Pigmentation

Damage Control We examine the different types of sun damage related pigmentation and talk to DrTapan Patel and Dr Stefanie Williams about their views on hydroquinone Sun damage is by far the biggest cause of premature ageing and one of the clearest signs that someone’s skin has been damaged is pigmentation. There are many different types of pigmentation including hyperpigmentation, age spots, brown spots, post-inflammatory hyperpigmentation, freckles, solar lentigines and melasma. Sun damage related pigmentation can affect people of all skin types and ages and aesthetic practitioners and dermatologists are at the front line when it comes to its prevention and treatment. “When we look at the scope of pigmentation it is such a ubiquitous problem,” says DrTapan Patel. “The majority of people have some evidence of pigmentation on their skin. The only difference is whether it bothers them or not or clinically is something that needs treating.”

WHAT CAUSES PIGMENTATION?

Abnormal skin pigmentation occurs when there is excess in melanin production, which forms deposits in the skin. This can be triggered by a variety of factors including hormones, genetics, medication, the ageing process, skin diseases such as acne and injuries to the skin, but by far the biggest cause is sun damage. Exposure to the sun can cause patches of pigmentation to form on the skin and can worsen existing pigmentation abnormalities such as freckles or melasma, which have been caused by other factors. This happens because melanin absorbs the energy of the sun’s harmful ultraviolet rays in order to protect the skin from overexposure. As such pigmentation is most common on areas of the body that have prolonged exposure to the sun, such as the face, arms, hands and décolletage. Dr Patel says, “If we look at what causes pigmentation it is a bit of a pyramid. Right at the top you have those esoteric rare medical conditions, which probably account for the minority of hyperpigmentation we see in the clinic. Melasma is obviously far more commonly seen but right at the bottom of the pyramid, the largest portion of patients we are going to see with pigmentation are those with some degree of photo-damage. That photo-damage could be mild, it could be simple freckles or it can be very advanced solar elastosis with poikiloderma.”

TYPES OF PIGMENTATION

AGE SPOTS/LIVER SPOTS/ SUN SPOTS/SOLAR LENTIGINES

Age spots or “liver” spots are a common form of hyperpigmentation caused by sun damage, and are referred to by medical professionals as solar lentigines. They are usually found on the hands and face or other areas frequently exposed to the sun and will most likely increase with age. Age spots can vary in colour from brown to grey and black. They can also be very small or quite large and often appear in groups or clusters. They are more common on people with fair skin who don’t have as much natural protection from the sun. The reasonthey are known as age spots isdue to the fact that the melaninaccumulating in your skin overthe years as you age can makeyou more susceptible to thembut these pigmentation marks arenot exclusively caused by ageing. Although they are also sometimes known as liver spots this has nothing todo with liver or anything that is associatedwith the function of the liver.

MELASMA/CHLOASMA

Melasma is the formation of irregular pigmented patches and is commonly foundon the sun-exposed face in the periodduring or after pregnancy or in women whoare on the contraceptive pill. It is thoughtto be caused by increasing levels of bothoestrogen and progesterone, which stimulate melanocytesresulting in increased production of the normal tanningprotective chemical. Melasma or chloasma spots aresimilar in appearance to age spots but are larger areas ofdarkened skin. The condition is also known as “pregnancymask” because of its prominence in pregnant women andbecause of its appearance as “mask like” patches on theface. Melasma is usually found on the cheeks, temples andforehead but can also be found on the body. Melasma isaggravated by exposure to the sun.

FRECKLES

Freckles are small brown spots that can appear anywhere on the face and body. Freckles are an inherited characteristicand are most common on fair skinned people. Millions ofpeople around the world have freckles and are less likelyto seek cosmetic treatment for them than those who haveother forms of pigmentation as they are often regarded as“a mark of beauty”. However people with freckles can bemore susceptible to other forms of skin pigmentation, such as such spots, when exposed to the sun and the prevalenceof freckles also increases with sun exposure.

POST-INFLAMMATORY PIGMENTATION

Post-inflammatory pigmentation is caused when the skin has been damaged or undergone some form of trauma. It iscommonly found in people who have had acne but can alsobe caused by sunburn or surgery.

