Practitioners would agree that an even skin tone is fundamental to fresh and healthy-looking skin. You could provide a patient with the very best injectable treatment; reducing lines and wrinkles, volumising cheeks and enhancing facial features, yet this cannot guarantee ultimate satisfaction – for you and them.
Addressing skin tone concerns and, in particular, managing hyperpigmentation, could make all the difference. First, it’s vital to understand what hyperpigmentation is and why it occurs. Here we will explore the three most common types and consider how it is best treated.
Hyperpigmentation occurs when there is excess production of melanin; the pigment produced by melanocytes which are the cells that give skin its colour.1
“The darker your skin, the more melanocytes you have,” says consultant dermatologist Dr Hiba Injibar, explaining that this subsequently means that those with darker skin types have a higher risk of hyperpigmentation. That said, she notes, lighter-skinned individuals are also affected – particularly those who’ve had excessive sun exposure.
However, sun isn’t the only cause. Aesthetic practitioner Dr Lori Nigro explains that hormonal, systemic, inflammatory and structural triggers can all lead to various forms of hyperpigmentation. And as consultant dermatologist Dr Jinah Yoo highlights, hyperpigmentation is simply a description. She emphasises that to appropriately treat the concern, it’s vital to identify exactly which pigment disorder your patient is suffering from. The three most common are: post-inflammatory hyperpigmentation, melasma and solar lentigines.
When skin is irritated or injured, for example through acne, eczema, or burns, it triggers an inflammatory response whereby more melanin is produced leading to post-inflammatory hyperpigmentation (PIH). Research has indicated that the location of the excess pigment within the different layers of the skin will determine its colouration.2
In the epidermis, it will appear tan, brown, or dark brown and may take months to years to resolve without treatment. In the dermis, PIH has a blue-grey appearance and may either be permanent or resolve over a significant amount of time if left untreated. PIH can worsen with sun exposure and persistent or recurrent inflammation.2
More common in women, melasma generally occurs as a result of hormonal changes. Birth control and hormone replacement medication can have an effect, while research suggests that up to 50% of pregnant women experience melasma.3
It usually appears on the cheeks, forehead, upper lip, nose, and chin, but can also occur on the other areas of the body exposed to the sun. Melasma becomes more noticeable in the summer and can improve with hormonal adjustments.3
Often referred to as sun, age, or liver spots, solar lentigines usually appear on sun-exposed areas of the skin such as the face, hands, neck and chest. They can be various shapes and sizes, and most don’t go away unless treated.4
There are other types of lentigines, which can be present from birth or form following radiation treatment, however they are outside the scope of this article.4
“The sun is a major culprit in all forms of hyperpigmentation,” says Dr Injibar; whether it’s causing or exacerbating the condition. She emphasises that sun protection is key to prevention. “Wearing SPF50, a broad, wide-brimmed hat, seeking shade and staying out of the sun in peak hours – between 11am and 3pm – is prime advice we should be giving all of our patients,” says Dr Injibar, with both Dr Nigro and Dr Yoo agreeing. “I tell my patients that if they are leading an active lifestyle, they are really using up their full quota of sun exposure. Sun tanning and sunbeds do not and should not be part of their beauty routine,” says Dr Nigro. She adds, “I remind them that there are really great and fully adequate bronzers available and try not to make them feel bad for wanting to do it. We must instead give patients better options.”
Particularly in cases of melasma, the practitioners recommend reviewing patients’ hormonal balance in order to target the cause, prior to tackling the effect. They suggest looking at different medication; for example, switching the combined oral contraceptive to an intrauterine device instead. Likewise, for those suffering from PIH, the practitioners believe it’s beneficial to review the condition that may be causing it if it’s something treatable such as acne.
“It’s a discussion to have on a case-by-case basis,” says Dr Nigro. She emphasises, “We must have a prevention strategy for every patient who walks through the door. We as aesthetic practitioners need to be able to treat our patients differently and accept that they have different requirements. And if we cannot, then we should refer to colleagues who can.”
There are a number of different ways in which hyperpigmentation can be treated, with the deciding factor being led by the type and severity.
For low-severity hyperpigmentation, the practitioners recommend that prescription-strength skincare is a good place to start. Hydroquinone is a well-known ingredient, however if this isn’t suitable for your patients there are other effective ingredients. Some of these are:5
- Vitamin C: blocks tyrosinase, an enzyme the body uses to produce melanin and, as an antioxidant, protects cells from further damage from the sun or pollutants.
