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By Jeanine B. Downie, MD
anagement of hyperpigmentation—and prevention of recurrence—can be a challenge for both
patients and dermatologists. The challenge
becomes more significant when patients present
with additional dermatologic concerns, such as
acne or atopic dermatitis. One rather common concern of
patients with melasma or hyperpigmentation centers on the cutaneous signs of aging. That is no surprise given that UV exposure
directly contributes both to skin aging and activation of
melanocytes.
Given the wide range of topical anti-aging therapies now
available on the market, dermatologists can recommend appro-
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priate interventions to help patients with a history of pigmentary
alteration to combat the signs of aging. In fact, for the dermatologists with a knowledge of the range of suitable products on the
market, this patient presentation quickly transforms from challenging to rewarding. Whether combined with prescription topical therapies for hyperpigmentation or used alone, various products can help patients achieve smooth, even-toned skin. Any
product that is irritating may lead to further post-inflammatory
hyperpigmentation and a worsening of symptoms. Importantly,
the dermatologist must instruct patients on appropriate sun protection and guide them to effective, non-irritating cosmeceutical
products.
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Hyperpigmentation
Basics of Hyperpigmentation
The most important fundamental advice that any dermatologist can give to any patient is particularly pertinent to both
pigmentary alterations and cosmetic concerns: wear sunscreen every day, rain or shine, January through December.
An appropriate sunscreen formulation will provide SPF protection of 30 or higher and must be reapplied every two
hours in northern climates and once an hour in
temperate/hot areas closer to the equator. Patients must
understand the importance of wearing sunscreen regardless
of skin type. When patients
with dark skin tones tell me
that they don’t think they need
to wear sunscreen, I remind
them that Bob Marley died of
melanoma. Marley’s melanoma
was originally misdiagnosed as
a hematoma in his toenail, as
he was an avid soccer player.
There is a misconception
among patients that typical
make-up provides sufficient sun
protection. While some makeup products are SPF rated,
many are not. Even for those
products with SPF, few patients
would ever apply enough product—even a foundation—with
sufficient coverage to adequately protect from UV radiation.
Therefore, it’s best for patients
to apply a moisturizing sunscreen to the face, ears, neck ,
and other exposed areas before
applying make-up. Melasma
can appear in some very sensitive individuals on their arms
and hands.
Prior to initiation of any cosmetic regimen or provision of cosmetic services, existing
hyperpigmentation should be evaluated and treated.
Hydroquinone remains the gold standard of topical hyperpigmentation therapy. Over the past few years, there was some
discussion of the safety and concern about the availability of
hydroquinone, and many over the counter (OTC) products
have become scarce. Ambi is my preferred OTC product
because it has been clinically tested and is safe and effective
for most individuals. Much of this controversy seems to have
been fueled by parties interested in diminishing the stature of
hydroquinone, as they stood to financially benefit. The
cumulative evidence provided by published studies and many
years of patient use show that FDA-approved formulations of
hydroquinone, when used properly, are both safe and effective. The FDA no longer appears to be investigating hydroquinone safety and is not expected to issue any new mandates
regarding the agent.
Legitimate concerns remain, however, regarding some
imported hydroquinone products that are distributed illegally in certain parts of the country, usually in stores that cater
to ethnic populations. These unapproved products may contain unsafe concentrations of
hydroquinone or other ingredients, such as high concentration
or high-potency corticosteroids
and/or heavy metals such as mercury or arsenic. These should not
be applied to the face for extended periods.
TriLuma (Galderma) cream,
with the combination of hydroquinone 4%, tretinoin 0.05%,
and fluocinolone acetonide
0.01%, is now the mainstay of
hyperpigmentation therapy in
my practice because it is effective
and non-irritating. It is the only
hydroquinone with a new drug
application (NDA) that is FDAapproved for melasma. Following
successful initial treatment, I
often have patients apply
TriLuma up to three days a week
as a maintenance therapy. In
cooler months when UV exposure is typically lower, reducing
application to once weekly may
be sufficient in many cases.
Other hydroquinone formulations to consider include
EpiQuin Micro (hydroquinone 4%, SkinMedica), formulated with microsponge technology, for patients with very sensitive skin. Aclaro PD (hydroquinone 4%, JSJ Pharmaceuticals)
incorporates sunscreens and vitamin C and may be a wise
choice for patients who have trouble complying with regular
sunscreen use or who seek the additional skin rejuvenating
benefits of topical vitamin C application.
The most important
fundamental advice
any dermatologist can
give to any patient is
particularly pertinent
to both pigmentary
alterations and
cosmetic concerns:
wear sunscreen every day,
rain or shine,
January through
December.
