There are a number of types and causes of pigmentation of the face. People with darker skin are more prone to pigmentation because they have more melanin in the top layer of the skin.
We are going to discuss a few of the more common forms of pigmentation that affect the face.
SOLAR LENTIGINES OR SUN FRECKLES
These are caused by chronic sun exposure and are usually present with fairly small, discreet round brown patches on the face.
- Solar Lentigines are relatively easy to treat and this is done by freezing them with liquid nitrogen (cryotherapy). It is important that this treatment is done with skill as over-freezing can leave white marks at the site of the freckle or sunspot.
- If the freckles or sun spots are spread over a larger area then treatment by laser or Intense Pulse Light (IPL) is recommended.
This is a more diffuse, symmetrical type of pigmentation that usually occurs in women with a darker skin type. Factors that can trigger melasma are hormonal factors including pregnancy and the oral contraceptive pill, when an overproduction of melanin occurs.
Initially the pigment occurs just in the top layer of the skin and this is called Epidermal Melasma. However, the longer the melasma is present, the pigment falls from the epidermis into the dermis and this is then called Dermal Melasma. Most patients with melasma in fact have a mixed form, in other words they have a mixture between an epidermal and a dermal component of the pigmentation.
The epidermal form of melasma may disappear spontaneously as the hormones settle after pregnancy and also with the regular use of a high factor, broad spectrum sunscreen. The mixed or dermal forms of melasma are unfortunately more stubborn to treat.
- Discontinue any oral contraceptive containing oestrogen.
- The meticulous use of a high factor, broad spectrum sunscreen on a daily basis throughout the whole year. It is important to note that just one day in the sun without a proper sunscreen can result in the melasma returning to its original state. Many sunscreens include a tint (iron oxide pigment) that not only helps to disguise the melasma but it also has the benefit of cutting out Visible Light. Recent studies have shown that visible light can trigger sun freckles as well as melasma. In addition some of the better sunscreens also contain an antioxidant which protects the skin against pollution and ground level ozone.
- The most effective initial treatment for more stubborn melasma is topical Hydroquinone. Dermatologists worldwide use this prescription-only medication for a limited period of time, especially in people with a darker skin types. In almost all cases there will be lightening of the pigmentation but often not complete clearing. Once the pigmentation is lighter, I usually prescribe various creams containing a mixture of any of the following ingredients – Retinol, Kojic Acid, Azelaic Acid, Ascorbic Acid, Arbutin and Liquorice extract, for use as a maintenance treatment. These non-hydroquinone products can be used for a long period of time and those containing Retinol will have, in addition, anti-acne as well as anti-ageing effects.
- Products containing Retinols cannot be used if pregnant, breast-feeding or planning on becoming pregnant and this needs to be discussed with your physician to identify safe alternative products.
- Light, gentle chemical peels which target more superficial pigmentation can help with epidermal melasma but in my opinion deeper, more aggressive peels especially for the dermal form of melasma can make it worse. In fact in my experience the peels may initially improve the melasma but often it will get worse because the more aggressive peels produce erythema (redness) and inflammation of the skin and if exposed to sunlight it can produce post-inflammatory hyperpigmentation.
POST-INFLAMMATORY HYPERPIGMENTATION (PIH)
This type of pigmentation also tends to occur in patients with a darker skin type. Any trauma or inflammation that occurs to the skin, in a person with darker complexion, will often leave discolouration and brown marks which can cause much distress. This type of pigmentation can be very difficult to treat and may take months or years to fade.
One of the most common causes of Post-Inflammatory Hyperpigmentation (PIH) is Acne. Pseudofolliculitis Barbae is a condition where hairs curl back on themselves puncturing the skin and this may leave scars as well as PIH.
The removal of facial hair by waxing or use of depilatory creams in people with darker skin types should be done with extreme caution. Depilatory creams, especially when used to remove hair on the upper lip, can cause an irritant contact dermatitis which can cause PIH.
- A person with a darker skin might have a fairly mild form of acne but as the acne heals it may leave significant post-inflammatory hyperpigmentation that may cause the person much distress. Therefore, I tend to treat the acne in patients with a darker skin much more aggressively to try and prevent the complication of PIH.
- The treatment of PIH is similar to melasma – initially one can use topical Hydroquinone under the care of a medical doctor and then later use creams containing Retinol, Azelaic Acid, Kojic Acid, Ascorbic Acid, Arbutin and Liquorice extract. Again the regular use of a high factor, broad spectrum sunscreen is recommended and in the acne-prone patient with a more oily skin, there are dry touch gel creams available that do not clog the pores and aggravate the acne.
- Consider laser hair removal of the upper lip with a qualified laser therapist as it is a safer option. If using depilatory creams make sure they are formulated specifically for the face and not the arms and legs.