- Kojic acid: similarly to vitamin C, also works by inhibiting tyrosinase enzymes and protects skin thanks to antioxidants.
- Retinol: encourages cell turnover, bringing healthier skin cells to the surface while exfoliating older, darker ones.
- Niacinamide: a form of vitamin B3 which can interrupt the process of cell pigmentation and brighten skin, while also being used to treat acne and prevent future hyperpigmentation.
- Azelaic acid: anti-inflammatory properties and can suppress melanin production – considered suitable to use in pregnancy so especially beneficial for melasma treatment.
- Mandelic acid: an alpha-hydroxy acid that helps exfoliate the skin.
- Arbutin: considered to be a natural form of hydroquinone – a chemical that bleaches the skin – so can be a preferred method.
Dr Yoo has seen success with Cyspera; the product uses a formula that contains cysteamine, which aims to regulate melanin synthesis in the skin. While it can be used as an intensive treatment when used daily for 16 weeks, Dr Yoo says that she finds it a valuable tool to maintain results if used twice weekly.6
For Dr Injibar, Eucerin Sun Pigment Control sunscreen or a mineral sunblock such as Bioderma Photoderm Mineral are her go-to skincare recommendations, while Dr Nigro advocates the use of the mesoestetic range.
Of course, these ingredients can also be used in chemical peels – one of the most popular methods for treating hyperpigmentation. “In terms of peels, you need to have the preparation phase, the treatment phase and the maintenance phase,” explains Dr Nigro, adding that the preparation phase is arguably the most important in order to limit localised skin reactions to the peel itself. She says, “Localised skin reactions can include redness, swelling, tenderness and tightness. By adequately preparing the skin, we can avoid this and amplify results.”
To prepare the skin, Dr Nigro advises you could either provide patients with fortnightly superficial peels or recommend a homecare regime, with less intensive products, which they would use every day for a period of two to six weeks, depending on their concern. When it comes to the peel itself, Dr Nigro is quick to remind practitioners that a medium peel can always become deep, whereas a deep peel cannot become superficial, so always take caution, and select a weaker ingredient to start. Dr Nigro’s go-to products are cosmelan for the preparation phase and dermamelan for the main peel; both from mesoestetic. She explains that they can be used on all skin types and use respected ingredients such as vitamin C, ferulic acid, niacinamide and vitamin E, that address more than the pigmentation. She notes, “If you use a treatment which has the intensive treatment phase and the maintenance phase, you can modulate the melanocyte response for years after a treatment, so patients’ results can be prolonged and they can get the best possible long-term outcome.”
For Dr Yoo, the Exuviance 20-30% glycolic acid peel is her product of choice. She says, “It’s a gentle superficial peel which allows me to combine with other treatments such as laser or radiofrequency microneedling.”
For solar lentigines, Dr Injibar prefers the use of the Synchro QS4 Q-switched laser from DEKA and also recommends a pico laser. She explains that short bursts of laser cause the pigment to shatter into tiny, microscopic fragments under the skin, which are absorbed by the body or peel off externally. “In my experience, Q-switched laser is very effective. I can often peel off the hyperpigmentation completely,” she says.
Topical anaesthetic should be used, but Dr Injibar says pain and downtime are minimal. “Side effects can include scabbing in the area and, as practitioners will know, any time you break the skin barrier, there’s always a very slight risk of infection. This is of course low if you keep the skin clean,” she says.
Dr Injibar adds that there is also always a risk of scarring and further hyperpigmentation but, in her experience, this is low if the device is used correctly so appropriate training is essential for all users. CO2 lasers are also an option, however, she notes that this risk is higher as they break the skin.
Generally, Dr Injibar says effective treatment will require between three and 10 sessions with the device she uses but you’ll also be able to refine the skin and see further improvement,” she explains.
For darker-skinned patients with a strong family history of hyperpigmentation and who’ve tried all the prevention strategies, Dr Nigro says there’s no justification for using a laser. “In my view, you must stick with combination peels as they’re much safer,” she advises.
Dr Yoo also uses laser, choosing to utilise the Hollywood Spectra from Lutronic. She says the Q-switched device has different modes to target different sizes of pigment. “I use a laser toning technique every two weeks for five to 10 sessions when treating PIH and melasma, which breaks down pigments into smaller fragments to be removed through the lymphatic system,” she explains. Dr Yoo also uses the Clarity II long pulse device, again from Lutronic, which she claims has a unique temperature monitoring feature, which allows it to be safely used to treat darker skin types.
