What determines our natural skin colour?
Our skin colour is determined by the activity of a special type of skin cell called melanocyte which is present in the epidermis of our skin. They produce a substance called melanin and transfers it to neighbouring skin cells giving them a colour so that when these cells reach the surface of our skin, it determines our complexion. This is genetically determined with lighter skin tones having less melanin than darker skin tones.
What causes pigmentation?
The main causes of increased pigmentation are sun exposure, ageing, pollution, skin trauma and hormonal influences but these factors do not operate in isolation. They have a combined effect on our skin causing hyperpigmented spots or patches. Pigmentation is the first sign of ageing in skin of colour and appears as uneven skin tone.
Types of hyperpigmentation
Hyperpigmentation itself is not a diagnosis so it is important to establish a diagnosis and then plan treatment accordingly. Although there are three common types, a person may present with more than one type.
When exposed to UV radiation, the melanocytes produce more melanin which absorbs the radiation and reduces damage to the DNA in deeper skin layers. With the increased production of melanin, the skin becomes darker. Therefore, melanin is also referred to as our natural sunscreen. Over time these cells are shed at the surface and we revert back to our natural complexion. If the UV exposure is constant or there are other triggers, the skin continues to produce excess melanin, but this is not uniform and rather irregular. Those with lighter skin tones are unable to produce sufficient melanin to protect from UV radiation hence tan easily and are more susceptible to sun damage earlier in their life.
As we age, there is background low-grade inflammation which causes cellular DNA damage. There is also damage to DNA caused by free radicals in the environment from pollution and UV radiation. This means that the defence and repair mechanism in the skin become inefficient. The number of melanocytes and their function reduce with age so there is an uneven distribution of melanin to the surrounding cells creating age spots. Skin pigmentation due to ageing or sun exposure tends to be uneven and may appear as freckles which join up over time to make spots which eventually form patches which is more pronounced in paler skin types due to the lack of melanin.
The success of treatment depends on when treatment is initiated, earlier the better.
When the skin is injured, the melanocytes get stimulated to produce more melanin. This type of pigmentation is much more common in darker skin tones as the melanocytes are easily triggered to produce melanin, but the pigmentation is confined to the site of traumatised skin. This can happen if the skin is not adequately prepared before clinic treatments like micro-needling or skin peels or following injuries, most commonly post-acne.
In theory, this type of pigmentation is more straightforward to treat as preventing further trauma to the skin will prevent further pigmentation.
Melasma is a complex, chronic skin disorder where sun exposure causes patches of pigmentation in the presence of other factors such as hormones, medical conditions, pregnancy or medication. The mask of pregnancy, chloasma, may remain after birth. It may start with the use of oral hormonal contraceptives but not reversed on discontinuation. The exact mechanism of what causes melasma is yet unknown.
The pattern of pigment is often larger patches in a symmetrical distribution and common sites are the forehead, cheeks, upper lip, chin and the bridge of the nose.
It is very resistant to treatment due to the factors that contribute to it and patients often have an ongoing battle with pigmentation worsening in the summer months.
How do we treat hyperpigmentation?
The aim of treatment is avoiding further insult, reversing damage and preventing further damage.
Protect with Sunscreen
A broad-spectrum sunscreen with at least an SPF of 30 should be worn all year round for two reasons. One is to prevent further damage to the skin from UVA radiation causing overactivity of the melanocytes. The second reason is that the treatment serums used in the treatment regime can sensitise the skin to UV radiation and the skin needs to be protected. As harmful UV radiation is present in daylight, sunscreens should be worn daily all year round regardless of the weather.
Vitamin C is a powerful antioxidant at 10-15% and can protect the skin from free radical damage thereby potentiating the benefit of sunscreen and preventing further damage.
Inhibit melanocyte activity
Ingredients such as hydroquinone is a powerful agent capable of stopping the production of melanin and is often called a ‘bleaching’ agent. It does have its limitations, risks and serious side effects so it is not suitable for everyone. It is a prescription-only medicine in the UK and must only be used under the guidance of a doctor.
Cysteamine, an antioxidant known to reduce pigmentation, is now available as a topical treatment, Cyspera® with comparable results to hydroquinone-based therapy.
Vitamin C decreases melanin production while reducing cellular inflammation and stimulating collagen synthesis hence it is often combined in treatment regimes. Vitamin A derivatives (retinoids and retinol) reduces melanin production.
Other milder suppressants of melanin production include arbutin, kojic acid, azelaic acid and resorcinol which are available without a prescription. Ingredients such as niacinamide (vitamin B3) are often incorporated into serums as they block the transfer of melanin to the skin cells.
Increase cellular turnover.
By increasing the cellular turnover, melanin that is already deposited in the skin surface can be exfoliated away so that new healthier cells can take their place. The skin has a unique ability to speed up its rate of cell division when the surface layers are removed by exfoliation. The most commonly used ingredients are alpha hydroxy acids and vitamin A derivatives (retinoids and retinol). Lower percentages are available over the counter whereas higher percentages have to be prescribed. Common examples of alpha hydroxy acids are glycolic acid, lactic acid, mandelic acid and citric acid. They break the connections holding superficial skin cells to the skin and cause ‘chemical’ exfoliation. With continued use, they also stimulate collagen stimulation.
These require skin preparation with medical skincare in order not to worsen the skin pigmentation post-procedure.
Targeted Chemical peels
These work by chemically exfoliating the skin and achieving faster results than homecare to accelerate cellular turnover and reveal radiant new skin.
Medical micro-needling, Lasers and other devices
This treatment helps to dislodge pigmentation and encourage the skin’s natural healing so that new skin is formed.
By directly injecting areas of discolouration with skin brightening agents, pigmentation can be reduced.
Pigmentation affects a person’s self-esteem so much that they’d rather not be seen in public or even by their family in their natural skin, believe me I know. It affects a person’s self-esteem, self-confidence and how they feel the outside world sees them. It can preoccupy their thoughts and be a barrier for them in their personal and professional life. At Skin Enhance Clinic, a combination of medical skincare, chemical peels, medical micro-needling and targeted mesotherapy are available after an in-depth consultation and skin analysis. Just as the hyperpigmentation took years to form, the treatment also takes time and requires patience and commitment on your part.