Laser Treatments for Skin Pigmentation
What is skin pigmentation?
Skin pigmentation is result of abnormal production and deposition of melanin by the melanocytes. Melanocytes are pigment-producing cells. The number of melanocytes present in our skin will determine our skin colour. Production of melanin is dependent on UV or sun exposure, and is a natural protective mechanism of the skin.
Hyperpigmentation, or areas that are darker than the rest of the skin, result from excess melanin production and deposition.
This page will discuss skin pigmentation and its treatment. This discussion will only encompass pigmentation that is in the skin, and will not involve discussion of raised pigmented lesions, moles, or skin cancers.
What causes skin pigmentation?
Excess skin pigmentation or hyperpigmentation is usually caused by an overwhelming of the melanin-protective system. This leads to excess production and clumping of melanin, and the appearance of brown or darker spots of pigmentation in the skin.
Reasons for skin pigmentation problems are;
- In most cases, especially in an area of high UV levels like Australia, this is caused by excessive UV or sun exposure (most common)
- Hormonal, as seen in melasma or chloasma that is a type of pigmentation usually caused by pregnancy or the pill (common)
- A response to some drugs, and some medical causes such as liver disease or haemochromatosis (uncommon)
- Trauma to the skin. This can be a result of physical trauma to the skin, chemical peels, laser treatments, or acne. This is known as post-inflammatory hyperpigmentation (common).
- Birthmarks and acquired pigmentation - skin pigmentation can be present at birth (birthmarks), appear in childhood, or adulthood. Examples of these include; congenital melanocytic naevus, cafe au lait spots, spilus naevus, hori's macules, and naevus of ota.
What are my options for treating skin pigmentation?
Essentially, pigmentation can be treated with lightening agents or lasers. The main difference between the two is that lasers can produce a faster and more effective result in most cases. There are however, more risks with the use of lasers as opposed to lightening agents, and these risks include worsening of the pigmentation, or scarring of the skin (very rare). Also, with laser treatment there is always a period of recovery post-treatment. Some forms of pigmentation such as post-inflammatory hyperpigmentation are better treated with lightening agents rather than laser.
Pigmentation can be treated on any part of the body including the; face, neck, hands,back, chest, arms, legs, and shoulders.
Sunspots / solar lentigos
The most common form of pigmentation is due to sun exposure. Pigmentation due to sun exposure are usually called 'sunspots' or 'solar lentigos'. This type of pigmentation is also commonly associated with other sequelae of sun damage/exposure such as wrinkles, broken capillaries, and pre-cancerous and cancerous skin lesions. Therefore, people who have skin pigmentation as a result of excess sun exposure may benefit more from laser treatments to simultaneously treat these associated problems (wrinkles, broken capillaires etc). Cancerous or suspicious skin lesions generally need to be excised rather than treated with lasers
Also see Clinical homecare treatments
Post-inflammatory hyperpigmentation
Post-inflammatory hyperpigmentation is due to trauma to the skin, resulting in inflammation and pigmentation. Causes include; acne, laser, laser hair removal, IPL, chemical peels, and physical trauma. In the case of post-inflammatory hyperpigmentation, it is important to note that treatment of this type of pigmentation can be worsened if the treatment further irritates the skin. In particular, laser treatments aggravate and irritate post-inflammatory hyperpigmentation and commonly make it worse. hyperpigmentation rather than lasers. Examples of these topical agents can be found in our home care range . A combination of lightening agents can be used also .The doctors canprescribe a combination of hydroquinone, tretinoin, hydrocortisone, and kojic acid (Kligman's formula) for post-inflammatory hyperpigmentation.
Melasma/Chloasma
Melasma or chloasma is a form of pigmentation that is stimulated by oestrogen (either from pregnancy, the pill, or normal circulating oestrogens) and is a difficult form of pigmentation to treat. It appears as brown-gray patches on the face. Melasma can never really be cured, but it can be treated to minimise its effect. It is important to try to find out if there are any causative factors that may be exacerbating the pigmentation, for example, the oral contraceptive pill. The next step is daily sun protection, and this is paramount in the treatment of melasma. The mainstay of treatment is a topical lightening agent. Kligman's formula is often recommended, as it is a combination of agents to help lighten skin. See below for more information on lightening agents for skin.
Most lasers are not extremely effective in the treatment of melasma. Laser resurfacing with a CO2 lasers can help reduce melasma, but commonly cause post-inflammatory hyperpigmentation (that is worse than the melasma) and also require a long recovery time. can help reduce melasma, through weekly to fortnightly treatments for 6 to 8 sessions should be expected The laser works by being selectively attracted to the pigmentation over normal skin. It also has very short pulses (as short as one billionth of a second) which helps to shatter the pigmentation. The downtime is minimal per treatment, there is usually some mild darkening of the pigmentation that lasts for one to two weeks, mild redness, and a mild flaking after the treatment. Generally, most people go back to work the day after treatment.
