Hyperpigmentation is a broad term for skin discoloration or darkening in several areas on the face and body, caused by prolonged UV exposure, hormonal fluctuations, and skin injuries such as acne scarring.
There are several causes of hyperpigmentation depending on the type. The most common causes of hyperpigmentation being prolonged exposure to the sun, which then triggers the body to produce more melanin as a form of protection. This over-production of melanin cause dark spots or patches on the skin also called age spots or sun spots. After an episode of inflammation from acne, eczema, lupus or an injury to the skin, areas of the skin can also darken and this is often referred to as post-inflammatory hyperpigmentation (PIH). Other causes include genetic predisposition, hormonal changes such as pregnancy, reactions to certain medications (anti-malarial drugs, phototoxic drugs, anti-seizure and tricyclic antidepressants), chemicals in topical treatments, as well as medical conditions such as Addison's disease and hemochromatosis can also cause hyperpigmentation in certain areas of the body, including lips, knuckles, toes and insides of cheek.
Types of Pigmentation
Commonly found on those with fair skin, age spots also known as liver spots, sun spots or solar lentigines, often appear on the face, hands and on sun-exposed areas of the body. They can vary in color from brown, gray to black, and in size, varying from very small to quite large and often appearing in groups or clusters.
Melasma or chloasma spots is a chronic skin condition with irregular patches of brown pigmentation commonly found on the cheeks, nose, temples and forehead during or after pregnancy or in women who are on the contraceptive pill. It is thought to be caused by increasing levels of both oestrogen and progesterone, which stimulate melanocytes resulting in increased production of the normal tanning protective chemical. It is more commonly found on Asian skin and can be extremely frustrating for those suffering from it.
Melasma is more likely to occur in medium to darker skin tone as there are more active melanocytes than those with light skin. Ultraviolet light stimulates pigment-producing cells in the skin (melanocytes) to produce more melanin as a result. These brown, sun or age spots may only start to show up in your 30s as you start to age.
Freckles are small brown spots that can appear on the face and body after prolonged exposure to the sun. Freckles, also known as ephelides, do not occur at birth even though they may be an inherited trait. They can occur around two to three years of age and are found more commonly on those with fair complexions. There are also certain genes that pre-dispose some to having freckles more easily. One of those genes is the MCR1 gene, also commonly referred to as the ‘red hair’ gene, which may explain the common occurrence of freckles in these individuals. Freckles may fade with age and in the winter months.
Post-Inflammatory Pigmentation (PIH)
PIH develops as a result of skin that has been damaged or undergone some form of trauma such as acne, sunburn or surgery. This is a common problem that plaques many teenagers and young adults in Singapore and the rest of Asia. These PIH spots happen more often in darker skinned individuals. The inflammatory response causes a build-up of melanin, melanin being the pigment in our pigment cells, leaving behind the brownish red blemishes on the skin which can occur anywhere on the body, face, chest and back. These marks can stay on for a few weeks to even months or years! The older we get, the slower the healing rate, and the longer the pigmentation will stay.
Lentigines are small pigmented flat or slightly raised spots with clearly defined edges. They are also a form of photo-damage caused by excessive sun exposure. But unlike freckles, lentigines usually happen much later in middle ages and they often show up in areas that are more exposed to the sun such as faces, arms, forearms, hands and legs. These pigment spots are benign and harmless. However, it may be difficult to distinguish them from malignant lesions. When in doubt, seek medical opinion as the doctor can perform a biopsy of the lesion.
Do's and Don't's
Do protect your skin
Maintaining and protecting good skin takes effort. Be diligent when it comes to protecting your skin from damages caused by sun exposure. Apply a broad spectrum sunscreen of SPF 30 and above daily and wear sun-protective gear and outfits.
Don’t try to self-diagnose or self-medicate
While you may know of ingredients such as hydroquinone and acids that may have been proven effective in fading pigmentation spots, be sure to do a test on your skin first as they may cause a skin reaction. It is best to first check with your doctor if your dark spots are hyperpigmentation and not an indication of another medical condition.
Do see a doctor
If you have stubborn pigmentation marks that won’t go away after the use of over-the-counter remedies, do consult a medical doctor on your treatment options.
Prescription medications or topical treatments to help lighten melasma include topical retinols and retinoid treatments to help speed up skin’s natural cell turnover process. This may help dark patches clear more quickly than they would on their own.
It is important to consult with a skincare professional prior to using products to even out skin discoloration as high percentages of strong ingredients can cause further irritation and lead to more discoloration.
A combined treatment plan that includes both products and services are best for treating hyperpigmentation. Consider daily use of sunscreen and brightening skincare products that contain whitening agents like vitamin C, kojic acid, niacinamide, hydroquinone and azelaic acid, coupled with in-clinic treatments like laser therapy and chemical peels.
Your medical professional should give a proper and accurate diagnosis of the dark spots before commencing treatment of hyperpigmentation.
Topical creams that contain retinoids derived from vitamin A (which can come in either a prescriptive or over-the-counter formula), azelaic acid or hydroquinone – though the latter is not as highly recommended, can lighten the marks from acne PIH or freckles. Using good skincare on a regular and long term basis like a good vitamin C and vitamin A product can lighten and prevent the freckles from enlarging or darkening. However, if acne PIH is very persistent despite topical creams or if patients desire quicker results, light treatments like IPL and Q-Switched laser can be considered.
