Hyperpigmentation

Hyperpigmentation is a very common skin complaint involving areas of skin that become darker in appearance compared with that of surrounding skin. Melanocytes are the skin pigment producing cells of the body and are responsible for the appearance of darker patches through the over-production of melanin. Excessive production of melanin leads to an uneven skin tone and the development of pigmentation spots on the skin which often appear blotchy. Hyperpigmentation can affect people of all skin types from very fair skin to dark skin, independent of ones age. Excessive pigmentation of the face is often what leads most people to seek treatment options. There a number of effective treatment options for treating hyperpigmentation depending on your Fitzpatrick skin type.

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The correct assessment of hyperpigmentation is crucial when it comes to formulating an effective treatment plan tailored to the individual. The effectiveness of treatment is determined both by the type of hyperpigmentation and the Fitzpatrick skin type of the patient. Some treatments have higher risks attached when applied to patients with darker skin types.

Age spots

Age spots, also known as sun spots are flat brown areas that are very commonly linked with the ageing process. Age spots are most commonly seen in people over the age of 50 and are benign (non-cancerous) in nature. Age spots commonly occur on the face and the backs of the hands although they can occur on any chronically sun exposed area of skin. Individuals with light skin types (Fitzpatrick type 1 and 2) are more likely to develop age spots. Although age spots are benign in nature, they do often have irregular borders and therefore close monitoring as part of a skin cancer screening programme is highly recommended to identify new changes in size, shape or thickness.

Melasma

Melasma typically presents as a diffuse and blotchy darkened patches most commonly found on the face. Melasma is a type of hyperpigmention which can involve both the superficial epidermal and deeper dermal skin layers. It can also present as a mixed case with both epidermal and dermal components. The basis of melasma lies in an imbalance in the normal production of melanin pigment by melanocytes brought about a dysfunction in the pathways that controls this process coupled with other skin cells absorbing pigment in a haphazard manner. Melasma is most commonly seen in women with darker skin types and can be caused by by both internal and external influences. The internal causes of melasma include the oral contraceptive, pregnancy and common skin conditions such as rosacea and acne. UV radiation from sunlight is the main external factor but there are other factors such as certain medications and cosmetic products, hot water and overuse of topical medicines. The chronic nature of melasma and its difficulty in treating effectively is largely down to hormonal imbalances. Hormonal changes include pregnancy, drugs containing hormones, chronic stress, and use of the oral contraceptive. These factors can initiate the onset of melasma. One of the most common times for melasma to present is during pregnancy.

As with many hyperpigmentation conditions, chronic sun exposure is a major factor both in the onset of melasma and also its ongoing progression. People with melasma often get more severe pigmentation during the summer months and will notice a milder form during the winter months. Avoiding sunlight exposure alone will not address the underlying cause of melasma if there is a source of ongoing hormonal imbalance such as oral contraceptive use. A robust prevention strategy is equally important as active treatment of melasma as melasma is a chronic condition that waxes and wanes in severity. There are a number of effective treatments for melasma including skin bleaching agents, light chemical peels and laser treatment.

Post-inflammatory hyperpigmentation

Post-inflammatory hyperpigmentation or PIH, has a number of causes and active acne is one of the most common causes in many younger people. PIH is most commonly occurs in individuals with darker skin, for example, those of Middle Eastern or African origin. Our dermatologists agree that one of the most common reasons they get consulted is for treatment of PIH especially those with darker skin. PIH can be challenging to treat and can take months or even years to settle if treatment is not sought soon enough.

PIH can affect both epidermal and dermal layers of the skin. The appearance of PIH varies from various shades of brown when the epidermis is involved. The uneven brownish appearance is caused by melanocytes which have been stimulated to produce melanin which then gets spread unevenly into the local skin cells. PIH which has more of a greyish or blue colour is due to a increase of melanin production in the deeper layers of the skin. The dermis possesses specialised cells called macrophages which are involved in the breakdown of melanin in the deeper layers of the epidermis. This process is what leads to the greyish blue colour in deeper forms of PIH.

Our specialist dermatologists are able to determine the type of PIH, whether superficial or deep, using specialised dermatoscopes which then guides the most appropriate form of treatment. The use of Wood’s lamp can determine if the hyperpigmentation appears darker, this would mean that the PIH is likely to be more superficial. With deeper pigmentation, the pigmentation should not change in brightness. This means the pigment resides deeper within the skin and is probably located in the deeper dermis. Another technique of assessing hyperpigmentation involves placing the skin on tension and look for any colour changes. Pigmentation that becomes less prominent is likely to be superficial in nature. Pigmentation that does not change in any way is likely to be deeply situated. The treatment of post-inflammatory hyperpigmentation requires a combination approach using prescription skin care products such as Obagi Nu Derm, chemical peels and laser treatment. In any treatment strategy, exposure to sunlight must be minimised along with the application of sunscreen.

