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PIGMENTATION

Pigmentation condition can be one of the most challenging skin concerns. There are many factors that can cause abnormal pigment in the skin and normally varies according to a racial origin and the amount of sun exposure. Pigmentation disorders are often more troublesome in skin of colour. 

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Currently, more than 150 causes of pigmentation including post inflammatory hypopigmentation and hyperpigmentation from acne, chicken pox, inflammatory skin conditions, melasma, chloasma, sun spots (solar lentigo, liver spots), freckles, birthmarks and many others. Location also can determine the type of the pigmentation whether it's from hormonal medications (oral contraceptive pills, HRT and other drugs), hormonal changes (pregnancy, menopause, stress), lifestyle and genetics (Thawabteh et al., 2023). 

 

Regardless what causes the pigmentation, there are two factors contributes to the pigmentation: the extrinsic and the intrinsic.

  • Extrinsic

Extrinsic means the pigmentation triggers are coming from outside the body. 90% is accountable from unprotected sun exposure to the ultraviolet radiation. Other triggers are pollutant, environmental stress and cosmetics.

  • Intrinsic

Intrinsic means the pigmentation triggers are coming from inside our body such as genetics, hormonal imbalances and the latest research is linked with internal inflammations. 

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Let's take a look a few common types closely. 

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  • Melasma

Melasma is a very challenging condition since there are no cure. However, the right  treatment in conjunction with homecare products, pigmentation can be improves and manageable.  Otherwise, it will make it worse. Melasma mostly common in women than men and also more likely happen on ethnic darker skin. It may have a genetic component like acne as it often runs in families. 

Hormonal induced melasma mostly show up in the central facial area like the forehead, cheeks, upper lip and possibly the chin and it can looks like a butterfly pattern due to symmetrically shape with irregular border. When resulted from pregnancy, it called chloasma. Hormonal induced melasma caused by hormonal imbalances and may related with health issues such as PCOS or endometriosis from dysfunction of the reproductive system (Doolan & Gupta, 2021). 

Stress-related pigmentation may show up around the temples, sometimes above the eyebrows, the jawlines, chin and upper neck. Melasma in most cases can be related to oral contraceptive pills containing oestrogen or progesterone, hypothyroidism (low levels of circulating thyroid hormone) and the latest research is the trigger found from liver damage and cause internal inflammation (Kwon et al., 2018; Lai et al., 2022).

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Treatment for Melasma: Usually utilise from multiple low strength peels and medium to high peels like Jessner and TCA (Trichloroacetic acid) gives better results. Glycolic acid peel starting with 20% working up to 70% in multiple peel treatments works and same thing with with Lactic acid. TCA 8% to 20% with appropriate level of frosting gives better results in particular if combine with Jessner peels application prior TCA.  Peels only form one arm of melasma treatment, the other treatments such as sun protection, vitamin A (retinol or retinoic acid), niacinamide (vitamin B3), ascorbic acid (vitamin C) are excellent as melanin and tyrosinase inhibitors in homecare use are equally, if not more important than peels alone (Zolghadri et al., 2019). Microdermabrasion, dermaplaning, dermatherapy and skin needling (CIT) may use in conjunction to achieve long-lasting results. For skin needling, the depth should not be exceeding greater than 1.5 mm, otherwise the melanocytes can be scattered further into the dermis which will be more difficult to treated. Low setting of laser such as Pico laser works while IPL on dark skin can make melasma worse (Wong et al., 2021). 

 

Important note: Higher concentration than 30% of TCA must be performed under strictly supervision of Board Certified Dermatologists. They are the authorised medical practitioners who can prescribe you with oral hormonal medication such as tranexamic acid or performed Intravenous (IV) injection of vitamin C to treating severe case of melasma which can be done weekly, if desired (Alsharif et al., 2022; Wang et al., 2023). 

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  • Post Inflammatory Hyperpigmentation

Post inflammatory hyperpigmentation or known as PIH for short, it's a common condition usually due to acne and can be managed along the same lines as melasma. This condition is due to an excessive inflammatory response to trauma and injury - like picking skin on acne and worsen with excessive sun exposure (Markiewicz et al., 2022; Alsharif et al., 2022). Commonly seen in darker skin types. The key to treating PIH is with gentle treatments, time and absolute sun protection Fatima et al., 2020). PIH due to other causes may take up to 12 months or longer before resolving (​Kaufman et al., 2018). 

