Dr Simi Adedeji treats a patient’s concerns while factoring in a budget
The treatment of acne and hyperpigmentation can pose a particular challenge in many patients, more so in skin of colour where the tendency to form hyperpigmentation is greater.1 Without appropriate precautions, attempts to treat the hyperpigmentation may inadvertently worsen the condition. It is estimated that by 2050, nearly one half of the US population will have skin of colour.2
According to the last UK consensus in 2011, 40.2% of residents in London identified as non-white,3 and 14% of the population in England and Wales is non-white. As the incidence and prevalence of post-inflammatory hyperpigmentation (PIH) is likely to continue to rise it is important that aesthetic professionals, especially in and around London, understand how to treat PIH effectively.
Hyperpigmentation, especially when it affects the face, has a social stigma attached to it and can cause the sufferer significant psychological distress as it can take years to resolve,1 thereby impacting on confidence and quality of life.4
Additionally, by the time a patient approaches an aesthetic practitioner for help with this condition, they will usually have used numerous over-the-counter products at a considerable expense, so their trust and confidence is at a low. It is therefore important to be able to treat PIH correctly and effectively. A standard approach would likely be chemical peel treatments, but as the patient wanted to specifically avoid this, the case study describes the treatment of acne and PIH in skin of colour, using non-hydroquinone products and skin-resurfacing acids.
My 27-year-old female patient with Fitzpatrick skin type VI presented to clinic complaining of acne scarring. At the time, she was wearing makeup and no obvious acne scarring was visible. When she returned for her formal consultation, she attended without makeup and it was clear that the scarring she was describing was in fact hyperpigmentation. During the consultation, we discussed and prioritised her areas of concern, how the condition affected her emotionally, her aesthetic goals and any previous treatments she had tried. She described suffering from acne breakouts, which left dark marks on her skin including a line of pigmentation across her nose (known as the allergic salute sign), from habitually rubbing her nose.5,6 These marks were her primary concern and they were extremely dark compared to her normal skin tone. She had previously tried numerous over-the-counter products and a chemical peel at another aesthetic clinic, which had not helped.
During the consultation, I noticed that she seemed embarrassed by her skin and maintained poor eye contact. Her main concern was that the blemishes were lasting a long time (months to years) and that she was developing new spots before the blemishes had time to clear. Also, her sibling had recently commented that the appearance of her skin was worsening, which prompted her to seek treatment with me.
The consultation revealed that she had a limited budget and that she did not wish to have the downtime associated with conventional chemical peeling due to work commitments. Following her assessment, I diagnosed PIH secondary to acne. I explained in detail about the causes of acne and hyperpigmentation at a cellular level, as I often find that understanding this aids compliance with the subsequent skincare routine and therefore helps in achieving optimal results. An important part of the consultation was managing patient expectations with regards to what could be achieved, depending on whether the pigmentation was epidermal or dermal. Usual methods of determining this include stretching the skin to observe for lightening of the pigmentation or using Wood’s lamp; however, I have found that Wood’s lamp is not effective in differentiating between dermal and epidermal pigmentation in Fitzpatrick type VI skin.
Because of the history of how the pigmentation developed, my findings on examination of her skin, combined with my professional experience of treating previous similar patients, I classed her pigmentation as predominantly epidermal. In my experience, this type of hyperpigmentation is much more responsive to chemical resurfacing or peels than dermal pigmentation, which may require different interventions such as laser for effective treatment.7
Before treatment it was vital that my patient understood that the treatment was a journey, rather than a one-off intervention.
Hyperpigmentation, especially when it affects the face, has a social stigma attached to it and can cause the sufferer significant psychological distress
Taking into account the patient’s budget and preference of minimal peeling, I created a personalised treatment plan which consisted of a course of chemical skin resurfacing using gentle combination acids, supported by a homecare regime. As requested by the patient, the skin will not experience the level of peeling associated with traditional chemical peels from this treatment.
I recommended a course of six treatments performed two weeks apart in clinic; however, for budgeting reasons we revised this and spaced the treatments out so that they were four weeks apart.
As she was a Fitzpatrick skin type VI, I advised my patient to prepare her skin with a tyrosinase inhibitor for at least two weeks before we started her first skin-resurfacing treatment. I also started her on a morning and evening homecare regime to maintain and enhance her results. Her morning regime consisted of a gentle exfoliating cleanser containing lactobionic acid, papain enzyme and urea, a serum containing a tyrosinase inhibitor and other combination acids including salicylic acid, an oil-free moisturiser containing niacinamide and strict sun protection (SPF 30) use, with instructions to reapply every two hours if she was outdoors. Her evening regime consisted of the gentle exfoliating cleanser followed by a serum containing a mixture of alpha, beta and poly acids, with 0.1% retinol and finally the oil-free moisturiser containing niacinamide.
