Pigmentation Treatment – To treat or not to treat?

Hi guys, and welcome to my podcast, Dermatologist Talks: Science of Beauty. I am Dr. Teo Wan Lin and this week, we are going to talk about hyperpigmentation. The commonly asked questions around this topic would often be: How can I lighten pigmentation around my face? What treatments are effective? Do I really need lasers? Well for today’s episode, we are going to talk about hyperpigmentation in a slightly different way to offer you a new perspective.

What is Hyperpigmentation?

First of all, not all hyperpigmentation must be treated either for cosmetic or medical reasons. Furthermore, certainly not all forms of hyperpigmentation are treatable. So, we are going to start with this. Hyperpigmentation is essentially a very broad dermatological term that encompasses a lot of different diagnoses. It is important for us to explain this in detail because a lot of stigma associates with having hyperpigmentation. So much so that sometimes as a dermatologist when people ask me that question, I almost feel like I should tell them that I also have hyperpigmentation, and everybody has it in some form or other.

Now, we are going to do this systematically. Firstly, because I want to change perceptions about beauty. In particular, perceptions on skin tone skin colour, which is a really important topic in Asia. For example, there are important diagnoses that dermatologists will not want to miss when we are looking at a case of hyperpigmentation. Also, the layperson should understand that there is a real reason why you need to see an accredited dermatologist for your pigmentation issues. This is because pigmentation is definitely not all cosmetic. In fact, some types of hyperpigmentation can be cancerous.

Hyperpigmentation itself is a broad morphological description of a group of fairly diverse dermatological conditions. These comprise the following. Natural hyperpigmentation which the skin creates by itself due to the activation of melanocytes. These are cells that produce the pigment melanin. Exogenous pigment deposition can occur due to drugs which we take orally. It can also occur or as a result of certain implantation, tattoos, foreign body etc.

Causes of Hyperpigmentation

The most common cause of hyperpigmentation, which is fairly benign and is important for the layperson to understand, is actually post-inflammatory hyperpigmentation, or PIH for short. It is very important to emphasise this because it is a form of scarring in the context of acne and eczema which are common conditions, and even mosquito bites. All these can and will lead to post-inflammation erythema, which is redness shortly after the condition resolves. This develops into post-inflammatory hyperpigmentation in fairer skin individuals. They can also cause post-inflammation hypopigmentation, which is loss of pigmentation in darker skin individuals. All these are forms of the body reacting to the inflammation.

There is also a category of hyperpigmentation which our genetics influence. An example would be freckles, also known as ephelides. It is important to consider these in the correct context. Individuals who have red hair and light colored eyes tend to predispose to freckles. Even myself, with fair skinn, I start having freckles from my early childhood years. These are not in any way considered pathological associated with aging or poor skin health.

If you are thinking of removing your freckles, it is important to note that methods such as the 532 Q-switch laser is capable of inducing a form of scarring. This is what we discussed before about post-inflammatory hyperpigmentation. Consequently, if you think that you are getting rid of your freckles, there is an equally significant chance that you will exchange it for a different form of pigmentation known as PIH. Furthermore, removal is rather impractical since most individuals with freckles have several of these.

When We Treat Pigmentation

I think it is also important to zoom in on commoner causes of pigmentation that we do treat. Melasma is a form of hyperpigmentation that triggers from hormones and is common in darker skin types. It is a form of hyperpigmentation that does warrant treatment not just for cosmetic reasons, but because of the immense psychosocial, psychological impact that it can have on the individual.

Cancerous Pigmentation

For the purposes of today’s podcast, I really want to emphasise that there is a group of pigmentary disorders that is potentially dangerous if merely dismissed by the layperson or a non-dermatologist. For example, an aesthetic physician who is not a trained dermatologist, may misdiagnose cancer as hyperpigmentation. Consequently, he or she may not refer the case out to a dermatologist.

There is a specific type of cancer that looks a lot like your run off the mill age spotter. This is what we call solar lentigines in older persons, but is in fact a very dangerous cancer. The cancer is known as lentigo maligna. It takes expertise and a high index of suspicion for a dermatologist to make the correct diagnosis. We diagnose the condition with a biopsy. The biopsy will detect malignant cells, the degree of spread, and will be read by a dermatopathologist.

The diagnosis of lentigo maligna is very important. It is a form of melanoma. If we diagnose the condition late, the cancer grows large and eventually leads to a loss of tissue. Since it occurs on the face, there is significantly higher morbidity in terms of disfigurement. In addition, there will be difficulty in removing the tumor at a later stage. Certainly, it also affects what doctors call mortality. This is because as a form of melanoma, it has potential to spread to other organs and lymph nodes. Such a spread could be fatal.

Benign Pigmentation

The above is certainly on one extreme end of the spectrum where pigmentation is clearly not a cosmetic issue. Treating it as such, which is also a result of societal influences as well, can be incredibly dangerous. The opposite end of the spectrum would be absolutely benign causes of pigmentation. I think it is also very fair for the laypersons and public to understand that first of all, these do not require specific treatment. Secondly, if the prognosis is not very good as well with treatment, do you actually want to spend the money or expect certain results from treatments? When the reality is there is not very good evidence for such treatments.

