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August 01, 2020 7 min read

Dermatologist top 5 Hyperpigmentation and what it says about your inner health?


In my out-patient clinic, one of the most frequent things I encounter is people wanting to get rid of those ‘dark spots’. These dark patches often take a toll on confidence and can have a significant psychosocial impact on patients. Around 5-10% of all the patients whom I see in a month come with this complaint. For most of them, it is just a dark spot and anything that bleaches should make it go away in no time. But as a dermatologist I know that all pigmentation cannot be put under one bracket. Hyperpigmentation is like a puzzle- to get the perfect final outcome, all pieces must fall in place - The cause should be recognized, preventive and lifestyle measures should be taken and only then comes the treatment part. 


With this article I am going to give you an overview about some of the common pigmentation problems that I come across  and a little insight on understanding it and a rundown on my recommendations for it.


What is hyperpigmentation?


Hyperpigmentation, simply put, is an increase in the skin pigment called melanin. Melanin is produced by the skin through a complex pathway involving various enzymes, most importantly tyrosinase. There are diverse factors involved in increasing the melanin producing cells and melanin production from inside the body as well as outside. Hyperpigmentation can show up on your skin as dark spots, patches or generally just uneven skin tone. 


Top 5 causes of Hyperpigmentation

 

1. Sun induced pigmentation and sunspots: 


Ultraviolet rays from the sun are the most notorious incausing pigment spots, and worsening it. Production of melanin as a response to UV rays is not just a reaction, but also the body's owndefense mechanism to prevent the damage caused by UV rays to some extent. At the same time we don’t want that extra melanin to be our knight in dark armour against sunlight too often because a). Hello, sunspots b). Melanin releases some free radicals that can cause our skin to age a little quicker. 


Sunspots, lentigines, or so called liver spots are small brown patches, usually only a few millimeters in diameter which appear in sun exposed areas like face, arms or sometimes even shoulders and back. They can be genetic, or can appear later in life. In any case, they increase and darken with sun exposure. 


What do I recommend against Sunspots

Prevention is always better than cure. A sunscreen with a high SPF and at the same time strong UV-A protection should be the first step for anyone with a skin type susceptible to sunspots. In addition, including an antioxidant ingredient with depigmenting properties to the daily skincare routine likeGreen tea orgrapeseed extract  also goes a long way in preventing sun spots.

Late on the prevention wagon, we can also make it better:Retinoids like Tretinoin or Tazarotene are my first line of treatment when it comes to sun induced pigmentation because they not only decrease the pigmentation but also other signs of photoaging like fine lines to just give an all-round improvement in the skin texture. I also combine retinoids with laser treatment and/or chemical peeling for faster results. 

 

2. Melasma

Melasma is a fairly common pigmentary condition affecting most commonly women in child bearing age. It causes symmetrical discoloration most commonly on the cheeks but can also involve the forehead, upper lips and nose.


Risk factors include sun exposure, hormonal changes like pregnancy (when it is referred to as chloasma- or the mask of pregnancy) or oral contraceptives (especially the oestrogen containing ones), thyroid disease and other medications like anti-seizure medicines. Since there are so many internal risk factors involved, it is a really challenging condition to treat. Not only does it show a very limited response to treatment, but it also keeps relapsing.


What do I recommend against melasma: 


-The key word is again-sun-screen. Broad spectrum sunscreen through the day, UV screens in cars and windows- to avoid all possible exposure to the sun. As little as a few hours of unprotected sun exposure could set you back weeks in terms of improvement.

-Topical lightening agents: Although traditionally hydroquinone has been the most prescribed and recommended agent against melasma,safety issues, irritation and the chances of causing deeperpigmentation as a side effect make it unsuitable to be used in the long term. Safer alternatives that have shown comparable results to hydroquinone are kojic acid andplant extracts like arbutin, licorice and mulberry which can be put to use either as lone warriors or in cycles with hydroquinone. 

 

3. Post-inflammatory hyperpigmentation


Post-inflammatory hyperpigmentation (PIH) is due to the overproduction of melanin or its irregular distribution after inflammation or irritation of any kind, like trauma, insect bite or most importantly acne. Post-inflammatory pigmentation most commonly affects skin of color and presents a distressing cosmetic issue which can persist from months to years depending on how severe the irritation was and how deep the pigmentation goes.


What do I recommend against PIH:

First and foremost- Resist popping that pimple at all costs, do not use abrasive physical scrubs and do not aggressively scratch that insect bite. Mechanical friction increases the chances of post inflammatory hyperpigmentation.