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Topical Antiaging Options
Two primary considerations guide the selection of rejuvenation products and procedures for patients with hyperpigmen-
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June 2009
tation or a history of hyperpigmentation. The first is to offer
interventions that do not irritate the skin; irritation can lead
to worsening of hyperpigmentation or new-onset postinflammatory hyperpigmentation. Secondly, ideal interventions are those that, in addition to providing cosmetic
improvement, either directly improve pigmentary alterations
or support pharmaceutical interventions. Luckily, a number
of cosmeceutical products may fit the bill.
RevaleSkin Intense Recovery Treatment (Stiefel) is in my
experience a good option for patients with hypersensitive
skin. With regular application, the product seems to actually improve barrier function, and clinical studies reported by
Stiefel suggest that use of the product shortened recovery
time for patients who had undergone procedures. The product contains CoffeeBerry extract 1.5% and is intended for all
skin types. I have found that my patients who have been
using RevaleSkin Intense Recovery can tolerate other topical
products better. As this is a powerful antioxidant clinical
studies have also proven that it decreases redness, enhances
tone, and decreases fine lines.
Another cosmeceutical option that I recommend to my
patients is TNS Essential Serum (SkinMedica), formulated
with growth factors (Human Fibroblast Conditioned
Media), plant-derived amino acid Dipalmitoyl
Hydroxyproline, hyaluronic acid filling spheres, and antioxidants, including Ergothioneine (EGT), ubiquinone,
Tocopheryl Acetate, and green tea extract. This is well tolerated by patients of all skin types and provides notable rejuvenating effects. TNS Recovery Complex (SkinMedica) is a
less expensive option. It features the manufacturer’s proprietary NouriCel-MD complex of human growth factors. All
of the cosmeceuticals containing TNS notably build collagen
and decrease fine lines and wrinkles.
Prescription topical tretinoin cream (Renova, OrthoNeutrogena) is the gold standard in topical wrinkle reduction and can be an appropriate option for many patients
with hyperpigmenation. However, I generally instruct
patients to apply Renova or any tretinoin product just twice
per week to minimize irritation.
All of the above products should be patch tested on the
inner arm twice a day for three to five days before using on
the face.
Glycolic acid may be appropriate for patients with
hyperpigmentation when delivered via facial washes rather
than leave-on formulations. For example, MD Forte facial
cleansers (Allergan) are acceptable options. These cleansers
range from 12% and 15% to 20% glycolic acid.
The Vivite line (Allergan) features botanicals that even
skin tone. I generally recommend this line, which also
includes glycolic acid, superoxide dismutase, peptides, and
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exfoliators. Vivite Vibrance is a newer option that is effective
for hyperpigmentation. Results of small, unpublished clinical studies suggest the product can provide results that are as
good or better than those from hydroquinone but without
the irritation. I recommend salicylic acid, which is a betahydroxy acid, in the form of Beta Lifts 20% and 30% chemical peels. These even skin tone and improve acne, texture,
and fine lines.
Future Directions
Several chemical compounds, some of which are tyrosinase
inhibitors, have gained interest for their possible beneficial
effects in treating hyperpigmentation. Azelaic acid (Azelex,
Allergan; Finacea, Intendis) is available in the US as a treatment for acne and rosacea and may also be used as a primary
treatment for hyperpigmentation. This agent may be considered as a first line acne treatment in patients with a history
of or at high risk for PIH.
Among botanical agents under investigation are the
tyrosinase inhibitor arbutin or bearberry extract (found in
Vivite products among others) and licorice extract, which
contains glabridin. Some published data show promise for
these agents, though any optimal “dosing/concentration” or
application data are lacking.
Kojic acid (5-hydroxy-2-(hydroxy methyl)-4-pyrone), is a
fungal derivative that has been investigated and widely used
in Japan for some time, though no FDA approved formulations are marketed in the US.
Finally, a new molecule that has been developed and
incorporated into cosmeceutical products has been shown to
lighten dark spots and even skin tone. Lumixyl, a synthetic
peptide that inhibits tyrosinase, was found to provide a 40
percent improvement in facial pigmentation after nine weeks
of use and a 50 percent improvement after 16 weeks, in a
small study reported by developer emed, Inc. Patch testing
reportedly showed the peptide did not elicit allergic reactions; it is water soluble and non-toxic. Basis Medical
Technologies is slated to begin distributing Lumixyl-containing products in the US.
Lighten Up
Addressing a patient’s desire to improve hyperpigmentation
and achieve notable rejuvenation had in the past represented
a true conundrum for dermatologists. Advances in both prescription therapies and cosmeceutical development have led
to the availability of many treatment possibilities. Today,
dermatologists may find that meeting patients’ dual goals
can be mutually rewarding. Key to success is an emphasis on
prevention of new cutaneous insult and meaningful correction of existing damage. ■
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