Case in point would be racial hyperpigmentation. This is actually a form of hyperpigmentation occurring in phototypes III, IV and V. These are individuals who have Asian, Hispanic or African American skin tones. In racial hyperpigmentation, we see increased melanin deposition in certain areas. They are essentially the flexural areas, but can also occur on the face, such as around the mouth. We should clearly distinguish all these from other causes of hyperpigmentation like melasma that may require evaluation and treatment. The thing with racial hyperpigmentation is that it is benign. Any promises to reverse that, by any physician with therapy, should be made with a very clear declaration that the medical evidence tells us that treatment is generally not very successful. This is different from an approach where we are advocating skin health.

Antioxidants for PIH

Something relevant would be in the treatment of PIH that has lessons for us as well in the current context. This is in the use of topical antioxidants, which while do not directly address the underlying conditions such as acne or eczema, it does support anti-inflammation. Anti-inflammation means that there is going to be less of the cytokines and chemokines. These are chemical mediators that can stimulate melanin production even more. Besides, we know that a lot of inflammation can worsen with photodamage, and antioxidants actually help to fight photodamage.

Freckles Pigmentation

Back to the topic of freckles, I think it is very important for us to communicate this message that freckles are actually beautiful. First of all, I think that it makes an individual look unique. Secondly, from a dermatologist perspective, it is not practical to be treating freckles. Think of it this way, it is a manifestation of an individual’s natural gene expression. This is with their original hair and eye coloration phototype, that is they are genetically encoded to have all of this on their skin. It is only a result of social conditioning that some individuals feel conscious of it.

Conversely, imagine if we were to focus purely on skin health. That way, a lot of the different causes of pigmentation can then be correctly pigeonholed into categories. These are categories of whether it is a true form of skin pathology for example, or if it is a cosmetic concern which we need to treat because of its psychosocial impact. In the case of freckles, which really should have no psychosocial impact, there appears to be an unrealistic societal sort of expectation especially in Asia. I feel that a lot of individuals are made to feel more conscious about their freckles in a negative way than it should be.

Prevalence of PIH

I also think that it is timely for us to address the types of treatment options available for PIH. Everyone will get PIH at some point of time in their life. For example, if you were to look at my Instagram videos, there are a couple recently where you can see I have these hyperpigmented spots. They are quite tiny on my wrist. Frankly, I do not bother with it. I can see it but I really do not think it is an issue at all. I know that there are many people who would be bothered by it if they had it. The spots were because I had a slight accident where my dog accidentally mouthed me when he was playing and then left some bite marks.

I know for sure that the marks are going to fade with time and it just does not bother me. However, I have seen many patients who have PIH that becomes really troubling for them. These can be from either small accidents they have had, surgical scars, or even acne that they had a few months earlier. It is really important for us to address how it got to that stage, because clearly, it is a very significant disturbance to them mentally.

Pigmentation As Part of Wound Healing

I think that the very first step that I can take as a public educator, who is also a trained dermatologist, is to explain that our body actually takes a certain amount of time to heal on its own. It is programmed to naturally heal our injuries. In fact, inflammation is the way the body heals itself. Now, with inflammation, we also have the stages of wound healing, and post-inflammation hyperpigmentation is a part of this process. Consequently, we can alleviate PIH with appropriate care of the underlying condition. This is relevant if your hyperpigmentation is not caused by trauma, such as in my case when I was mouthed a little bit too hard by my pet.

Treating Pigmentation At Its Cause

For example, in the case of acne, if you have acne that is untreated, it is important for it to be addressed before you speak about any treatment options relating to scars. If you have eczema, we need treat it with appropriate medications to avoid a vicious cycle. This is rather than for you to focus on the hyperpigmentation, which will fade with time. The degree to which hyperpigmentation lightens also depends on your biological age. The key here is perhaps we do not need to be so bothered by that, or even feel that there is an expectation for anybody to be flawless and perfect in order for them to look good.

I think it is critical to understand that a lot of the treatment options which the industry touts for pigmentation, whether it is prescription or non-prescription, actually work by inhibiting the enzyme that involves in production of melanin. This enzyme is known as tyrosinase which can be inhibited by compounds such as hydroquinone. On the other hand, there are treatments that utilise antioxidant. For example, in the case of cosmeceuticals like vitamin C, and certain botanical plant extracts like Centella Asiatica, these reduce post-inflammation hyperpigmentation by improving the antioxidant ability of skin cells. From this perspective, I feel it is much healthier than depigmenting treatments such as hydroquinone. This is primarily because hydroquinone will not work directly for PIH and can have adverse events such as depigmentation. In addition, if you have eczema, it will trigger an eczema flare up.

Healthy Skin Is Perfect Skin

The use of antioxidants as a form of skin tone brightening or evening sort of treatment, is actually evidence-based and is focused still on skin health. In fact, it has an added photoprotective mechanism. This means that on a day to day basis, it helps you fight free radical damage. Free radical damage is a significant cause of skin aging and sun-induced skin damage. These factors actually increases your risk of getting precancerous and cancerous lesions on your skin.

That just about wraps up today’s podcast episode. There are a few take home points I want to emphasise here. Firstly, we do not need to treat all forms of pigmentation or view them negatively. All of us will have had some form of post-inflammation hyperpigmentation at some point of time in our lives. So don’t fret, the next time you have a small accident, or you get a mosquito bite, or you have a pimple. The pigmentation spot will fade with time, so you don’t have to worry too much about it.

An approach focussing on skin health and your skin concerns is far more important than societal expectations of what one considers beautiful or flawless. This is because oftentimes, societal expectations exacerbate a lot of the mental anxieties that sufferers of these skin conditions already have. Well, I hope that today’s podcast has helped you. For the full podcast transcript, you may go to my podcast website at www.scienceofbeauty.net. I wish you all a great week ahead!