Skin hyperpigmentation is a very common aesthetic problem, but few people know how unfair it is. People of colour are more frequently affected by pigmentation, due to differences in structure and functionality of the skin, including pigment content and cells dispersion patterns.
Hyperpigmentation can be superficial (epidermal) or deep (dermal) or mixed, it can be localised or generalised. Aesthetic medicine is, quite obviously, more interested in localised pigmentation, i.e pigment spots etc.
The most common hyperpigmentation disorder is melasma which appears primarily on the face, neck and arms. Women get it more often than men and people of colour a lot more often than white people. Key risk factors are skin phototype (with a prevalence of Fitzpatrick III and IV), genetic background, hormone levels (specifically in pregnancy and while taking hormonal contraceptives) and sun exposure. To put it simply, if you are a white man working from home, your chances of getting melasma are virtually non-existent, whereas if you are a dark-skinned woman on a pill, you may get melasma from even a tiny bit of sun exposure during your commute to work.
Melasma can be much more visible if it is superficial (epidermal) and less visible if it is deep (dermal). In very dark or black skin deep melasma can be non-apparent, only seen with the help of Wood’s lamp. Despite being harmless melasma often causes significant emotional and psychosocial distress. For example, 94% Brazilian women diagnosed with melasma, report being bothered by it, 65% frustrated and 53% even depressed due to their skin condition. The treatment of melasma is difficult, time consuming and expensive, thus its prevention is very important.
The key rule of preventing pigmentation: shielding those in risk groups! (where have we heard this before?). Women with III, IV phototypes and skin of colour need to use sunscreen when IUV is 3 and higher (even on a cloudy day check UV Index in your weather app or on a weather site). If you are pregnant or taking hormonal contraception and especially if you have a family history of hyperpigmentation disorder it is best to minimise your sun exposure during the day from 10 am till 5 pm when you can and continue using SPF 50+, at least for the face. A wide-brimmed hat and a pair of trendy sunglasses are highly recommended! Dermatologists also advise the use of antioxidant skincare products daily to reduce potential UV damage and improve natural skin protection. The rest of the population can follow standard recommendations: protect the skin according to the IUV intensity and standard WHO recommendations.
PIH (post-inflammatory hyperpigmentation) is considered a normal biologic response to injury or inflammation. Multiple skin disorders may result in PIH including atopic dermatitis, acne, psoriasis (curiously, it is unlikely for rosacea!) and skin injury, including aesthetic treatments, such chemical peels, laser and RF treatments, injections and others. Once again, it is more common in people of colour and white people with darker complexion, whereas sex is irrelevant in this case. PIH may take several months or even years to fade, it is easier prevented than treated. If you are suffering from acne and atopic dermatitis you need to minimise sun exposure – this isn’t the right time for sunbathing! The use of high SPF sunscreens is mandatory and antioxidant/anti-inflammatory products are recommended as well for your daily routine. Look for products containing centella asiatica, aloe vera, green tea, malva sylvestris and resveratrol. Niacinamide and tranexamic acid can lighten the skin and simultaneously improve the skin’s natural resistance and protection.
When we’re talking about sunspots aka solar lentigines, it is important to understand the difference – this is not classic hyperpigmentation disorder, but rather benign hyperpigmented macules distributed over the areas of chronic sun exposure (face, neck and arms). They typically occur at an older age but can appear at a younger age after acute UV exposure (although very rarely before 40). Sunspots are fairly common in white and Asian elderly, and a lot less so among people with III, IV and skin phototypes and darker. Solar lentigines are characterised by well-defined bordered macules ranging in diameter from a few mm to over 1 cm. They do not fade with time and are considered a sign of photo-ageing. They have less of an effect on emotional comfort than other hyperpigmentation disorders, probably because they are perceived as normal by most. The only way to prevent solar lentigines is regular and consistent sun protection from early age, including control of sun exposure, the use of sunscreens and maintenance of good skin health.