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Are you surprised to learn that unwanted dark spots account for about 20% of visits to the dermatologist? Hyperpigmentation (the general term for conditions that cause some patches of skin to be darker than others) can be stubborn, and often stressful for those who experience it.
Are you surprised to learn that unwanted dark spots account for about 20% of visits to the dermatologist? Hyperpigmentation (the general term for conditions that cause some patches of skin to be darker than others) can be stubborn, and often stressful for those who experience it. But with a little insight into the biology of skin -- and the increasingly effective lightening products on the market -- almost anyone can see significant improvement in their complexion's evenness.
In addition to professional treatments, many patients turn to makeup as a quick and effective way to minimize the appearance of pigmentation disorders. Consider this cheat sheet on your next visit to the makeup counter:
Then simply follow the appropriate shade of concealer with a layer of your usual foundation or powder to achieve the most natural look.
In This Issue:
A Quick Lesson in Pigmentation
First things first: How is skin color produced? The short answer is that melanin -- its amount, quality, and distribution -- creates human skin color.
The slightly longer answer is that melanin is produced within melanosomes, organelles located in the cytoplasm of melanocytes (skin cells in the basal layer of your epidermis). The number of melanocytes in human skin is the same in people of all races; in darker-skinned individuals, though, the melanosomes are larger and contain more melanin. Once melanin is produced, melanosomes migrate to the melanocytes' dendrite tips, where they come into contact with keratinocytes, skin cells closer to the surface of the epidermis. The final stage of the pigmentation process, however, wherein melanin is transferred from the melanocytes to keratinocytes, is still poorly understood.
Of course, that's how pigmentation happens undisturbed by external influences -- doctors call the result constitutive skin color (CSC), a person's genetically influenced skin color without the impact of UV light or environmental factors. As we consider specific pigmentation disorders, we'll also see the importance of facultative skin color (FSC), or a person's skin color once influenced by UV light, hormones, and other external influences.
Professional treatments can be crucial in treating all types of hyperpigmentation, but the first line of defense is a targeted daily skin care regimen:
Disorders of Pigmentation
While there are certain rare genetic pigmentation disorders outside the scope of this newsletter, I see these four varieties of treatable (and in some cases, preventable) hyperpigmentation every day in my practice:
Symptoms: Melasma typically appears as patches of light to dark brown pigmentation on the upper lip, nose, cheeks, chin, forehead, and (less often) neck.
Causes: There is still disagreement among dermatologists over the primary causes of melasma, but several factors are known to contribute to its development and to aggravate the existing condition:
Melasma is so common during pregnancy that it is often called "the mask of pregnancy." The use of oral contraceptives is another known cause. Not surprisingly, therefore, estrogen is the primary influence on melasma. (The good news is that it consequently tends to improve after menopause.)
UV exposure is also known to worsen melasma, and seems to be necessary for the disorder to develop. For example, melasma is typically less noticeable in the winter months.
Anti-epilepsy drugs, like Hydantoin and Dilantin, seem to contribute to melasma.
Stress may also produce certain hormones that worsen melasma.
Other causes, such as nutritional deficiency and genetic predisposition, have been suggested but not proven.
Treatment: There can be both a dermal and epidermal component to melasma. Most patients experience both to some degree, but only the epidermal presentation can be treated. A consistent daily skin care regimen (see right) is the first step in minimizing the appearance of melasma.
Melasma patients may also benefit from an in-office peel every two weeks (i.e. a Jessner's, glycolic, or salicylic acid peel). Intense pulsed light (IPL) and Q-switched Alexandrite laser treatments are also effective, but should be used with caution by dark-skinned patients or those who experience post-inflammatory pigmentation alteration.
Fractional photothermolysis (a.k.a. Fraxel laser treatments) is another promising new treatment for melasma patients, as it can target hyperpigmented skin without affecting surrounding skin.
Symptoms: Solar lentigos appear as brown lesions (about 1 centimeter in diameter), typically on the face and hands.
Causes: Sun! Both acute and chronic UV exposure can cause lentigos. While they rarely appear on patients under fifty, they are not caused by age -- sun-protected skin is not affected, even in elderly patients.
Treatments:Solar lentigos are completely preventable with sun avoidance and daily sunscreen use. (And if you think you're unaffected by this condition, ask your dermatologist to look at your skin with a Wood's light -- a type of black light -- or a UVB camera. My patients are often shocked by the as-yet-invisible dark spots that those techniques reveal!) Individuals with solar lentigos should also follow the regular skin care regimen above.
