Skin pigmentation and evidence-based solutions

Dr Ginni Mansberg is a TV doctor and the founder of ESK, a skincare brand that focuses on scientific evidence to create effective formulations. She created the brand because of her personal interest in skincare.

You are speaking at Aesthetic Medicine London on skin pigmentation issues. What are the common causes of pigmentation changes in the skin?

Just to be clear when we talk about pigmentation, we aren’t talking about the natural level of pigmentation in our skin responsible for our skin colour and tan, but hyperpigmentation or uneven areas of darker pigmentation. That kind of pigmentation can be caused by a number of issues, but mainly the sun plays a role.

The most common pigmentation is from Melasma, which is related to our hormones (and is triggered by exposure to the sun) and from ageing where accumulated sun damage results in some areas of our skin trapping melanin and it shows up as “age spots”. We can also get pigmentation following some form of trauma to the skin (acne is a common cause) and some medications and medical conditions can result in pigmentation.

What are the current clinical approaches to the effective management of pigmentation?

The current consensus for the treatment of pigmentation is to start with topical products and then, if necessary and appropriate, move on to device-based approaches. With topicals, you can opt for the prescription (usually irritating, can only be used for a limited amount of time and is increasingly under a safety cloud) or non-prescription products. These tend to be safer and better tolerated but don’t have the same level of evidence.

There is also some emerging evidence for oral tranexamic acid.

If those fail, Microneedling and Laser are alternatives. But especially in the case of the Laser, a chat with your clinician is advised, due to the risk of hyperpigmentation in darker skin.

Could you explain the role/relationship between sun exposure and pigmentation changes and how it affects different skin types?

The sun’s rays, particularly a segment in the UVB spectrum, are great for synthesising Vitamin D, one of the essential Vitamins for healthy functioning of our bodies. But UV exposure can also result in the production of free radicals, which can damage cell DNA, and over time and with enough exposure, result in skin damage and even cancer. The body’s defence is to produce more melanin (ie. A tan) following exposure, particularly to the sun’s UVA rays. That tan helps protect our skin by absorbing UV energy and converting it into heat (rather than free radicals). In the case of age spots, repeated exposure to the sun’s UV rays can see pigment-producing cells clumping together, producing melanin unevenly and a slowed skin cell turnover (it slows from turning over about once every 28 days to once every about 48 days, as we age), resulting in melanin getting trapped in the skin. The result: stubborn areas of hyperpigmentation. Strangely, they show up more in winter when there is less overall tan, making the hyperpigmented areas more visible.

Very pale skin tends to produce very little melanin, so following exposure to the sun, it will often burn and then peel, but not really tan. Very dark skin has a high level of melanin in the skin permanently. As a result, exposure to the sun's rays will usually see it remain quite constant in colour. In the middle, we have skin types that can tan quite significantly in response to UV exposure, and these are the skin types that are most at risk of hyperpigmentation as they get older.

Can you discuss the treatment options available for pigmentation skin conditions and is it a regime of products or one in particular?

Because pigmentation is a multi-stage and complex process in the skin, it is recommended to target multiple pathways at the same time for the best results. That makes it a regime. The “gold standard” for topicals is Hydroquinone, which targets tyrosinase, an enzyme crucial to the production of melanin, but it can be irritating, should also only be used for three months at a time and there are growing safety concerns around its use.

Of the non-prescription alternatives, three out of the four ingredients with the best evidence are rarely found in skincare and are the main reason that we started ESK.

Similarly to Hydroquinone, 4-n-butylresorcinol targets tyrosinase but has excellent tolerance and safety profiles and has some of the best evidence of the non-prescription ingredients. It can be used once or twice a day.

Vitamin A (we use Retinal, similar in efficacy to prescription Vitamin A, without the irritation) increases skin cell turnover helping flush pigment from the skin. It can increase sun sensitivity, so it is used at night.

Vitamin C, which interferes with the conversion of tyrosine to pigment and also reduces the signal to create pigment, also enhances the effect of sunscreen, so we suggest using it in the morning.

Finally, Vitamin B3 reduces the dispersion of melanin in the skin and can be used morning and night.

What would you say is the biggest consumer misconception about the treatment of hyperpigmentation?

I think there are two that are poles apart. The first is that devices including lasers and peels should be the starting point for managing pigmentation. Because of the risk of inflammation and post-inflammatory pigmentation, especially in skin of colour, guidelines suggest these techniques be used only after topicals (if they fail).

The other misconception is what doctors used to say 15 to 20 years ago…. Nothing works, just use sunscreen and moisturiser and otherwise, suck it up. The evidence for managing pigmentation topically is strong now.

What is your go-to “hero” product for pigmentation?

That is so hard because, while 4-n-butylresorcinol has some of the best evidence, it just targets pigmentation, and it does a great job of that. Personally, I love our C Forte. With Vitamin C, Vitamin E and Ferulic acid, it helps with pigmentation, fine lines and wrinkles, skin sallowness and laxity and I find it really moisturising.

What was the inspiration behind the development of the ESK skincare range?

As a teenager, my skin was terrible. I had a face full of acne which stuck around into my 30s and that morphed straight into Rosacea. At the same time, I was doing quite a lot on TV which meant lots of coverup makeup, getting that off inflamed my skin even more. It was at about that time that we started doing more segments about what works in skincare.

For every segment, I would consult the National Library of Medicine to see what had evidence for working and then share that with viewers. But when viewer emails after my segments started increasing, with viewers asking what products to use, I realised that there were no skincare ranges which contained evidence-based, active ingredients in their products. Instead, I saw a market with pseudo-science and marketing, preying on our insecurities. That really lit a fire in me to do something about it.

If you want to hear more from Dr Mansberg about pigmentation, you can attend her talk, Dyspigmentation- the role of topical therapies, on the skin and body stage at AM London. Register here, and don't miss out!