Other types of hyperpigmentation:

Freckles (ephelides)

Freckles also known as ephelides are small brownish spots that develop due to UV radiation found in sunlight. They are very commonly found in patients with lighter skin types and those who have blonde or red hair. Freckles develop very early on in life, often as early as a toddler. Freckles tend to become darker in colour in the summer because of the more intense and stronger sun exposure. Freckles may also increase in number during summer due to faster melanin production. Many people are happy with their freckles and do not wish to have any treatment. For those that are unhappy with their appearance, there are a range of effective treatments available for the removal of freckles. It is important to remember that continued sun exposure may lead to their reappearance. Freckles are entirely benign, though as with age spots, it is very important to keep an eye on their appearance. Suspicious features of any skin lesion include raised borders, changes in size or shape and any irregularities of pigmentation. In these case, it is always important to see your GP or one of our specialist dermatologists for an expert in-depth assessment.

Tanning

Tanning is a form of hyperpigmentation and is the response of the skin to excessive levels of sunlight leading to skin damage. Tanning can be caused by both sunlight and tanning beds and causes the skin cells to undergo accelerated degenerative changes leading to a higher risk of developing skin cancer. Younger women in their 20s who tan have a significantly higher risk of developing melanoma as compared to those who do not use tanning beds or spend long periods in the sunlight. In popular culture, a tan is often seen as a desirable feature. The truth is that both UVA and UVB radiation lead to the accelerated appearance of age spots and lines and wrinkles. The ‘base tan’ theory is based on a flawed premise that achieving a base tan before going on holiday will offer a degree of protection against sunburn. In reality, a base tan does not offer significant protection from the dangers of getting sunburn. Most experts agree that a base tan is equivalent to an SPF level of 3 which is virtually useless when it comes to adequate sun protection. In common with other lifestyle choices such as smoking, research has shown that tanning can become very addictive. Most people are aware that they feel in better mood during the summer months but the excessive exposure to UV radiation can lead to the release of endorphins which give rise to a heightened sense of well-being perhaps similar to what one feels after a workout at the gym. This almost euphoric effect is often sought on a regular basis leading to significant exposure to very harmful levels of UV radiation. The important take home message is to be aware that tanning is harmful with an increased risk of skin cancer in those who undertake it frequently.

The difference between UVA and UVB radiation

Normal sunlight releases two types of ultraviolet radiation – UVA and UVB. UVB radiation is shortwave radiation and is linked to skin redness and the development of sunburn if excessive amounts are absorbed. UVB radiation have a depth of penetration which reaches the superficial layer of skin only. Long standing exposure to UVB radiation is linked with the subsequent development of skin cancers including both non-melanoma skin cancer (basal cell carcinoma and squamous cell carcinoma) and malignant melanoma.

UVA solar radiation has a deeper depth of penetration into both the deeper epidermis as well as the dermis. The dermis contains the structural support of the skin including the cells which produce both collagen and elastin. Long term UVA exposure leads to fine line and wrinkles formation, skin thinning and accelerated aging of the skin. People who enjoy tanning and develop a tan do so because of the effects of UVA radiation. The effects of UVA radiation can be serious. UVA rays can interfere with normal production of DNA, the genetic code of our cells and errors in DNA synthesis can lead to the formation of mutations which cause hyperpigmentation. The development is a tan is actually a protective response to try and shield the delicate skin cells from further skin injury from the effects of sunlight. With ongoing damage to the DNA in cells from sunlight exposure, potentially harmful and even fatal skin cancers can eventually develop.

The most important tip for selecting the right sunscreen for your skin involves checking that the sunscreen is a broad spectrum suncream with both UVA and UVB protection.

Although hyperpigmentation is often harmless, it is usually more of a cosmetic concern for many people. An increase in levels of melanin, the pigment found in our skin, hair and eyes, is responsible for the appearance of hyperpigmentation. Melanin production can be triggered by a number of factors including certain medicines and a number of medical conditions. However the most common causes are excessive and prolonged sun exposure, traumatic injuries to the skin and hormonal imbalances.

Sun exposure

The main cause of hyperpigmentation is sunlight. Sun exposure is what initially stimulates melanin production which gives the skin its distinctive colour. Melanin functions as a natural protective barrier in the skin against the harmful effects of UV radiation. This is why sunbathers develop a tan. Chronic exposure to sunlight leads to hyperpigmentation because of prolonger exposure to UV radiation.