Medical grade lightening creams that contain hydroquinone (bleaching agent), tretinoin or a variety of combinations can be very effective in reducing melanocytes that are responsible for the production of melanin. However, these prescriptive creams need to be monitored for side effects like redness, itching and stinging of the skin. Lightening of melasma can be expected after five to seven weeks of treatment.
Acids like glycolic (alpha-hydroxy acid or AHA) or salicylic acid (beta-hydroxy acid or BHA) has an exfoliating effect to help break down melanin, get rid of pigmented dead skin cells, resurface the upper layers of the skin and promote collagen production, revealing healthier, brighter looking skin. But more effective for hyperpigmentation than glycolic acid is lactic acid that smooths skin texture and reveals fresh, glowing skin. Trichloroacetic acid or TCA is another strong acid found in at-home chemical peels too.
Technology has advanced so much that there are also over-the-counter products such as IDS Skincare C-Plus and IDS Prestige Fair Complex with powerful active ingredients such as vitamin C, kojic acid, azelaic acid and tranexamic acid coupled with good delivery system to effectively lighten dark spots and brighten the skin.
Prescribed medication such as tranexamic acid works by modulating blood vessels in the skin. Non-prescriptive or supplements that contain antioxidants (vitamin C and glutathione) are also recommended to help prevent the oxidative process that often leads to pigmentation in the skin.
Medical professionals and doctors may use various procedures ranging from chemical peel, laser therapy, microneedling, to radio frequency and IPL to reduce the appearance of stretch marks. For optimum results, your medical doctor may use more than one procedure.
Light Based Therapies:
On top of topical creams, light treatments such as Intense Pulsed Light and lasers can further help to fade freckles and dark spots. Post laser, the pigmented spots will form a scab and eventually fall off.
Intense Pulsed Light (IPL)
In Singapore, IPL is a popular and well-established means of treating aging skin concerns. It is a generic term for any procedure that uses a flash lamp to improve skin appearance. In IPL, light energy of a precise wavelength is absorbed by damaged skin, raising its temperature, and cells then respond by stimulating the production of collagen. With more collagen produced, aging skin will appear more youthful, age spots and pigmentation will fade, fine lines and wrinkles improved, and pore size reduced. Multiple treatments are recommended for best results.
Broadband Light (BBL)
This light therapy works by depositing pulses of light energy that gently heats the upper layers of skin. The light energy is then absorbed within the skin especially working on those problem areas such as fine, broken vessels that cause redness and brown spots or pigmented lesions that are caused by an overproduction of melanin.
LED (Light Emitting Diodes) light
Compared to other light therapies such as lasers, LED may not seem as potent and the results will take months rather than weeks to become visible but there will be no scarring or downtime that usually come from the more aggressive treatments. Red light which lies next to infrared at the end of the visible light spectrum, and its wavelengths can help to disable inflammation triggers linked to acne, pigmentation and rosacea. Red light acts as an anti-inflammatory agent, with long enough wavelength to penetrate the epidermis (outermost layer of the skin) and reach the dermis (the middle layer of the skin). This enables it to stimulate fibroblasts (cells that manufacture collagen) and as a result boost skin’s ability to repair and heal. Green LED light is used to target melanocytes (melanin-producing cells at the bottom of the epidermis) by inhibiting excessive melanin production and breaking up melanin clusters to minimize existing discoloration.
Lasers often produce a faster and more effective result but a period of post-treatment skin recovery is to be expected. Depending on the type of pigmentation, different types of laser can be used; from Aerolase, Q-Switched, Pico, Sylfirm, Mosaic, to Thuliam. The non-ablative laser works by breaking down excess melanin so the skin will absorb the light energy and then clear away the pigmentation. As with any treatments, expect minimal side effects such as mild itching or a slight pinkish flush, but this goes away within a few hours. Although you can immediately get back to work, it is best to avoid sun exposure as much as possible. Wearing sunscreen daily to protect the skin from the sun is a must.
There are varying strengths of chemical peels: superficial, medium, and deep. Superficial peels only target the outermost layer of the skin. Medium-depth peels are effective for age spots, actinic keratoses, and freckles while deep peels can penetrate deep into the skin.
This treatment works by reacting to the various layers of the skin and dissolving damaged or pigmented skin cells, revealing younger and healthier looking skin. During the treatment, patients may experience a tingling sensation but will subside once the solution has been neutralized. Deep peels may require some numbing cream as it is more aggressive and works deeper into the skin.
Non Light-Based Treatments:
Beyond just using a specific treatment, combining treatments prove much more effective. During consultation, your medical doctor may recommend using at-home skincare programs such as IDS Fair Complex (FC) and IDS Lyco-White (LW) that work in synergy with laser therapy or other medical procedures such as Rejuran Healer for much faster results. Skin appears much brighter, clearer and smoother.
R-Mask, an in-clinic whitening peeling mask may also be offered to address hyperpigmentation issues. It is usually left on for six to eight hours for enhanced results.
What’s important is to ensure there’s no recurrence post treatment. It is easy for hyperpigmentation to be aggravated by sun exposure (especially freckles, solar lentigo, melasma) which tend to recur if there’s insufficient post-treatment maintenance like sun protection or a proper skincare regime.