Recent studies have found that localized dermabrasion is highly effective in treating solar lentigos, with minimal discomfort and downtime. Laser treatments are also effective, although they typically cause temporary scabbing. IPL and cryotherapy (in which extreme cold, often in the form of liquid nitrogen, is used to destroy small patches of hyperpigmented cells) are also effective. Chemical peels are often used in treating solar lentigos, but are best used on small surface areas due to the discomfort they can cause.
Finally, whether solar lentigos are treated or untreated, patients should undergo routine skin exams, as they may be at greater risk for skin cancer.
Symptoms: Post-inflammatory hyperpigmentation (a.k.a. post-inflammatory pigmentation alteration, or PIPA), presents as darkly pigmented spots in areas of previous inflammation.
Causes: PIPA can result from any inflammation of the skin, including cuts, bug bites, ingrown hairs, or areas of skin that have been waxed. Professional treatments like chemical peels and laser resurfacing can also result in this type of hyperpigmentation.
Treatment: Patients who experience PIPA are best served by careful prevention -- the cycle of inflammation and hyperpigmentation is difficult to beat. Anyone predisposed to this type of hyperpigmentation should avoid potentially irritating spa treatments like waxing or facials, as well as harsh professional dermatological treatments. Sun avoidance and sunscreen use are also particularly important, as hyperpigmentation is a result of excess melanin production at the site of inflammation -- and UV exposure only darkens melanin. Topical ingredients like hydroquinone, kojic acid, and retinoids are effective in the treatment and prevention of dark spots (see skin care regimen above).
I often hear darker-skinned patients, or those who claim to "tan well," proclaim that they don't need sunscreen. Wrong! In addition to the myriad other reasons to protect every type of skin against the sun, UV rays increase melanin production and worsen the appearance of unwanted dark spots.
Circles Under the Eyes
Symptoms: The "circles" in question appear as dark areas under the eyes.
Causes: There are generally two types of under-eye darkness. The first results from slow blood flow, a genetic issue that often appears in people of Latin American and Mediterranean descent. Slow blood flow results in an accumulation of hemosiderin (a pigment that contains iron oxide) in the skin. The second primary cause of under-eye darkness affects pigmented types, who make more melanin, particularly under the eyes. Sun exposure can cause that melanin to darken further. Finally, sleep deprivation may worsen existing darkness by restricting blood flow and creating puffiness in delicate under-eye skin.
Treatment: The best thing you can do for this condition is wear sunscreen every day, both to minimize the appearance of darkness and to determine if it is caused by melanin production or slow blood flow. If sunscreen does not decrease darkness after a couple of weeks, you may be experiencing slow blood flow under your eyes -- a harder condition to eliminate. There is some evidence that a combination of vitamin K and retinol can help, but I have not seen any cases of significant improvement. My advice is to avoid expensive peels and laser treatments, which really can't do much to improve under-eye darkness.
Shopping List: Fight Hyperpigmentation Every Day
Interested in some of the products I've mentioned? Use these quick links for easy ordering from my online store, where my proceeds always benefit The Dermatology Foundation:
10: Percent of melasma sufferers who are men, most often of Middle Eastern, Caribbean, or Asian descent.
90: Percent of elderly patients with solar lentigos.
14: Number of days you will notice the effects of increased melanin production following unprotected UV exposure.
80,000: Approximate number of people who buy over-the-counter skin care products to reduce dark spots each year.
On the Horizon
The process by which melanin is transferred from melanocytes to keratinocytes in the epidermis has been poorly understood, but recent studies have offered new insight into the role certain protease inhibitors and hormones play. Such research will no doubt help doctors more effectively treat pigmentation disorders in the upcoming months and years.
For those of you following the controversy, hydroquinone's fate continues to hang in the balance. Although many of us in the dermatological community expected the FDA to rule on a proposed ban of this common skin-lightening ingredient in the spring, there is still no word about whether over-the-counter and/or prescription products will be pulled from shelves. Some brands are already removing hydroquinone from their formulas to be on the safe side (Philosophy's A Pigment of Your Imagination, for example, no longer contains hydroquinone).
Whichever way the FDA rules, though, the dermatological community is increasingly turning to organic substances and plants in the treatment of pigmentation disorders. For example, Angelica dahurica has been shown to reduce the activity of tyrosinase, an enzyme that stimulates melanin production. / (Hydroquinone also works by inhibiting tyrosinase.) In a recently published study, the extract of Lepidium apetalum (ELA) was shown to decrease UV light-induced pigmentation in brown guinea pigs and certain human melanoma cells.
While anti-wrinkle treatments may still capture greater popular interest, one thing is clear: Patients, doctors, and cosmetics companies alike are realizing more and more that uneven pigmentation contributes just as much to an aged appearance -- and can cause a great deal of stress too. Our treatment options will only continue to improve.
Wishing you great skin!
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