The mainstay of treatment remains, like melasma, sun protection and hydroquinone. But like mentioned above, since hydroquinone was shown to be kind of dubious with regards to its safety in the long run, especially in darker skin, I prefer to combine milder options like azelaic acid, Vitamin C, niacinamide or soy extract with an alpha hydroxy peel every 15 days to deliver the same result with minimum side effects. Azelaic acid and niacinamide also work against acne, so for someone with acne prone skin with a tendency towards hyperpigmentation- these 2 ingredients are multitaskers and have a great safety profile. 

 

4. Acanthosis Nigricans

Acanthosis nigricans, often mistaken as another one of the pigmentation disorders because of the dark discoloration, has really nothing to do with pigment. It is usually due to thickening of skin in the folds like the nape of the neck, groin, axilla or rarely forehead and cheeks due to various reasons. The skin on these areas starts looking dark, coarse, velvety and has a ‘dirty’ look to it, like it hasn’t been cleaned properly. 


What does it say about your health:

While in some cases acanthosis nigricans can be completely innocuous, in many it is a predictor of insulin resistance, and in turn diabetes and cardiovascular risk factor, especially when it is associated with obesity. Sometimes it may also be associated with autoimmune disorders like lupus, can be a side effect of medications like glucocorticoid or oral contraceptive pills and rarely, if it progresses really fast and in atypical regions like the mouth or nipple, it may even be a sign of cancer. 


What do I recommend against Acanthosis Nigricans: 


For acanthosis nigricans the first step should be to see a doctor to rule out any internal causes which need intervention, say anti-diabetes drugs for insulin resistance.Cosmetic appearance of acanthosis nigricans associated with obesity can be improved with some simple measures: 

- Weight loss: To reduce acanthosis nigricans, weight loss plays the most instrumental part.Weight loss improves insulin resistance and gradually as the BMR (Basal metabolic rate) begins to improve, so does the acanthosis.

- Topical treatment: Since it has got nothing to do with pigmentation, bleaching and depigmenting agents are pretty much useless in the treatment of Acanthosis Nigricans. Ingredients which decrease the thickness of the skin like tretinoin, urea or chemical peels speed up improvement when accompanied by weight loss


5. Pigmentation of systemic diseases


Some pigmentary changes could be telltale signs of internal diseases: 


Pigmentation on the lower legs:Pigmentation on the both the lower legs spontaneously without a preceding injury could be due to broken or leaky capillaries and deposition of a component of blood called hemosiderin. They are multiple round or oval brown to reddish brown spots or patches. The two common causes for this are diabetes and varicose veins. The diabetic pigmentation or shin spots, as the name suggests appear on the shins of both sides and usually after a long standing diabetes which hasn't been under control. The pigmentation due to vein insufficiency or varicosity, calledpigmented purpuric dermatosis, typically starts at the ankle, moves up, sometimes reaching even the thighs and affecting front and back of the legs.


Knuckle pigmentation:Darkening of the knuckles can sometimes be the only symptom of avitamin B12 deficiencyin the beginning phase. Recognizing and identifying it at the right time and getting it checked from a doctor could save a lot of complications like anaemia or neurological disability.

Hormonal imbalance: An increase in pigmentation on the hand creases, in and around the mouth, genital area could indicate a hormonal disorder called Addison’s disease which leads to reduced production of steroids in the body which could wreak havoc in many of the body’s systems.

Diffuse increase in pigmentation:A spontaneousdiffuse discoloration of the skin should always raise suspicion of an internal problem hidden behind it and warrants a doctor consult. It could be due to excess iron stores in the body which deposits on the skin, and many other organs or could indicate a potential hyperthyroidism. In any case an examination is warranted. 


What do I recommend against the pigmentation associated with internal disease: 


Most of these pigmentary changes mentioned above improve when the reason behind it is identified and treated. They almost never require cosmetic treatment. 



Conclusion


Hyperpigmentation is a complex matter. It is not a straightforward thing to treat most of the time, we have to Sherlock it before treating it . I hope this article helped you gain an insight on something which is just a ‘dark patch’ to most. 


Do you have questions about hyperpigmentation, its treatments, or just generally about anything skin related? Leave a comment below. I would love to hear from you. 

 

DISCLAIMER: The information provided in this post is for educational purpose only and does not constitute medical advice. 

Rashmi Singh
Rashmi Singh

Dr. Rashmi Singh is an Indian board-certified Dermatologist and sexually transmitted diseases specialist. Currently working in Germany, she has a passion for skincare and minimally invasive cosmetic treatments. She loves to break down complex skincare science for everyone to understand and apply effectively in daily life


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