Dr Yoo, on the other hand, uses a radiofrequency microneedling device called Sylfirm X. She explains, “This device reaches a 300micron depth where it is targeting fibroblasts in the papillary dermis to modify the crosstalk between fibroblasts and melanocytes in melanogenesis.” With minimal downtime and discomfort, she has found it to be a reliable addition to her practice. Dr Yoo notes, “As radiofrequency microneedling works by delivering radiofrequency energy through the microneedle in a controlled way and it is not affected by chromophores – such as pigments like in laser – it is safe to use as long as not too much heat is delivered.” To treat melasma, Dr Yoo says the device is suitable for all skin types and uses 0.3mm needles and offers five sessions every two to four weeks.
Hyperpigmentation in the intimate area
Dr Nigro says there is often an assumption that only facial hyperpigmentation is a concern. Yet, she has found that many patients are bothered by the condition occurring in intimate locations. Hormones and factors such as friction can contribute to skin darkening,7 and it’s vital that practitioners are able to offer safe treatments before patients turn to unregulated products found online.
She highlights, “Culture has suggested that only porn stars should want to treat their intimate area but, the reality is, when your body starts to change you may not like it and that’s nothing to be ashamed of.” Dr Nigro uses the mesoestetic dermamelan intimate product, which contains a combination of active ingredients with depigmenting efficacy, as well as formula that aims to control the inflammation. Useable in the genital-perineal area, perianal area, mons pubis, inner thighs and groins, Dr Nigro says she’s seen excellent results with the product. She emphasises, however, that if you don’t feel confident or comfortable treating intimate areas, then always refer your patient to a practitioner who does.
The practitioners recommend always performing a patch test on a patient prior to laser or peels which, as well as checking the treatment is appropriate for them, allows the patient to see the effect after one treatment and get an idea of expected downtime and help manage expectations.
When investing in a laser device, Dr Injibar says it’s important to understand the technology before making a selection. She advises, “Try different machines before you invest, research its track record and get to know the company itself. The laser company is very important as you will need the post-purchase support.” Dr Injibar recommends finding out what training is available, what their upgrade policy is and the maintenance service they offer. “I would recommend investing in a company that is here in the UK, so if something does go wrong, they will have local engineers who can fix any error as soon as possible. They’re very fancy machines but something can go wrong on the spot and, if you have patients booked, what do you do?” she highlights.
Dr Injibar also advises being cautious of new technology – sometimes the latest doesn’t mean it’s the best, she says, adding, “It has to stand the test of time, so do your research by checking clinical studies and sourcing first-hand experiences of the devices you plan to purchase!”
Of most importance, is recognising when and when not to treat, agree the practitioners. “Skin cancer is pigmented,” says Dr Injibar, emphasising what you assume is simply hyperpigmentation, could be more sinister. “If it’s suspicious or you’re unsure, always refer to a dermatologist,” she warns.
And, as always, sun protection is key to avoid and reduce the chance of severe hyperpigmentation. The practitioners conclude that SPF50 and above should be recommended for maximum protection, while educating patients on the sun’s impact on skin overall is imperative to achieving healthy, aesthetically-pleasing skin.
1. MaryAnn De Pietro, What You Should Know About Hyperpigmentation (Healthline, 2022) <https://www.healthline.com/health/hyperpigmentation#outlook>
2. Erica C Davis, Valerie D Callender, ‘Postinflammatory Hyperpigmentation’, The Journal of Clinical and Aesthetic Deramtology, 2010. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921758/>
3. What Is Melasma? (British Skin Foundation, 2022) <https://knowyourskin.britishskinfoundation.org.uk/condition/melasma/>
4. S. Behring, Lentigo (Liver Spots) (Healthline, 2022) <https://www.healthline.com/health/lentigo#types-of-lentigo>
5. Kate Watson, The best ingredients to treat hyperpigmentation and brighten your complexion, accordingto dermatologists (Insider, 2022) <https://www.insider.com/best-ingredients-for-hyperpigmentation>
6. Cyspera Intensive Pigment Corrector (Face the Future, 2022)<https://www.facethefuture.co.uk/products/cyspera-intensivepigment-corrector>
7. Intimate Area Hyperpigmentation: A Common But Personal Concern (Cyspera, 2022) <https://www.cyspera.com/intimateareas-hyperpigmentation/#:~:text=Darkening%20of%20the%20skin%20of,can%20contribute%20to%20skin%20darkening.>