Tuesday, May 17, 2022

Types, Causes, Treatments and Prevention

  • Hyperpigmentation refers to spots and patches of skin that are darker than the surrounding area
  • It develops when skin overproduces melanin, the pigment responsible for skin’s color
  • Hyperpigmentation can result from skin injury, overexposure to the sun and as part of the aging process
  • Over the counter and prescription-strength topicals are available, as well as professional treatments

Hyperpigmentation is a very common condition that is characterized by dark spots or patches of skin that result from increased melanin production, the pigment that provides color to skin. These spots go by a number of different names including age spots, sunspots, liver spots, solar lentigines or postinflammatory hyperpigmentation (PIH), depending on the cause. 

Treatment can be challenging and focuses on different mechanisms to prevent or hinder melanin production; break down and slough off pigmented cells, enhance skin cell turnover and decrease inflammation.

What Is Hyperpigmentation?

Hyperpigmentation refers to an excess of pigmentation that can develop in the outermost layer of skin (the epidermis) and the layer below (the dermis). 

It is a harmless, relatively common condition that can affect anyone at any age, however, it  is one of the most common complaints for skin of color. This is due to the higher amounts of melanin in darker skin tones.  

Hyperpigmentation can manifest in several forms with the most common being melasma, sunspots and postinflammatory hyperpigmentation.

Melasma

Melasma presents as irregular patches of brown or gray areas of skin that are most commonly exposed to the sun – such as the face, neck and arms. 

Fluctuating hormones can cause this skin condition to develop during pregnancy or menstruation but there is also a strong genetic component. In one study more than 40% of patients reported having relatives with the same skin disease.  

Its development can also be attributed to ultraviolet A (UVA) sun exposure which is why this skin condition is referred to as a photoaging disorder. UVA rays trigger the skin’s melanocytes to produce more melanin which results in a buildup of pigmented cells. 

Melasma is a chronic condition that worsens in summer and improves in winter as a result of sun exposure.

Postinflammatory hyperpigmentation

When an injury or trauma occurs to skin such as a cut, burn, bug bite, infection or abrasion the skin responds by overproducing melanin during the healing process. 

It is important to identify the cause of the inflammation in order to seek appropriate treatment and stop the progression, otherwise dark spots will remain at the site of injury, once healed.

Studies show that skin of color is most vulnerable to PIH due to the greater degree of pigmentation in their skin.

Sunspots

Sunspots, also referred to as age spots, liver spots and solar lentigines are flat, light brown to black pigmented lesions that develop on any areas of skin that are chronically exposed to the sun’s damaging UVA rays. To shield itself from DNA damage, skin reacts by overproducing melanin as a protective mechanism. 

Sunspots are a form of photodamage and have been linked to an increased risk of skin cancer.

While all skin types and skin tones are susceptible to this type of hyperpigmentation, people who fall within types I–III of the Fitzpatrick skin type scale have pale to medium light skin, and are most vulnerable to this type of hyperpigmentation. 

What Causes Hyperpigmentation?

Hyperpigmentation results when internal or external stimuli such as UV exposure, skin injury, infection or inflammation stimulate melanin-producing cells called melanocytes found inside melanosomes. The basic function of melanocytes is to produce melanin.

While the cause or condition can differ, this mechanism of action is ultimately the same.

Acne

Inflammatory skin conditions such as acne increase the risk of hyperpigmentation. This inflammation stimulates melanin production during the healing process leaving behind  discolored areas of skin once lesions have healed.

This discoloration appears as dark spots in skin of color and redder in lighter skin tones. Treating the underlying cause of inflammation quickly can reduce the severity of this hyperpigmentation. 

Aging

Over time, intrinsic factors such as genetics and hormones combined with extrinsic factors such as sun exposure and environmental pollutants take their toll on skin and speed up the aging process.   

Sun spots and age spots develop as a protective mechanism, to protect skin from further damage. Skin can also take on an uneven color or appear mottled due to an alteration in pigment distribution and turnover. 

Hormonal influences

An increase in hormones progesterone and estrogen are known to occur during menstruation, pregnancy or menopause. This increases melanin synthesis which causes overpigmented areas of skin. 

This is the case as well for melasma. Brown patches of pigmented skin appear on the skin around the eyes, nose and cheeks, which is commonly referred to as the mask of pregnancy given how common the condition is among pregnant women. Sun exposure worsens symptoms.

Other causes

Hyperpigmentation is a common symptom of some health conditions such as cancer; Addison’s disease, a rare endocrine disorder; and acanthosis nigricans, which presents with dark patches of skin in body folds. 

Some drugs have also been known to induce hyperpigmentation such as non-steroidal anti-inflammatory drugs (NSAIDs), antipsychotics and tetracyclines. 

Topical Hyperpigmentation Treatments

There are a number of topical treatments available that can effectively lighten the appearance of dark spots on skin. Established therapies include corticosteroids, hydroquinone, tretinoin and triple combination creams. 

Corticosteroid cream

Corticosteroids have been shown to be effective in treating hyperpigmentation but they are associated with adverse effects, especially with long-term use. They are usually paired with other topical treatments to mitigate these issues as well as to produce a synergistic effect.     

Corticosteroids help hyperpigmentation by suppressing the body’s inflammatory response which has been shown to trigger excess melanin. They can also effectively constrict blood vessels to reduce swelling and pain, which typically accompany inflammation. 

Hydroquinone creams

Hydroquinone is considered the gold standard in hyperpigmentation treatment. Hydroquinone inhibits the activity of the key enzyme, tyrosinase, that is required for melanin synthesis. 