Dark spots are a characteristic feature of hyperpigmentation and the ongoing chronic sun exposure can result in the development of age spots, melasma and post-inflammatory hyperpigmentation to more advanced degrees.

Hormonal imbalances

Hormonal imbalance can lead to a specific types of hyperpigmentation called melasma also known as chloasma. Melasma is very common in women and is related to the 2 female sex hormones, oestrogen and progesterone stimulating the production of excessive melanin when the skin is exposed to high levels of sunlight. Hormonal medications can also be a cause of hyperpigmentation as an unintended side-effect.

(1) Reducing sun exposure

It is very important to minimise sun exposure in order to reduce potential damage to the skin from the UV radiation in sunlight. This is especially important when the sun is strong which is usually between the hours of 10am and 4pm. Appropriate protective measures should be taken include wearing protective clothing, sunglasses which block UV radiation and most importantly, sunscreen of SPF 30 or higher.

What is SPF?

Sun protection factor or SPF, is a method of determining the safe level of time which someone can spend in direct sunlight before the development of sunburn. For people who start to sunburn after 10 minutes of sun exposure then the most appropriate product would be sunscreen with an SPF of 30. With this level of protection it will last 30 times longer (300 minutes or 5 hours), before a sunburn develops. The ideal sunscreen is an approved product with an SPF of between 30 and50 and has protection against both forms of UV radiation (UVA and UVB). Centre for Surgery only recommend the very highest quality sunscreens which will have optimum protection when used for up to 90 minutes before having to be reapplied.

Can sunscreens of different SPF be combined together to give even more sun protection?

At Centre for Surgery, our dermatologists commonly get asked this question and all agree that it is not recommended to combine sunscreens of different levels of SPF. It is possible that by combining 2 or more products then the individual products will become less concentrated and may therefore achieve weaker protective effects. Another risk relates to possible chemical interaction between two different skincare products that could lead to important constituents being rendered inactive or even lead to the production of new chemical entities that are potentially dangerous for the skin.

(2) The benefits of antioxidants

Antioxidants play a crucial function in the repair of damaged skin and they also exert a skin protective function which prevents future skin damage. There are many foods which are rich in antioxidants and these include fresh fruit and vegetables containing vitamins and minerals and the more colourful – the better!. Whilst eating a healthy and varied diet is important, the use of carefully selected supplements containing Vitamin A,C and E will have an additive effect in helping in the maintenance of healthy skin. It is widely known that many commonly available skincare products fail to meet their ambitious claims, and this is very often because they lack the correct mixture of antioxidants needed to adequately penetrate the skin. Our dermatologists promote the premium SkinCeuticals cosmeceutical range. SkinCeuticals antioxidant products are medical grade and are designed by doctors for doctors – scientifically and clinically proven.

(3) Avoid picking your skin

An obvious yet often overlooked skin care tip to prevent hyperpigmentation is to refrain from picking at your skin. Many acne sufferers often develop worse scarring that what would be expected due to picking at scabs that form after active acne episodes begin to resolve. Always resist the temptation to skin pick and use prescription grade skin care products to prevent exacerbations of acne.

(4) Choosing the right skincare products

Skin care products are largely unregulated in the UK with many unfounded claims of treatment efficacy being made on an almost daily basis. It is a sad fact that the vast majority of skin care products are completely useless as they fail in penetrating the skin sufficiently enough to address underlying hyperpigmentation. Many manufacturers fail to test their products regularly to prevent the skin care ingredients from degrading during the transport process. Many companies promote antioxidant lines that fail to penetrate even the most superficial layer of the skin leading to a lack of treatment effect. Dermatologists at Centre for Surgery work with only clinically effective skincare products and have selected SkinCeuticals as their cosmeceutical range of choice. SkinCeuticals work closely with Dermatologists to ensure that the latest scientific breakthorughs are translated into clinically products that benefit patients leading to healthy and vibrant skin.

The principles of treatment of hyperpigmentation is to prevent the pigment producing cells or melanocytes from producing melanin, the pigment found in skin. Many treatment methods focus on preventing the action of an enzyme called tyrosinase. Tyrosinase inhibitor treatments work to prevent the stimulation of pigment producing cells from making melanin which would otherwise get spread irregularly in the skin. Many common skincare treatments for hyperpigmentation have skin brightening properties because they block the action of tyrosinase. Treatment for hyperpigmentation can be gentler or more aggressive depending on patients tolerance of downtime. More aggressive in-clinic treatments like ablative laser carry more downtime compared with topically applied home skincare regimens but with more dramatic results achieved a lot quicker.