POIKILODERMA

Poikiloderma is a skin condition that usually appears on the neck and is characterised by brown patches of pigmentation as well as skin redness or erythema causedby broken blood vessels. It is also known as Poikiloderma ofCivatte after the physician who first reported its symptoms.It is thought that sun damage or prolonged exposure toUV rays is the main cause of the condition because itsindividual symptoms are also side effects of too muchsun. The condition can be affected by hormones and bythe use of certain cosmetics, such as perfume, which arephotosensitive and are usually applied onto the neck wherethe condition is most common.

TREATMENT OPTIONS

Although skin pigmentation is in most cases harmless, many people seek treatment for cosmetic reasons. Wearing a broad-spectrum sunscreenis the most important factor inpreventing skin pigmentationhowever there are a wide variety of treatments for pigmentation including prescription productssuch as hydroquinone, tretinoin andRetin-A as well as non-prescriptiontopicals, chemical peels and laserand light treatments. Dr Stefanie Williams says, “With sundamage the best treatment would beprescription tretinoin combinedwith something like kojic acid orarbutin to inhibit tyrosinase,which produces more melanin. The other thing that would be ideally added for anypigmentation would be ananti-oxidant serum becausefree-radicals are also involvedin the pigment generation.”

THE HYDROQUINONE DEBATE

There has been a lot of controversy surrounding the use of hydroquinone. In 2006 the Food and Drug Administrationproposed a ban on the sale of products containinghydroquinone without a prescription and its use is alsobanned for non-prescription use in many countries aroundthe world including Britain and other EU states. Howeverit is still considered to be the gold standard treatment forpigmentation. Dr Patel says, “The majority of dermatologists around the world would probably agree that the gold standard inwhich we measure other treatments against is going to besome combination of hydroquinone and tretinoin with orwithout corticosteroids. This is probably what is used day inand day out in most clinical practice. However hydroquinonehas had some bad press. My personal opinion is that it is notparticularly well-founded. I have been using hydroquinonefor 15 years and know a lot of dermatologists around theworld who have been using it for probably double that timeand have enjoyed a very good safety record.” Dr Williams agrees, she says, “I prescribe hydroquinone regularly, it is a great perception medicine for cases that areresistant to those over the counter things like kojic acid andarbutin. It is the gold standard of pigmentation treatmentand it works particularly well if combined with tretinoin anda mild steroid, which acts as an anti-inflammatory to make itless irritating and more tolerable. That is the strongest antipigmenttreatment that we have.” So what about the studies that suggested hydroquinone was dangerous? Dr Williams explains, “Hydroquinone is safeif it is prescribed and used under supervision. The problemsand the bad reputation really came for that unregulated use.People were using it without any supervision, so they wouldjust buy it from the shelves and would applyit for long periods. It should only reallybe applied for a limited time, Iadvise 12 weeks, and then youneed a break. The otherproblem was that people would use it over large areas to try and lightentheir entire skin andthat is not somethingthat is advisable. “One possible riskwith hydroquinoneis called ochronosis,which is a dark bluishbrownish discolourationthat you can get fromhydroquinone that is onlyreally associated with longerterm use. If you use it on smallareas such as the face for only 12weeks at a time under supervision it isabsolutely fine to use.” Dr Patel adds, “For years when we have been using hydroquinone there has always been the lobby thathydroquinone is evil and everything else is ok but if youcompare it to other drugs like isotretinoin or potent steroids they have much more of a side effect profile. “The reality is when you look at the studies that raisedthe alarm they are animal studies. There was a rat toxicitystudy where they used a certain breed of rat, which is predisposedto renal cell tumours anyway. The rats were fedhydroquinone as opposed to it being used topically in a dose70 times that we would use in clinical practice and low andbehold some of these rats ended up getting renal tumours. When three other groups tried to repeat that study they didn’t get the same findings but the damage was done, italready raised the alarms. Kodak Eastman, which is one of the companies, which has used the most hydroquinone onthe planet when they were processing photos on film, did a30-year longevity study and they found that their workerswho handled the hydroquinone had longer life spans andless risk of cancer than those who didn’t. I am not saying that hydroquinone infers any protective abilities but there is a fair bit of data that suggests it is safe.” Dr Patel always recommends giving patients a break from powerful prescriptives however and maintains thatit is not right for everyone. He says, “Even those of us whoare very comfortable using hydroquinone get nervousafter three-six months and we definitely want our patientsto have that HQ holiday. Not everybody tolerates it andor some patients it is contraindicated. Also some peoplehave very mild pigmentation and using tretinoin andhydroquinone can sometimes be a bit of a sledge-hammercracking a walnut.”