Treatment for PIH: same principle with the treatment of melasma regarding lower concentration of chemical peels. Mandelic acid peel has been shown great result on darker skin, since PIH are commonly seen in Fitzpatrick IV to VI skin photo types (Markiewicz et al., 2022).

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  • Periorbital Melanosis

Appears as a darkening around the eye area which can increase with age and frequently seen in individuals of darker skin colour. The exact cause is still unknown although it's strongly related with origin race backgrounds (Indian, some Italian, some African). ​

Treatment for periorbital melanosis: start by being diligent with daily sunscreen application and treatment will be same lines as melasma (Lai et al., 2022).

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  • Sun Damage (Solar lentigines, sun spots, liver spots)

Seen in ​90% of the population of individuals aged 60 and above. Most commonly in lighter skin and occur on sun exposed areas of the body. Sources including light exposure to UV, visible and infrared sources, environmental pollutants and free radicals that lead to oxidative stress, phototoxic drugs, phototoxic cosmetics and genetics (Zhou et al., 2021). Photo-induced pigmentation can show up on the forehead, upper cheeks and chest area.

Treatment for sun damage: start by being diligent with daily sunscreen application (Fatima et al., 2020).

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  • Freckles

Commonly seen in lighter skin individuals ​as a result of sun exposure. Can be red, tan or dark brown in colour and they may fade with discontinued of sun exposure (darker during summer and lighter during winter months). Sun protection is essential​ (Li et al.. 2020).

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There are four types of pigmentation based on the location of the pigmentation. This can be detected by visual analysis using wood's lamp or skin scanner. The four types of pigmentation based on the pigmentation location are:

  • Epidermal pigmentation

  • Dermal pigmentation

  • Epidermal-dermal pigmentation

  • Fourth type does not have any name yet, however, is characterised by melanocytes in dark-skinned people. In rare cases, skincare specialist may need to perform a skin biopsy for diagnosis (Plensdorf et al., 2017).

 

The conclusion is for pigmentation disorders, the important first step is to determine the causes. The reason being is because no treatment un-likely to be effective if the underlying cause isn't addressed. Even the oral treatments that now exist for severe melasma are really pointless to do if there are still triggers in place. If you still being exposed to exacerbating factors, you could be just like a hamster on the wheel - keep running around and not getting any better. In some cases, hydrating and cooling treatments gives significant result and quicker outcomes, and this more likely link to reduce melanocytes activity rather than to provoke these melanin producing pigments (Li et al., 2020; Moreiras et al., 2021; Zhou et al., 2021). Be patient even with treatment, it may take months sometimes years for melasma to clear up. There is no quick fix. And last but not least, be diligent as any pigmentation types will be quick to return if you are not careful about daily sun protection (Boo, 2021). Therefore, long-term maintenance requires as ongoing commitment to protecting your skin. 

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At Skinderm Aesthetics, our best services for pigmentation are:

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REFERENCES

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Alsharif, S. H., Alghamdi, A. S., Alwayel, Z. A., Alaklabi, S. N., Alyamani, N. A., Sabsabee, M. A., . . . Alajlan, A. M. (2022). Efficacy and Best Mode of Delivery for Tranexamic Acid in Post-Inflammatory Hyperpigmentation: A Systematic Review. Clinical, cosmetic and investigational dermatology, 15, 2873-2882. doi:https://doi.org/10.2147/CCID.S394889

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Boo, Y. C. (2021). Mechanistic Basis and Clinical Evidence for the Applications of Nicotinamide (Niacinamide) to Control Skin Aging and Pigmentation. Antioxidants (Basel, Switzerland), 10(8), 1315. doi:https://doi.org/10.3390/antiox10081315

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Doolan, B. J., & Gupta, M. (2021). Melasma. Australian Journal of General Practice, 50(12), 880-885. doi:https://doi.org/10.31128/AJGP-05-21-6002

