By Cynthia Golomb, MD
One of the most common complaints I hear from patients is about facial hyperpigmentation. These are the spots that range in color from tan, brown or dark brown. There are several causes of facial hyperpigmentation, but the most common one I see is melasma.
What causes melasma?
Melasma is a chronic inflammatory pigmentary disease that is not curable but is manageable with multiple medications or a combination of different types of treatments.
Melasma is caused by increased amounts of pigment and not an increase in the number of pigment-producing cells (melanocytes), like in photodamage or sun-induced brown skin lesions. Melasma typically affects the mid-forehead, eyebrows and cheeks. It usually spares the sides of the forehead, eyelids and nasal folds.
Melasma affects both light and dark-skinned individuals and often leads to significant psychological distress.
The cause of melasma is not entirely understood, but it has been associated with hyperestrogenism (from pregnancy and oral contraceptives) and autoimmune thyroid disease.
It is important to note that melasma has a vascular component. Once the pigment is removed, the redness is unmasked, and the blood vessels must be targeted. This can be done with the BBL HERO or a vascular laser such as my excel V laser. I find many patients have gone wrong by using a monotherapy consisting of 4% hydroquinone alone. This just does not work. I recommend a combination approach that includes hydroquinone, a topical steroid and a retinoid. Below, I outline a year-long Melasma treatment cycle.
What is post-inflammatory hyperpigmentation?
Another type of facial hyperpigmentation is post-inflammatory hyperpigmentation. In this case, correcting underlying causes like acne and eczema is essential. Other causes can be NSAIDS like torolac (not ibuprofen ) or minocycline. Diabetes can bring about hyperpigmentation because insulin is a growth factor that can cause skin tags and facial acanthosis nigricans (dark thickening of the skin), and pigmentary demarcation lines. Inflammation is also caused by too much skin irritation.
Protection from the sun is part of preventing and treating facial hyperpigmentation
As with melasma, the first step against post-inflammatory hyperpigmentation is photoprotection (sunscreen, hats, sunglasses and sun-protective clothing). Ultraviolet and visible light can induce redness and hyperpigmentation. Any visible light, such as light coming through a window, can cause hyperpigmentation. Sunscreen alone, three times a day, decreases the pigmentation score by 26% after three months.
It is also important to protect against visible light by using a tinted sunscreen that contains iron oxide. I carry many cosmetically elegant tinted sunscreens in the office, such as the Avene compact, Revision Intellishade, Dermatology Boutique BB cream and ISDIN. Tinted sunscreens are favorable since they mask the white hue of physical sunscreens.
Year-round melasma treatment
The hallmark of effective melasma treatment is to start a hydroquinone-based treatment. Hydroquinone is the number one skin-lightening agent. Other products can be added, including vitamin C, azelaic acid, tretinoin and arbutin. There can be side effects, including irritation or allergy, or unwanted halo hypopigmentation. The risk of irritation increases with the addition of some of these ingredients.
Some patients are concerned about using hydroquinone, but these concerns are unwarranted. No human cancer has been reported from topical hydroquinone, and there is no substantial evidence that hydroquinone is a proven carcinogen. As a practicing dermatologist for over 25 years, I found the only adverse effects to be rare contact allergies and a generalized lightening of the skin that may be undesirable in some people.
Typically, I prescribe hydroquinone (Obagi) in combination with tretinoin. A daily regimen of this combination for 12 weeks is best done in the summer.
So, the cycle depicted in the graphic below is to use a daily regimen during the summer months and decrease it to weekends only during the fall. I have my patients take a hydroquinone holiday in the winter and start again on weekends during the spring. From fall to spring, I recommend a non-hydroquinone medication such as cysteamine (Cyspera), tranexamic acid, or 20% azelaic acid, along with continued use of tretinoin.
In my office store, we have several very effective hydroquinone alternatives. One is Cyspera (cysteamine), which is applied for a brief period and washed off. This gives a definite improvement in melasma. Other topical alternatives include arbutin, tranexamic acid and Ascorbic acid (vitamin C).
In severe cases, an oral medication, tranexamic acid, stops inflammatory mediators (messengers that promote an inflammatory response), which are fuel for the production of melanin pigment. Many studies have shown it to be safe and effective in more severe cases.
Adding in-office procedures takes your treatment to the next level. I recommend my BBL HERO device with at-home triple combination cream (hydroquinone, tretinoin and hydrocortisone) to provide excellent results. Photorejuvenation with the BBL (or IPL) can cause rebound hyperpigmentation when used alone without the at-home topicals. Following a BBL treatment with Laser Genesis facial toning increases success. Both the BBL and facial toning require a combination of prescription creams, and two to three treatments are recommended.
We also offer several other procedural interventions, including chemical peels, microneedling and the Clear+Brilliant laser treatment.
Along with Mylene, my laser technician, and Bianca, one of our aestheticians, I can offer several therapies for acquired facial hyperpigmentation, which is a persistent and relapsing dermatologic complaint.
See A Trusted Dermatologist
Dr. Cynthia Golomb is widely considered one of the top dermatologists in Hallandale Beach. She welcomes patients for facial hyperpigmentation treatment from Aventura, Sunny Isles Beach, North Miami Beach, Golden Beach, Pembroke Pines and Hollywood, Fl. Dr. Golomb is triple board certified in Dermatology, Dermatopathology and Micrographic Dermatologic Surgery (Mohs).
Schedule your cosmetic consultation online with Dr. Golomb to start your treatment for melasma or post-inflammatory hyperpigmentation.