Following two weeks of skin preparation, we began the in-clinic treatment by addressing the acne using a combination of salicylic acid and incorporating LED light treatment on the blue setting to target the Propionibacterium acnes (P.acnes) bacteria that are often implicated in acne formation.8,9
Following successful treatment of her acne, I then moved on to treating the hyperpigmentation using a clay mask formulation containing a combination of acids:
I cleansed and degreased the skin before the clay mask and applied a timed pre-resurfacing solution, which allowed me to assess her skin sensitivity and also to prep her skin for better penetration of the combination acids described above. The prepping solution contained the alpha hydroxyl acids lactic acid, mandelic acid and glycolic acid, which help to break down the desmosomal bonds holding stratum corneum keratinocytes together.14,15 After confirming that she would tolerate the treatment well, I applied the mask to her face in a thin layer to allow the skin underneath to be visible so I could watch for any signs of excessive redness or frosting, which are the clinical endpoints of the treatment.16 The mask was removed after 20 minutes.
I followed each resurfacing treatment with the application of L-ascorbic acid and a calming mask. On a couple of occasions, there seemed to be excessive erythema of my patient’s skin post treatment; therefore, I used a sheet mask specially formulated with ingredients such as 4% niacinamide and panthenol (anti-inflammatory) to help calm her skin and to avoid overstimulating her melanocytes.
I needed to customise each of her six resurfacing treatments according to the condition and response of her skin on that day. This included the use of an activated charcoal peel-off mask and on one occasion, as her skin was quite sensitive, I was unable to perform an acid resurfacing treatment and instead opted for a fruit enzyme ‘peel’ for its gentle exfoliating effects.
After I became used to working on her skin and understood how it behaved, I was able to enhance her results by spot treating her areas of hyperpigmentation individually, prior to applying a full-face mask, ensuring that the skin’s exposure to the acids did not exceed the times specified by the protocol.
The consultation revealed that she had a limited budget and that she did not wish to have the downtime associated with conventional chemical peeling
My post-treatment advice included staying off her homecare actives (retinol and tyrosinase inhibitors) until her skin stopped flaking and any erythema subsided (typically two to five days). I also implemented mandatory sun protection with SPF 30+ as some of the products used, such as retinol, increase skin sensitivity to UV radiation and also due to the need to block UV radiation mediated melanogenesis.17,18
Follow-up consultations were arranged every four weeks after the treatment with an open appointment given for the patient to contact me should she have any concerns or queries before the four weeks. At the follow-up, we discussed the patient’s experience of her treatment journey, if she noticed any improvement in her pigmentation and/or any side effects. Common side effects she experienced included dryness of the skin, which responded well to the moisturiser in her homecare regime, and some initial flaking of the skin. I also checked her compliance with her homecare regime and sunscreen use, as well as ensuring she was using adequate quantities to achieve visible results.
As mentioned, the first challenge that occurred was determining if her PIH was epidermal or dermal. Erythema is also not so easily detected in type VI skin, so it is extremely important to frequently ask the patient about their sensitivity level using a sensitivity scale (I used a scale of 1-10 with 1 being no sensitivity or heat and 10 being the most extreme sensation). It’s also important to compare the patient’s treated skin with areas where the mask has not been applied, such as the eyelids, to help detect redness.
A patient’s budget can often present a challenge for the practitioner to be able to offer maximum results. For my patient, I managed this by selecting the highest impact ingredients, combined with those that worked in synergy with them, whilst also increasing the interval between resurfacing treatments from two to four weeks. This allowed my patient to spread the cost of the treatments across a few months.
Another challenge was not being able to progress to the highest strength clay preparation which, according to the resurfacing protocol used, is not recommended in type V or VI skin. When treating skin that is prone to hyperpigmentation, I find that ‘strongest’ is not always best and that a gentle approach is preferable. I was still able to enhance the results by combining her treatment with other forms of exfoliation such as enzyme peels, retinol and pre-resurfacing solution to avoid excessive irritation of the skin, which could have worsened her PIH.
My patient saw visible results from her first treatment. That night, she noticed that her pigmentation was darker, which caused her initial anxiety and required reassurance. It helped that she knew to expect this as it was discussed in our consultation. Her skin experienced some mild flaking from two to five days post treatment, which she covered with makeup. After the flaking, she noticed that the skin underneath was brighter and less pigmented.
Her pigmentation and acne improved with each subsequent treatment. Interestingly, after her third treatment, she felt that she was no longer seeing any improvement in her skin because she was no longer experiencing flaking. In my experience, this is a common misconception; that if visible peeling or flaking does not occur, then the treatment has not been successful. It is also quite common for patients to grow accustomed to their clearer skin and to forget what it looked like previously because the results occur gradually over time. I managed this by exploring these observations with my patient and by sending her progress pictures, which clearly showed significant improvement in her PIH and helped to improve her trust in the process, while encouraging her to persevere with her treatment plan.
By the end of her sixth treatment, the patient’s PIH had improved dramatically from severe to barely visible and she was extremely satisfied with her results. She was particularly pleased that she achieved her aesthetic goal of being able to go out without makeup and her results had been noticed and commented on by friends, work colleagues and family.
Treating PIH in darker skin tones can be challenging, but it is also extremely rewarding as it can have a significant impact on the patient’s self-esteem. It is first necessary to treat the cause of the PIH to break the cycle of inflammation influencing it.
It is possible to achieve significant lightening and even resolution of PIH in type VI skin using non-hydroquinone products, combined with chemical peels or chemical skin-resurfacing treatments. Prepping of the skin is strongly recommended for type IV, V and VI skin to avoid worsening the hyperpigmentation. Working within budget constraints can add a further challenge and it is important for practitioners to be able modify their treatment plans to accommodate this.