfoliates the skin: helps to rejuvenate the skin and prevent and treat ageing skin changes.
  3. It improves the penetration of certain topical ingredients: this enhances the effect of your topical skin regime.
  4. It has both antibacterial and antifungal effects.

Salicylic acid causes an exfoliation of skin through loosening and detachment of corneocytes. Corneocytes are epidermal skin cells that make up the outermost part of the epidermis. The importance of this is that salicylic acid does not ‘burn’ or wound skin cells. Exfoliation is allowed simply by the breakup of cells from one another.

Salicylic acid is an excellent exfoliating-at-home chemical peel that will have a direct effect on fine lines and wrinkles, improve hyperpigmentation, soften and smooth the skin texture, prevent ageing skin changes, and increase collagen and elastin production without thinning the skin.

chemical exfoliation indicated for normal and/or combination skin:

sk.in avenge | glyco-10 

The sk.in avenge | glyco-10 solution has been formulated with potent ingredients to target and repair the skin by acting as an at home chemical peel that requires no neutralisation.

its three primary goals are to:

  1. Target specific skin concerns such as: ageing prevention, hyperpigmentation, pored and textured skin, and fine lines and wrinkles.
  2. Prevent intrinsic skin ageing and repair UV damage to the skin.
  3. Maintain and repair the skin barrier.

Glycolic acid is an alphahydroxy acid that was originally derived from sugar cane and has become one of the most popular alphahydroxy acids (AHA) used in skincare products. Glycolic acid has a small molecular size which allows it to be easily absorbed through the skin and its primary action is to exfoliate the outer skin layer and to increase cell turnover. Glycolic acid has demonstrated excellent clinical efficacy in the treatment of superficial hyperpigmentation and mild-to-moderate intrinsic skin ageing and UV induced skin changes.

Salicylic acid is an excellent exfoliating-at-home chemical peel that will have a direct effect on fine lines and wrinkles, improve hyperpigmentation, soften and smooth the skin texture, prevent ageing skin changes, and increase collagen and elastin production without thinning the skin.

target and prevent recommendations

sk.in gloss

sk.in gloss is a daytime use high strength lipid soluble vitamin C serum that is specifically indicated for the use as an antioxidant, to treat hyperpigmentation, and provides skin brightening effects. 

its primary goals are to:

  • Synergistic antioxidant effect with Vitamin E.
  • Vitamin C has an added benefit in helping to reduce pigmentation.
  • Increasing skin hydration.
  • Niacinamide helps to reduce pigmented discolorations.
  • Ferulic Acid Ester helps defend skin against environmental assault and helps to reduce skin inflammation.

sk.in bounce

sk.in bounce is sk.in’s flagship serum with a unique combination of both hydroxypinacolone retinoate 1% (vitamin A) and lipid soluble vitamin C 5% that provides a powerful antioxidant duo. Indicated specifically for treating and preventing ageing skin concerns such as fine lines and wrinkles, textured skin, sallow complexion and hyperpigmentation. No fuss, easy single serum application. It’s our flash, marvel and gloss in one.Its primary goals are to:

  • To reduce the signs of ageing
  • A lightening and breakdown of hyperpigmentation.
  • Repair the skin barrier
  • Protect the skin against environmental damage
  • Improve hydration.
  • a plumping effect of the skin.
  • skin inflammation.

hyperpigmentation targeting super-serum:

sk.in avenge | HPR 3%

sk.in avenge | HPR products contain high concentrations of hydroxypinacolone retinoate (granactive retinol) and are designed to deliver a potent treatment for the skin that should only be used once or twice weekly. Formulated for preventing ageing skin concerns and to counteract the signs of UV sun damage and intrinsic skin ageing.

its primary goals are to:

  1. Improving hyperpigmentation, fine lines and wrinkles, blemishes and acne. Acting as an antioxidant.
  2. Minimising pores and sebum production.
  3. Reducing sebum production.

before and after results

Before and After Results
Before and After Results-2

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