Top Aesthetics Treatments For Hyperpigmentation

A Tricky Condition

Hyperpigmentation can be a troublesome issue for many people. It can be difficult to treat and, unfortunately, for some people, the treatments can cause the pigmentation to either get worse, or go and come back with a vengeance (rebound hyperpigmentation).

In a further blow, those with darker skin types, tend to have the most resistant hyperpigmentation and the most difficult to treat.

Let's first look at how pigmentation (and hyperpigmentation) works and what causes it.

Melanin is a pigment produced in the skin by melanocytes in the basal layers, then carried to the surface by keratinocytes to protect it from the harmful effects of sunshine. It does this by absorbing the energy from UV light before it can get to the sensitive DNA in each cell. There is evidence to show that melanin can also mop up harmful oxidative molecules, prevent formation of stomach ulcers, as well as reduce inflammation in the body. Naturally, darker skin tones have more of the melanin, and produce it quicker in response to sunlight. (As an interesting aside, different hair colours are the result of different quantities of various types of melanin.

So far, so good.

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Causes of hyperpigmentation

Differences in pigmentation are due to the number of melanocytes and the distribution of different types of melanin. So a large part of hyperpigmentation will depend on genetics. There are of course other causes

• Age. Sunspots or liver spots are a result of years of sun exposure. This leads to overactive pigment cells where melanin is produced in high concentrations and becomes clumped together.
• Sunbathing. Sun Exposure will cause an increase in melanin production, but in some people the process will not be even, leading to darker areas.
• Inflammation e.g. due to acne.
• Post-inflammatory hyperpigmentation (PIH) is where the inflammation triggers excessive melanocyte production as part of the healing response, which darkens the area, and is left after the previously inflamed area heals.
• Hormones. Changes in hormone levels eg during pregnancy, sometimes called melasma or chloasma. A steep rise in oestrogen and progesterone can stimulate excess melanin production.
• Disease states. For example Addisons Disease. The low levels of cortisol triggers production of a hormone called ACTH which causes an increase in melanin production.

This is not a comprehensive list, but as we can see, hyperpigmentation can have many causes, which is why its not always easy to treat.

What Is The Best Treatment For Hyperpigmentation?

In many cases, identifying the initial cause of hyperpigmentation and addressing that will go some way towards treating it.

For example in pregnancy, once the baby is born and the hormones normalise, the skin is very likely to go back to normal over a period of months. Any hyperpigmentation that is left might be treated effectively with a mild peel.

In cases where the pigmentation remains intractable for whatever reason, there are various forms of treatments:

• Creams. Hydroquinone is the gold standard cream when it comes to depigmentation. It is a tyrosinase inhibitor meaning it reduces the production of melanin at the cellular level. While this has been used for decades and has a good safety profile, it is a derivative of benzene which can be toxic, meaning its use in cosmetics is highly regulated. Though this is extremely effective, creams like this do not give immediate results. Several months of use is necessary to achieve a good outcome. This can lead to a particular side effect of hydroquinones 'paradoxical exogenous ochronosis' which results in increased skin darkening. This is nevertheless a very rare side effect. More common is skin irritation which can be managed with appropriate use and concurrent skincare. Hydroquinones are best used in conjunction with other treatments such as retinoids to allow deeper penetration of the active ingredients.
• Acids - L-ascorbic acid/glycolic acid/azelaic acid/arbutin. Some acids used in a higher concentration act as a peel, but in lower concentrations, can help to increase cell turnover thereby bringing lighter skin to the surface (glycolic acid), act as antioxidants to reduce sun damage (L ascorbic acid) or reduce inflammation due to acne to reduce pigmentation (azelaic acid). Arbutin is similar to hydroquinone and suppress melanin activity. This is sometimes used when hydroquinone is not suitable for a patient.
• Corticosteroid creams. Used in post inflammatory hyperpigmentation, steroids will reduce the inflammation caused by acne. However they have many side effects which make them unsuitable for long term use. They can cause an increase in pigmentation and thinning of the skin (atrophy) which can be permanent. Use of steroids creams must be closely monitored and is usually not the first choice for treating hyperpigmentation.
• Retinoids. Retinoids reduce melanin production by blocking the part of the melanin production pathway, disperse the pigment granules, enhance cell turnover and can induce desquamation (peeling of surface layers of dead skin). they can also enhance the effects of other creams by making the skin more porous. 
• Laser therapy. A targeted laser beam is used to break up the melanin without damaging the surrounding cells. Different types of lasers might be used to treat different conditions as each laser will penetrate to a different level in the skin. There have been studies to show some efficacy with treating hyperpigmentation with lasers, however, there may be many sessions required to achieve a good result, and outcomes are inconsistent. There are too many types of lasers to fully discuss here, but in expert hands, they can be a good alternative or adjunct to traditional treatments.
• Chemical peels. Chemical peels are a good adjunct to other treatments for hyperpigmentation, and often consist of alpha-hydroxy acid like glycolic acid and lactic acid. However, these medium/deep peels need to be used with caution in darker skinned individuals as they can trigger hyperpigmentation. In these cases, beta hydroxy peels, like a light salicylic acid is used. Peels are useful in PIH, but the effects are often transient as they address surface pigmentation, but not the cause

Thanks Nanu for sharing your insight and advice. You can book in with Nanu here or if you're looking for someone closer to you, search here.

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