Pigmentation and treatment

 

What is pigmentation?

Pigmentation is the formation of pigment within the basal layer of the epidermis which is visible at surface level of the  as a marked area which is differentiated in colour from the rest of the skin and more often than not hyper-pigmented.  The molecule responsible for the pigmentation is called melanin, the up-regulation and production of melanin is regulated by a number of different factors.

There are two sub-variants of melanin which are known as eumelanun and pheomelanin, each of these respective variants are responsible for different colour pigments within the skin. Eumelanin produces pigmentation more within the brown and black colour spectrum and pheomelanin produces pigmentation which is visible more within the yellow and red colour range. The ratio of eumelanin to pheomelanin is reflective in the colour of the pigment that is produced and seen within the skin. 

There are a number of biochemical pathways involved in the production of melanin and an enzyme called tyrosinase plays a pivotal role in production of melanin within these biochemical pathways.   Active ingredients within skincare protocols which target pigmentation selectively switch the tyrosinase enzyme off or reduce production of it and down-regulate it thereby limiting or reducing the production of melanin  and reducing the amount of pigmentation within the skin.

Which ingredients are used in skin care protocols to tackle pigmentation? 

Key ingredients within skincare protocols which work to reduce  pigmentation include hydroquinone, tretinoin, retinol  tazarotene, tranexamic acid, thiamidol and niacinamide.  A number of alpha-hydroxy acids, vitamin C,  arbutinin and licorice also work to reduce pigmentation. 

Alpha-hydroxy acids which work to reduce tyrosinase levels and switch off production of melanin production include kojic acid and azelaic acid. In addition, glycolic acid which is also an alpha-hydroxy acid formulated into a number of skincare products and reduces pigmentation through its effects on desquamation of the outer layer of the skin by breaking down the bonds between dead skin cells and sloughing away dead skin and the pigment that is within this aswell resulting in pigment fading over time. Kojic acid is commonly formulated in skincare protocols, this works by reducing the free tyrosinase enzyme levels and it also works as antioxidant as well.

Licorice is formulated into skin care protocols to regulate pigmentation. This contains a compound called glabridin this inhibits tyrosinase and enzyme which produces melanin and also contains liquirtin which disperses melanin from the skin and evens out skin tone. 

Other skin  actives which reduce pigmentation include vitamin C and arbutinin. Vitamin C works by down-regulating the tyrosinase enzyme and melanin production. 

Arbutinin is an active ingredient incorporated into many skin care protocols to treat pigmentation. This is a hydroquinone glycoside derivative. When applied to the skin it breaks down into hydroquinone  which reduces tyrosinase activity. In addition to the hydroquinone component of its formulation for exerting anti-pigment effects this also works by acting as a competitive inhibitor of the tyrosinase enzyme and so reducing melanogenesis.  It is particularly effective in lighter skin tones, fitzpatrick grades 1 to 3 and those patient groups with mild to moderate pigmentation who perhaps prefer an alternative to vitamin C. Arbutinin is much quicker in its absorption profile within the skin than vitamin C.

Tranexamic acid is another treatment option for hyperpigmentation especially in patients who have perhaps not responded very well to arbutinin.  Very much like arbutinin it is a good treatment option in patients  with mild to moderate hyperpigmentation and Fitzpatrick Glades 1 to 3.

Causes of pigmentation?

There are multiple causes of pigmentation within the skin. Some of these can be intrinsic and other causes can be caused by extrinsic factors. 

The most common extrinsic cause of pigmentation is exposure to radiation in the form of sunlight. The action of UVA and UVB rays on the surface of the skin induces a chemical reaction which manifests in the production of excess melanin on the surface of the skin and hyperpigmentation. Sun protection is therefore vital to protect the surface of the skin against hyper pigmentation. The skins natural defence mechanism in response to sun exposure is to increase the formation of melanin therefore to prevent sunburn and sun damage it is essential to minimise exposure in peak hours and wear sunscreen at all time. Protective clothing can also be very useful in protecting the skin against sun-induced damage.

Another common reason for pigmentation can be due to hormonal related changes within the body. Pregnancy and menopause, as well as the use of birth control pills are commonly seen as potential root causes in patients who present with pigmentation. 

When dealing with pigmentation, which is hormone related, it can be difficult and challenging. This is because internal factors which are at play within the body are harder to control or even stop,  however the pigmentation can still be controlled and reduced with appropriate skincare protocol and ingredients.

Some studies have evaluated links between mineral deficiencies and pigmentation in particular with regard to vitamin B12 and vitamin D levels.  It has been reported in some studies that low levels of vitamin D can induce melanogenesis and formation of excess pigment. In other studies it has been reported that low vitamin B12 levels can be a root cause of pigmentation. In such cases, a full blood test can evaluate if there are any interrelated mineral deficiencies which are playing a role in the pigmentation concerns of the patient and appropriate mineral supplementation options can then be explored and advised by way of nutritional supplements or intravenous nutritional therapies and drips which are becoming increasingly common place as available treatment in clinics. 

Which skincare protocols can be prescribed to treat pigmentation?

There are a number of skin care protocols which can be used to treat patients who have hyperpigmentation concerns.

When selecting Skincare it is important to note the active ingredients which are in the product and how these work to reduce pigmentation.

For any patient who presents with established pigmentation as a result of melasma or hormonal changes or other causes the most potent protocol to treat this is the OBAJI nuderm protocol.

This Protocol is a seven step programme. It comprises a foaming gel cleanser and a toner which contains sage and which hazel aswell as borrage extract and aloe vera to calm, soothe and purify the skin. 