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Fatima, S., Braunberger, T., Mohammad, T. F., Kohli, I., & Hamzavi, I. H. (2020). The Role of Sunscreen in Melasma and Postinflammatory Hyperpigmentation. Indian journal of dermatology, 65(1), 5-10. doi:https://doi.org/10.4103/ijd.IJD_295_18

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Kaufman, B. P., Aman, T., & Alexis, A. F. (2018). Postinflammatory Hyperpigmentation: Epidemiology, Clinical Presentation, Pathogenesis and Treatment. American Journal of Clinical Dermatology, 19, 489-503. doi:https://doi.org/10.1007/s40257-017-0333-6

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Kwon, S.-H., Na, J.-I., Choi, J.-Y., & Park, K.-C. (2018). Melasma: Updates and Perspectives. Experimental Dermatology, 28(6), 704-708. doi:https://doi.org/10.1111/exd.13844

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Lai, D., Zhou, S., Cheng, S., Liu, H., & Cui, Y. (2022). Laser therapy in the treatment of melasma: a systematic review and meta-analysis. Lasers in medical science, 37(4), 2099-2110. doi:https://doi.org/10.1007/s10103-022-03514-2

 

Lee, Y. S., Lee, Y. J., Lee, J. M., Han, T. Y., Lee, J. H., & Choi, J. E. (2022). The Low-Fluence Q-Switched Nd:YAG Laser Treatment for Melasma: A Systematic Review. Medicina (Kaunas, Lithuania), 58(7), 936. doi:https://doi.org/10.3390/medicina58070936

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Li, Q., Fang , H., & Dang, E. G. (2020). The role of ceramides in skin homeostasis and inflammatory skin diseases. Journal of dermatological science, 97(1), 2-8. doi:https://doi.org/10.1016/j.jdermsci.2019.12.002

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Markiewicz, E., Karaman-Jurukovska, N., Mammone, T., & Idowu, O. C. (2022). Post-Inflammatory Hyperpigmentation in Dark Skin: Molecular Mechanism and Skincare Implications. Clinical, cosmetic and investigational dermatology, 15, 2555-2565. doi:https://doi.org/10.2147/CCID.S385162

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Moreiras, H., Seabra, M. C., & Barral, D. C. (2021). Melanin Transfer in the Epidermis: The Pursuit of Skin Pigmentation Control Mechanisms. International journal of molecular sciences, 22(9), 4466. doi:https://doi.org/10.3390/ijms22094466

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Plensdorf, S., Livieratos, M., & Dada, N. (2017). Pigmentation Disorders: Diagnosis and Management. American family physician, 96(12), 794-804.

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Thawabteh, A. M., Jibreen, A., Karaman, D., Thawabteh, A., & Karaman, R. (2023). Skin Pigmentation Types, Causes and Treatment-A Review. Molecules (Basel, Switzerland), 28(12), 4839. https://doi.org/10.3390/molecules28124839

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Wang, W. J., Wu, T. Y., Tu, Y. K., Kuo, K. L., Tsai, C. Y., & Chie, W. C. (2023). The optimal dose of oral tranexamic acid in melasma: A network meta-analysis. Indian journal of dermatology, venereology and leprology, 89(2), 189-194. doi:https://doi.org/10.25259/IJDVL_530_2021

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Wong, C., Chan, M., Shek, S., Yeung, C., & Chan, H. (2021). Fractional 1064 nm Picosecond Laser in Treatment of Melasma and Skin Rejuvenation in Asians, A Prospective Study. Lasers in Surgery and Medicine, 53(8), 1032-1042. doi:https://doi.org/10.1002/lsm.23382

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Zhou, S., Wang, Q., Huang, A., Fan, H., Yan, S., & Zhang, Q. (2021). Advances in Skin Wound and Scar Repair by Polymer Scaffolds. Molecules (Basel, Switzerland), 26(20), 6110. doi:https://doi.org/10.3390/molecules26206110

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Zolghadri, S., Bahrami, A., Hassan Khan , M. T., Munoz-Munoz, J., Garcia-Molina, F., Garcia-Canovas, F., & Saboury, A. A. (2019). A comprehensive review on tyrosinase inhibitors. Journal of enzyme inhibition and medicinal chemistry, 34(1), 279-309. doi:https://doi.org/10.1080/14756366.2018.1545767

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