Guide for effective hyperpigmentation treatment:

• Reduce sebum production
• Use a skin preconditioning protocol prior to peels or lasers
• Skin bleaching
• Use of exfoliation agents
• Use lasers and treat more aggressively if possible (light skin types)
• Optimise skin barrier function
• Reduce or eliminate inflammatory processes

Topical treatments for hyperpigmentation

Hydroxyquinone

Hydroxyquinone is a skin bleaching agent available in 4% prescription strength. It exerts its action by blocking the production of melanin although its effects are temporary in nature. This leads to a reduction hyperpigmentation. Hydroxyquinone is the most powerful of the topical agents used to treat hyperpigmentation and works by eliminating the pigment producing cells that make melanin. For more extensive types of hyperpigmentation, hydroxyquinone is combined with other topical agents including tretinoin, weak acids, vitamin C and steroids. Hydroxyquinone can cause increased sun sensitivity to the skin and so it is important to avoid exposure to sunlight and tanning is not advised. The presence of melanin helps to block harmful UV radiation from damaging the skin and our dermatologists therefore recommend that hydroxyquinone not be continued beyond 4-6 months of use. Prolonged use can have adverse effects on the skin. In rare cases, the use of prolonged high doses of hydroxyquinone can lead to effects that are opposite to its intended use – the development of oochronosis. Oochronosis is a condition that results in hyperpigmentation due to excessive production of melanin.

Retinoids

Retinoids are a class of topical agent that originates from Vitamin A and is used either alone or combination with other topical products for the treatment of hyperpigmentation. The most well known product is tretinoin and is a prescription only product that comes in three strengths – 0.025, 0.05 and 0.1% concentrations. Retinoids have a number of mechanisms in which they act to reduce pigmentation and cause lightening of the skin. Use of retinoids leads to death of pigment producing cells, has anti inflammatory effects and also acts on other skin cell functions to address hyperpigmentation. It typically takes 4-6 months to see an improvement in hyperpigmentation when retinoids at prescription strength are used regularly. In many patients, they can expect to notice an increase in redness, some skin peeling and a certain amount of skin irritation when retinoids are initially started which should settle with time. Your dermatologist will determine the most appropriate dose of retinoid to use and will be regularly modified based on your skin response to treatment. As with hydroxyquinone, it is important to stay out of sunlight when on retinoid treatment. The most powerful form of retinoid comes in oral tablet form and is known as Isotretinoin or Roaccutane and is use for the treatment for severe acne and only under the supervision of a dermatologist.

Lactic acid

Lactic acid comes from milk and has been used for skin lightening for thousands of years from the time of ancient Egypt when Cleopatra allegedly used to takes baths in milk to maintain her healthy looking skin. Lactic acid has a number of ways in which it acts to increase lightening and reduce hyperpigmentation. Firstly it has mild exfoliative properties and it also helps to inhibit the pigment producing cells from making melanin. Lactic acid also has anti aging benefits through the reduction of fine lines and wrinkles, improvment in the appearance of acne and the stimulation of collagen production leading to healthier skin. Lactic acid is a common ingredient of many popular skin care products and mild chemical peels.

Vitamin C

Vitamin C or Ascorbic acid, is an antioxidant found in many fresh fruits and vegetables such as oranges and green vegetables. Vitamin C is a tyrosinase inhibitor and by reducing the production of melanin leads to skin lightening. Vitamin has anti inflammatory effects. Vitamin C needs to penetrate the skin effectively to deliver its beneficial effects and this is the problem with many inferior skin care product lines containing Vitamin C. Our dermatologists use only premium medical grade skin care products including CE Ferulic made by SkinCeuticals.

Azelaic acid

Azelaic acid or AA, originally comes from wheat, rye and barley and is an effective agent in the treatment of hyperpigmentation. AA is a tyrosinase inhibitor and is effective in eliminating defective pigment producing cells. As with most of the topical agents for hyperpigmentation, best results when combinations of topical agents are used especially for difficult cases of hyperpigmentation like melasma and post-inflammatory hyperpigmentation. Azelaic acid is also very useful for the treatment of rosacea as it possesses anti inflammatory activity and also for active acne treatment. Propionibacterium acnes is a common bacteria found in acne skin. By reducing the keratin component of skin with AA treatment, the bacterial growth is reduced or even stopped.

