Hyperpigmentation is one of the most challenging skin conditions to treat. Part of its challenge is its stubbornness – which often drives individuals plagued with this condition to the brink of insanity! Repeating the same procedures over and over and getting no results is an all-too-common occurrence when dealing with hyperpigmentation.
So, why is hyperpigmentation so difficult to treat?
The truth is, most forms of hyperpigmentation are transient and quite simple to correct. The problems arise when dealing with specific types of hyperpigmentation in different areas of the skin. To effectively treat hyperpigmentation with minimal frustration, it’s important to understand how and where in the skin it develops.
What causes hyperpigmentation?
Several factors can contribute to the development of hyperpigmentation. Having naturally darker skin (Fitzpatrick skin types III-VI) is a major factor, as are oxidative and inflammatory compounds. The biggest oxidative and inflammatory instigator is UV radiation, which stimulates prostaglandins in the body that spike melanin synthesis. Melanin is a defense mechanism for the skin, and damage of any kind – especially UV damage, which translates into DNA damage, will trigger melanogenesis.
Other instigators which release inflammatory mediators include acne, and the use of harsh, irritating products (or procedures like dermabrasion or chemical peels).
Inflammatory mediators that form from acute sun exposure, acne, and the use of irritating products/procedures stimulate excess melanin in both the epidermis (outer layer of skin) and the dermis (inner layer of skin between the epidermis and subcutaneous tissues). When confined to the epidermis, hyperpigmentation has a tan, brown, reddish-brown, or dark brown appearance, while hyperpigmentation in the dermis typically has a blue-grey hue to it.
Hyperpigmentation can also be caused by hormonal imbalances, as well as certain diseases (type II diabetes) and medications.
Why is hyperpigmentation so difficult to treat?
As stated earlier, most forms of hyperpigmentation are not too difficult or stubborn to treat. These forms are not only transient (i.e. sun tan), but do not have inflammation as a major instigator, so the risks of exacerbating any existing inflammation and excess melanin production are greatly reduced. This can allow for less compromise in the use of skin lightening products, which results in a quicker and less complicated recovery.
Hyperpigmentation, in which inflammation plays a major role in is called post-inflammatory hyperpigmentation (PIH). This form is particularly stubborn, in that its highly reactive and easily prone to setbacks. For example, using chemical peels (which are typically beneficial for non-inflammatory hyperpigmentation in lighter skin types) on post-inflammatory hyperpigmentation (PIH) lesions can worsen the condition, as the irritating nature of hydroxy acids can induce a cascading inflammatory response in the skin, leading to the production of MORE excess melanin.
The location of inflammation plays a vital role as well. Traditionally, epidermal PIH is ‘easier’ to treat than dermal PIH, which can linger for years. Dermal PIH forms when large amounts of melanin are deposited to the site of injury or trauma from inflammation-induced damage to basil keratinocytes. On the surface of the skin, they can appear grey or blue-ish. Any form of hyperpigmentation (acne marks, sun damage etc.) can be found in the dermal layer.
Additionally, many skin lightening ingredients (i.e. tyrosinase inhibiting ingredients) cannot penetrate the dermal-epidermal junction, resulting in a major limitation of treatment options. Dermal PIH is often permanent or impossible to fully treat.
What you can (and cannot) do about it
Once the root cause of hyperpigmentation is determined, an effective treatment plan can be implemented.
With epidermal post-inflammatory hyperpigmentation, treatment plans should adhere to the 3 fundamentals of skin lightening (protection, exfoliation, and treatment) – with an emphasis on gentle exfoliation to reduce existing excess melanin without inducing further inflammation.
The treatment aspect of all forms of hyperpigmentation should focus on the inhibition of future melanin synthesis. Ingredients that intercept the 2 main points of melanogenesis, such as tyrosinase creation and melanocyte to keratinocyte transfer are ideal – especially in non-dermal hyperpigmentation.
With dermal post-inflammatory hyperpigmentation, treatment options are extremely limited. Most of the frustration that people experience comes from dermal hyperpigmentation, which is deeper, and more stubborn to treat than epidermal cases.
The cardinal rule when dealing with dermal PIH should be a realistic goal. Individuals with this form of hyperpigmentation should understand that this condition may take months to years to treat or possibly remain permanent.
Once this fact is taken into consideration, the treatment plan should consist of excellent sun protection and the use of invasive or more aggressive exfoliation/treatment options such as chemical peels or lasers. However, the problem with utilizing aggressive procedures is that they can exacerbate the problem (inflammation), and lead to more melanin being produced – especially in those with dark skin.
Having said this, moderate level alpha hydroxy acid peels (40% and above) can be beneficial to those with non-inflammatory dermal hyperpigmentation, and lighter skin, as the risk for developing inflammation-induced pigmentation is less in these circumstances.
Consulting a board-certified dermatologist specializing in cosmetic dermatology is highly recommended when treating dermal hyperpigmentation, as they can determine which procedure is best for your case.
Hyperpigmentation forms that are rooted in hormonal imbalances, such as melasma, should emphasize on excellent sun protection – with physical sunblocks (zinc oxide, titanium dioxide-based) being the products of choice, as many individuals with melasma find chemical UV filters exacerbate their condition.
Treatment options consist of: triple topical therapy (glycolic acid or retinoid, hydroquinone, topical corticosteroid), non-hydroquinone based skin lightening ingredients at optimal strengths, the use of sepiwhite (antagonist of the melanocyte stimulating hormone (MSH)), or the synergistic combination of sepiwhite and niacinamide.
Certain forms of hyperpigmentation can be more difficult and stubborn to treat. Understanding the source and location of these forms of hyperpigmentation can lead to possible solutions and less frustration and disappointment.