Hyperpigmentation

Information on Dark Marks

Most skin diseases occur in all types of people, regardless of their skin color (pigment). Certain skin problems are more common among people with darker skin tones. A wide range of racial and ethnic groups, including African-Americans, Asians, Hispanics/Latinos, and Native Americans, constitute people who have skin of color.

Variations in Skin Color

Skin color is determined by cells called melanocytes. All races have the same number of these cells. Melanosomes are structures in the melanocytes that produce the pigment melanin. There are more and larger melanosomes in darker-skin melanocytes than in those of lighter skin. Although people with skin of color are better protected against skin cancer and premature wrinkling from sun exposure, a good broad-spectrum UVA/UVB sunscreen with SPF15 should be used routinely to protect all individuals with skin of color.

POSTINFLAMMATORY HYPERPIGMENTATION

Postinflammatory hyperpigmentation (the darkening of skin) may occur after an injury such as a cut, scrape, or burn, or after certain skin disorders such as acne or eczema. It is seen in all skin types but is more common and noticeable in darker skin. Early treatment of the underlying problem can help prevent development of dark spots.

Darkened areas of skin may take many months or years to fade, although medication may help. Chemical peeling, microdermabrasion, and bleaching medication prescribed by a dermatologist may fade pigment more rapidly. Avoid picking, harsh scrubbing, and abrasive treatments unless prescribed by a dermatologist.

The daily use of sunscreen is very important to prevent postinflammatory hyperpigmentation from becoming darker.

LENTIGINES (SUN SPOTS)

Solar lentigines (liver spots, age spots, senile lentigines) also occur in response to sunlight, but are more common in middle-aged or older patients, are thought to be caused by years of cumulative UV exposure, and tend to persist even in the absence of sunlight. They favor sites of maximum sun exposure such as the dorsal surface of the hands and the extensor forearms, vary in color from tan to dark brown, and can be up to 1cm in diameter. Solar lentigines typically have a normal number of melanocytes plus increased melanin in the basal layer of the epidermis, overlying a background of solar elastosis (abnormal elastic fibers in the dermis due to cumulative UV exposure).

MELASMA

Melasma is a skin condition presenting as brown patches on the face of adults. Both sides of the face are usually affected. The most common sites of involvement are the cheeks, bridge of nose, forehead, and upper lip.

Who gets melasma?

Melasma mostly occurs in women. Only 10% of those affected are men. Dark-skinned races, particularly Hispanics, Asians, Indians, people from the Middle East, and Northern Africa, tend to have melasma more than others.

What causes melasma? The precise cause of melasma is unknown. People with a family history of melasma are more likely to develop melasma themselves. A change in hormonal status may trigger melasma. It is commonly associated with pregnancy and called chloasma, or the "mask of pregnancy." Birth control pills may also cause melasma. However, hormone replacement therapy used after menopause has not been shown to cause the condition.

Sun exposure contributes to melasma. Ultraviolet light from the sun, and even very strong light from light bulbs, can stimulate pigment-producing cells, or melanocytes in the skin. People with skin of color have more active melanocytes than those with light skin. These melanocytes produce a large amount of pigment under normal conditions, but this production increases even further when stimulated by light exposure or an increase in hormone levels. Incidental exposure to the sun is mainly the reason for recurrences of melasma.

Any irritation of the skin may cause an increase in pigmentation in dark-skinned individuals, which may also worsen melasma. Melasma is not associated with any internal diseases or organ malfunction.

How is melasma diagnosed?

Because melasma is common, and has a characteristic appearance on the face, most patients can be diagnosed simply by a skin examination. Occasionally a skin biopsy is necessary to differentiate melasma from other conditions.

How is it treated?

While there is no cure for melasma, many treatments have been developed. Melasma may disappear after pregnancy, it may remain for many years, or a lifetime.

Sunscreens are essential in the treatment of melasma. They should be broad spectrum, protecting against both UVA and UVB rays from the sun. A SPF 30 or higher should be selected. In addition, physical sunblock lotions and creams such as zinc oxide and titanium oxide, may be used to block ultraviolet radiation and visible light. Sunscreens should be worn daily, whether or not it is sunny outside, or if you are outdoors or indoors. A significant amount of ultraviolet rays is received while walking down the street, driving in cars, and sitting next to windows.

Any facial cleansers, creams, or make-up which irritates the skin should be stopped, as this may worsen the melasma. If melasma develops after starting birth control pills, it may improve after discontinuing them. Melasma can be treated with bleaching creams while continuing the birth control pills.

A variety of bleaching creams are available for the treatment of melasma. These creams do not "bleach" the skin by destroying the melanocytes, but rather, decrease the activity of these pigment-producing cells. Over-the-counter creams contain low concentrations of hydroquinone, the most commonly-used depigmenting agent. This is often effective for mild forms of melasma when used twice daily. A dermatologist may prescribe creams with higher concentrations of hydroquinone. Normally, it takes about three months to substantially improve melasma. Creams containing tretinoin, steroids, and glycolic acid are available in combination with hydroquinone to enhance the depigmenting effect. Other medications which have been found to help melasma are azelaic acid and kojic acid. It is important to follow the directions of your dermatologist carefully in order to get the maximum benefit from your treatment regimen and to avoid irritation and other side effects. Remember, a sunscreen should be applied daily in addition to the bleaching cream. Some bleaching creams are combined with a sunscreen.

Chemical peels, microdermabrasion, and laser surgery may help melasma, but results have not been consistent. These procedures have the potential of causing irritation, which can sometimes worsen melasma. Generally, they should only be used by a dermatologist in conjunction with a proper regimen of bleaching creams and prescription creams tailored to your skin type. People should be cautioned against non-physicians claiming to treat melasma without supervision because complications can occur.

Management of melasma requires a comprehensive and professional approach by your dermatologist. Avoidance of sun and irritants, use of sunscreens, application of depigmenting agents, and close supervision by your dermatologist can lead to a successful outcome.

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