Arbutin

Arbutin is a chemical which is commonly found in blueberries. Arbutin when applied to the skin, rapidly becomes converted into the chemically active agent, hydroxyquinone. Arbutin is more tolerated than hydroxyquinone as a skin bleaching treatment as the slow conversion to hydroxyquinone  only occurs within the skin. This leads to less side effects typically seen than with hydroxyquinone including less skin irritation. As with vitamin C, arbutin is a tyrosinase inhibitor and reduces the production of pigment producing cells. It has been that arbutin may better suited to the treatment of hyperpigmentation in lighter Fitzpatrick skin types compared with darker skin types.

Combination topical treatments

The treatment of hyperpigmentation requires time to achieve effective results. Many patients have expectations of seeing results within a few weeks to 3-4 months. Each of the topical agents described above is effective in treatment on its own, however the very best results are seen when multi-agent combination treatments are used. The Obagi Nu Derm system uses the well known combination of Hydroxyquinone 4% combined with tretinoin cream. Patients on the Nu Derm protocol can expect to see results within 2-3 months of commencing treatment. The best results are obtained when Obagi Nu Derm applied at home is combined with dermatologist delivered chemical peels and laser treatments in the clinic. This method also reduces the time taken to see significantly improved results. The downside of a more aggressive treatment protocol is the more sensitive nature of skin arising from treatment. Both redness and irritation are not uncommon symptoms to experience during the first couple of weeks of treatment. All hyperpigmentation treatments should be combined with sunscreen with an SPF of at least 30 to prevent against adverse side effects or complications.

Dermatologists at Centre for Surgery are recognised experts in hyperpigmentation and will assess and manage you closely to achieve optimal results. Once you have achieved optimal treatment, it is important to maintain healthy skin habits such as reducing sun exposure. Although reducing skin exposure is the pillar of any prevention strategy, it is also important to use medical grade skin products on a custom designed protocol by one of our dermatologists for long term healthy and youthful skin.

Chemical peels

There are a variety of chemical peels which can be used to treatment hyperpigmentation. The depth of penetration of determined by the strength of the peel. Patients with lighter skin types may be well suited to a 30% TCA peel for significant improvement in hyperpigmentation. Your dermatologist will be able to discuss with you all the type of peels and their pros and cons and which is best for your skin type.

Erbium laser resurfacing

Erbium laser resurfacing is extremely effective in reducing and eliminating hyperpigmentation. The outstanding Fotona SP Dynamis laser is fully equipped to perform all types of laser resurfacing at all skin depths, whether superficial, medium or deep resurfacing.

The superficial laser peel is great for removing pigmentation occurring at the outer epidermal layer and results in a more refreshed appearance with minimal downtime of 3 to 5 days.

The medium peel addresses more significant pigmentation at the deeper skin layers. Coarse skin texture can also be treated. The downtime with medium depth peels is about 1 week.

Fully ablative laser resurfacing

The fully ablative erbium laser peel is a deep laser resurfacing treatment performed only by a dermatologist. After a skin preconditioning protocol for 6 weeks, the laser is performed to the depth of the dermal level, fully ablating the epidermis. Even severe degrees of hyperpigmentation are treated along with coarse skin texture and fine lines and wrinkles. Fully ablative laser peels are not advised in those with darker skin types due to the risk of aggravating the hyperpigmentation. The downtime after fully ablative laser resurfacing is approximately 2 weeks.

Before and after of fully ablative Erbium laser resurfacing:

CO2 laser is an older type of laser similar to Erbium YAG laser in that it is an ablative laser. CO2 laser is only applicable to light skinned patients and can only be performed as a fractional laser treatment. This is because CO2 laser carries significant risks of scarring and hyperpigmentation. At Centre for Surgery CO2 laser has been superseded by state of the art Erbium laser resurfacing for hyperpigmentation.

Our specialist dermatologists have years of experience in treating hyperpigmentation on a range of skin types. Your dermatologist will carefully assess you to determine the correct diagnosis and formulate a customised treatment plan. We have the full range of treatment options from topical skin care to peels and lasers to get the results for each patient.

Centre for Surgery is located at 106 Crawford Street in Marylebone. Crawford Street is just off Baker Street. We are easily accessible by all major bus routes that pass through Baker Street as well as Baker Street underground station.

From the tube station, we are just a 5 minute walk southwards down Baker Street followed by a right turn onto Crawford Street. The clinic is about 200 yards on the left.

There is ample local pay & display parking in the surrounding area and an NCP car park is located further west along Crawford Street. Our local residential parking zone is the City of Westminster.

Address: 106 Crawford Street, Marylebone, London, W1H 2HY