The main active ingredient is hydroqinone 4%, this is incorporated into the clear Fx serum which is applied at night. The hydroquinone down regulates tyrosinase activity thereby inhibiting the production of melanin. The fourth product is exfoderme  forte which is applied in the morning, this exfoliates the top layer  of the skin and removes the broken down pigment. The fifth product is the clear blend Fx which contains arbutinin this is applied a.m. and p.m. and this produces skin lightning,  brightening and de- pigmentation.  The sixth and seventh products are the hydrating cream to protect the skin barrier from drying and SPF 50 which is critical at all times to protect the skin barrier from the effects of UVA and UVB radiation.

For those patient groups who have a contraindication to the OBAJI nuderm protocol and its ingredients or perhaps cannot tolerate hydroquinone or are not suitable patients to be on a protocol which contains hydroquinone the ZO Skin health protocols offer an alternative solution. The ZO Skin health solutions are also a very good follow on maintenance programs after the OBAJI nuderm protocol has initially been completed and the pigment has been removed.

The ZO Skin health brightening program comprises gentle cleanser, exfoliating polish scrub, complexion  renewal pads with brightalive and daily power defence serums.

The exfoliating polish scrub contains magnesium crystals which are very good for exfoliation and sloughing away dead skin cells and fading pigment.  The brightalive serum contains tranexamic acid and niacinamide which down-regulate tyrosinase activity and inhibit the production of melanin. It also contains lactic acid and glycolic acid as well as ascorbic acid for skin exfoliation and renewal alongside lightning and brightening.

A retinol can be added to the protocol to further the anti-pigmentation effects and number of different SPF products are also available to protect the skin from sunlight. ZO Skin health offer the retinol skin brighter which contains bakuchiol, this works to soothe and  calm sensitive and dry skin types. The wrinkle and texture repair contains retinol and is effective for skin renewal and hydration. The best retinol product can be advised after a consultation and analysis of the skin type. 

Neostrata also offer a  product range which addresses pigmentation. The product range is called the Enlighten range. This is made up of a seven step program containing seven different products. The cleanser is an ultra brightening cleanser which contains 6% neoglucosamine. The second, third and fourth  steps comprise serum pigment controller, a light gel and a bionic cream. The active ingredients are primarily retinol, 4% glucosamine,and  a blend of alpha-hydroxy and poly-hydroxy acids including Kojic acid, ascorbic acid and licorice root extract; all of which are anti-pigmentation in there effects and action. The exact instruction for the protocol can be advised after consultation.

All the skin health protocols involve layering of different products in specific orders. This is why it’s really important to seek advice from a qualified dermatologist or a skincare specialist before selecting the exact protocol that you wish to use to target the pigmentation.  This should also enable you to receive the most appropriate advice in product usage and understanding which order to apply which product in to gain the best effects.

The active ingredients which are formulated in the Skincare products do determine which order they should be applied in and if they are applied in the wrong layer this can often undermine or negate the effect of the active ingredients altogether and render the protocol ineffective for the treatment. 

Which clinic treatments will help to treat my pigmentation?

There are a number of different treatment options available which can be explored to help to treat the pigmentation.  These range from topical medications, micro-needling to microdermabrasion and laser treatments and in-house skin peels. The skin therapist who you consult  should be able to advise on the best available treatment options depending on the pigmentation.

Microdermabrasion is a very good option for exfoliating the top layer of the skin and fading pigmentation scars associated with acne, ice-pick scarring and pigmentation The combination with micro-needling is particularly effective. A number of different serums can also be applied during the microneedling session such as the ZO Skin health brightalive serum which is very good for fading pigmentation and scars, it contains niacinamide, ascorbic acid, tranexamic acid,  lactic acid and glycolic acid.  The Genosys pigment control serum which is a South Korean brand of skincare contains licorice root extract, Kojic acid and botanical stem extracts. 

Skin peels are another good option for treating pigmentation. Skin peels include the ZO Skin Health invisapeel which contains alpha-hydroxy acid glycolic acid which has exfoliant properties and the enzymes papain and bromelain alongside hydrating kukui seed oil and safflower seed which replenish hydration and lipids in the skin barrier giving this a really nice finish after the treatment and not overly drying the skin out either. Epiderma skin peels include the  glycolic 30% and 70% skin peels which are really good at lifting surface pigment, breaking down dead skin cells and sloughing and removing away pigment to reveal fresh new healthy skin cells. 

Other more extensive and advanced peels include those which are TCA peels and the ZO Skin health three step peels as well. Advice on these procedures can be sought after thorough consultation as well as detailed  information on the after-care and social downtime needed and associated with more stronger chemical peels for treating pigmentation. 

Another more recent and very highly effective treatment for pigmentation is that of polynucleotides. These have shown effective results in the treatment of pigmentation not only across the face, décolletage,  hands and other body areas but also on the under-eye areas as well in addressing pigmentation and dark under eye circles, puffiness and eye bags. These are injected  as a course of three treatments spaced at four weekly intervals and the results go on  to continue for months after treatment progressively getting better. In combination with  an eye cream,  which targets pigmentation such as the ZO advanced brightening eye cream this achieves even better results, the active ingredients in this eye cream include kojic dipalmitate which lightens dark circles, shea butter,  squalene and sodium PCA which hydrate and replenish the lipid barrier and moisturise the under-eye area and caffeine which reduces puffiness and increases micro- circulation around the eye area.

Polynucleotides are bio-stimulating agents that are injected underneath the surface of the skin to stimulate fibroblasts activity and up-regulate the production of collagen and elastin. They have also shown results in down-regulating pigmentation and effectively fading pigment scars and pigment marks. Vitaran is one such example of a polynucleotide which is used in clinic. In the popular salmon DNA facial which recently has gone viral on social media this can be either injected underneath the surface of the skin across the face or it can also be micro-needled as well to achieve similar results in a facial treatment to address scarring acne, pigmentation, fine lines and wrinkles.