As with corticosteroids, this agent is typically combined with other topical treatments to achieve maximum results, such as with a retinoid or one of many professional procedures available to lighten dark spots. 

In one study trial of melasma that compared a skin whitening complex with hydroquinone versus placebo, hydroquinone showed the highest improvement overall at 77%.

Tretinoin creams

Tretinoin interacts with receptors in the nucleus of dermal cells to block the release of inflammatory mediators to prevent PIH from occurring and the accompanying hyperpigmentation.

This agent can reduce the appearance of dark spots by accelerating skin cell turnover so that healthy cells can take the place of damaged cells. 

By increasing collagen production and elasticity to strengthen skin, soughing off dead skin cells, and clearing debris from pores, it can prevent acne lesions from forming and marring the face. 

In one study of PIH among skin of color, tretinoin was found to significantly lighten PIH lesions.  

Professional Hyperpigmentation Treatments

Corticosteroids and hydroquinone are available over the counter (OTC) as well as in prescription strength. 

However, if your skin fails to respond to these treatments you can see your dermatologist who may prescribe a stronger formula, opt for another treatment or use triple therapy, depending on your skin type and severity. Professional treatments are commonly used alongside topical therapy to achieve optimal results.

Chemical Peels

Professional chemical peels can effectively remove hyperpigmentation by exfoliating several layers of skin to prompt the growth of even, smooth skin with more evenly distributed melanin. This also stimulates collagen production to plump and strengthen skin. 

Chemical peels for hyperpigmentation offer flexibility and a range of options. They can be found in superficial or medium strengths using a range of chemical peels to choose from such as glycolic acid, salicylic acid and trichloroacetic acid (TCA).

Each chemical peel has its own characteristics and benefits, and they can be combined with other treatment modalities for greater effects. 

In a split face study of women with moderate to severe melasma, glycolic acid peels produced greater improvements when combined with other topical treatments. Glycolic acid is considered gentle enough to be safely used on skin of color. 

Laser Treatments

There are a wide range of laser treatments available including ablative and nonablative lasers as well as fractionated and nonfractionated lasers. Ablative removes the top layers of skin; nonablative uses heat to penetrate skin tissue to produce collagen. 

Nonfractionated lasers target the entire treatment surface area whereas fractionated lasers focus on a fraction of skin at a time.

Within this category is also intense pulsed light (IPL) which has been shown to be effective against photodamaged skin and especially melasma. IPL is also used in combination therapy and has been demonstrated to produce dramatic results when combined with a fractional Q-switched ruby laser. 

These treatments have been shown to be effective, but results will vary from person to person.  

Microdermabrasion

Microdermabrasion offers an alternative to more invasive techniques and is considered a superficial resurfacing procedure.

It involves applying either a diamond-tipped handpiece or a spray of crystals to the face to gently exfoliate dead skin cells and smooth the outer layer of skin. It also addresses uneven skin tones and reduces the appearance of hyperpigmented spots.

Microdermabrasion has been shown to mild to moderate improvement by reducing pigmented skin as well as increasing collagen production. As it only treats the surface layer of skin, results tend to be mild, however, with repeated sessions, skin should show greater improvement. 

As this procedure deeply exfoliates and clears pores, it can help bolster the effects of topical treatment by enabling better penetration. Lastly, it can also be combined with other treatments for greater skin benefits.

Home Remedies for Hyperpigmentation

There are several home remedies that are believed to be effective in treating hyperpigmentation but there are few scientific studies on the topic. One remedy is aloe vera and the other is green tea extract. The former requires further studies to substantiate this claim, the latter does have studies to support its efficacy.

Hyperpigmentation Prevention

While hyperpigmentation can not always be avoided, there are concrete steps you can take to minimize the risk of developing dark spots and to avoid exacerbating existing hyperpigmentation.

Don’t Pick at Your Face

Picking at or touching acne blemishes or any skin injuries such as cuts, scrapes and bug bites spreads bacteria, causes irritation and inflammation, and increases the risk of pigmented spots.

Wash your hands before and after applying any topicals to your face and allow time for any lesions to heal. 

Seek treatment 

Inflammation causes damage to the skin; if left untreated this inflammation can worsen and cause deeper and more widespread discoloration to skin. By treating the cause of inflammation, skin can heal and damage will be minimized.

Wear sunscreen

The first line of defense against skin damage is to consistently wear at least an SPF 30 sunscreen when outdoors. Limit time outside between 10 a.m. and 4 p.m. when rays are strongest and wear a hat or cap. 

Protecting your skin from the sun will also prevent existing sun spots from becoming darker. 

When to See a Dermatologist

If you do not see an improvement with OTC topicals, your dermatologist can prescribe a professional-strength treatment or suggest a combination of treatments that would be most effective for your situation.

You should also seek immediate medical advice if your dark spots change color, shape or texture. This could be an underlying sign of a more serious skin condition.

Takeaway

Hyperpigmentation is a very common condition that results from several causes including skin injury, hormonal fluctuations, some skin conditions and photodamage. It develops when skin overproduces melanin, the pigment responsible for skin’s color.

Lightening hyperpigmentation can be challenging and typically includes several treatments combined for greater efficacy. First-line therapy includes treating the existing hyperpigmentation and preventing further damage by including a sunscreen.

Topical and professional solutions focus on preventing or reducing melanin production; depigmenting damaged cells from the top layers of skin, increasing skin cell turnover and decreasing inflammation.

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