Finally, chemical peels can help speed the process of improvement from melasma by helping with skin turnover, and by helping to shift the melanin deposits from the affected area, although this is generally not particularly effective. The lightening cream (Kligman's formula) tends to be the most effective means of treating melasma, followed by laser, followed by a course of chemical peels
Freckles, brown birthmarks, and epidermal (superficial) pigmented lesions
Freckles are responsive to the laser. Patients who tend to freckle may refreckle with sun exposure. Most patients show an improvement > 50% after treatment in their freckling as long as daily sunscreen is used.
Brown birthmarks such as cafe au lait spots and congenital melanocytic naevi can also be treated with laser.
Nd:YAG1064 nanometer wavelengths are deeper penetrating, and are able to shatter deeper pigments. Types of dermal pigmentation include; melasma, Naevus of Ota, Naevus of Ito, Becker's naevus, and acquired bilateral naevus of Ota-like macules (Hori's macules/naevus).
How can skin pigmentation be treated with topical agents?
The first method of treating skin pigmentation is to prevent its appearance or worsening by daily application of sunscreen. UV exposure from sunlight or sun beds will invariably worsen any existing pigmentation and promote further pigmentation to arise. The risk of skin cancers also rises with increasing exposure to UV.
At The Victorian Cosmetic Institute, we recommend physical sunscreens as opposed to chemical sunscreens. Physical sunscreens contain titanium dioxide and zinc oxide. These are not absorbed by the skin and provide long lasting protection through the day. Chemical sunscreens such as Para-aminobenzoic acid, are absorbed into the skin and need reapplication after two hours. Studies have found that these chemicals are absorbed by the skin and found in the liver soon after application.
All sunscreens should be applied twice, ten minutes apart, to ensure an even coat. Furthermore, sunscreen should be applied everyday, even if it is cloudy, or overcast, as UV light is still present. It is also important to avoid direct sunlight, especially during the middle hours of the day, seek shade when possible, and wear a hat and protective clothing.
See our Clinical homecare range for sunscreens. Once sun protection has been implemented, it is now possible to treat the skin pigmentation.
Common lightening agents include;
Hydroquinone - This is the most widely and successfully used skin lightening agent. It can be used for melasma or chloasma, post-inflammatory hyperpigmentation, and other disorders of pigmentation. Over the counter strengths can go up to 2%, but concentrations higher than this require a script. It can also be compounded with some of the other agents listed below by a compounding chemist. Hydroquinone can be quite irritating to the skin and cause redness or contact dermatitis when used in higher concentrations. There is also the rare risk of developing ochronosis, which is a paradoical reaction to the hydroquinone in the treated area leading to an increase in pigmentation. This appears to occur in darker individuals after prolonged use. Alternating use of hydroquinone with other lightening agents every four months can help prevent this.
Kojic acid - This is derived from fungus such as Aspergillus and Penicillium. It can be used in concentrations between 1% and 4% and can be compounded with other agents. Again, irritation can occur with use. It is not as effective as hydroquinone, but has no chance of rebound pigmentation or ochronosis.
Arbutin - originating from bearberry, arbutin helps to lighten the skin by inhibition of the enzymes that help produce melanin. It has less irritation than kojic acid and hydroquinone. Available as L-arbutin in our products.
Vitamin C - Topical vitamin C also helps interfere with pigment production. An additional benefit of vitamin C is the anti-oxidant effect it has, so it will help prevent skin from environmental damage. Also stimulates the production of collagen. Stability of vitamin C is the main problem of most vitamin C products.
Glycolic acid - is an alpha-hydroxy acid (AHA) that can has a discohesive effect on the epidermis, or top layer of skin, to help desquamate (exfoliate) the pigmented skin cells. By doing so, it speeds skin turnover and pigment is lost more rapidly. Glycolic acid is found in varying concentrations in our clinical products.
Retinoids - Retinoids are derived from vitamin A. Retinoids work in a number of ways to help reduce pigmentation. The actual mechanism of action is not clear, but it is thought that their depigmenting properties arise from inhibition of the enzymes causing pigmentation, dispersion of pigment granules in the top layer of skin, and also by accelerating skin turnover to help pigmented skin cells shed more quickly. It is also this final property that helps retinoids smooth skin, reduce wrinkles, and active acne. L-retinol, a type of retinoid, is found in various products. Retinoids can be irritating to the skin and may need to be commenced slowly. Retonoids should not be prescribed to patients waiting for laser treatment
We can offer all the above lightening agents to your patients most of these lightening agents cannot be used during pregnancy or breast-feeding.
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