Research has shown that perceived attractiveness stems from visible skin color distribution,1 so achieving an even skin tone is important to many consumers. Hyperpigmentation or uneven pigmentation is, in the mind of the consumer, usually connected with inadequate sun protection and often enhanced by smoking, although it can result from other causes. It presents as diffuse and focused, dark, uneven patches and is typically asymmetrical. Here, the author describes a pigment condition and the three steps of protecting against, treating and concealing it.
In the United States, skin conditions related to pigmentation are not the most common diagnoses for Caucasians, although in this author’s practice in the U.K., post-inflammatory hyperpigmentation (PIH) is seen when treating women with oily and combination skin types prone to premenstrual acne. PIH, a sequela of inflammatory chin or jawline acne, was identified by this author in adult women in their 30s. Epidermal PIH presents as tan or darker brown patches on skin due to an increased production of melanin in melanocytes and transfer to surrounding keratinocytes.
PIH can occur in all skin types but is more frequently observed in heavily pigmented skin. PIH is sometimes associated with macrocomedones, i.e., large whiteheads present on the chin area. These are often treated with gentle cautery prior to commencing isotretinoin treatment to prevent a severe and repetitive inflammatory response.
Some consumers have suffered with chin acne for years. Having tried conventional skin care and medication, they have found nothing eliminates their acne. These consumers are afflicted with large flare-ups of bright red, painful spots on a monthly basis with subsequent pigmentation. Further, in this author’s practice, consumers have communicated that PIH makes them feel very low, significantly impacting them psychosocially. It can become even more anxiety-provoking than their primary acne, which is often magnified by the lack of quick and effective treatment other than covering the pigmentation with makeup. Most PIH seems to be of epidermal origin, and this superficial melanin location provides a rationale for the topical application of anti-inflammatory active ingredients.
Sun protection is the first step to protecting skin with PIH, as PIH can worsen with UV irradiation and related persistent or recurring inflammation. Consumers with PIH, and in general, must be educated about photoprotection. This author recommends the use of a daily broad-spectrum sunscreen with an SPF 30, as well as avoiding direct sun exposure to the face.
Topical ingredients shown to reduce pigmentation include: azelaic acid, which competitively inhibits tyrosinase and is selectively and directly cytotoxic against melanocytes; kojic acid, a tyrosinase inhibitor that acts through the chelation of copper; arbutin, another tyrosinase inhibitor; niacinamide, a melanosome transfer inhibitor; n-acetyl glucosamine, which inhibits glycosylation or tyrosinase; licorice extract and retinoids. Also, peels containing salicylic acid, an active ingredient with exfoliating and anti-inflammatory properties, as well as glycolic and lactic acid, are popular. However, these products are recommended for use at night to avoid photosensitization.
Considering these options, this author recommends treatment routines using azelaic acid-containing masks and niacinamide-rich moisturizers. Azelaic acid, a naturally occurring di-carboxylic acid, as noted previously, has several tyrosinase-inhibiting mechanisms of action. Also, niacinamide, a derivative of vitamin B3, often referred to as niacin, has been shown in vitro to reduce melanosome transfer to keratinocytes as noted, but without inhibiting tyrosinase activity.2 It has been suggested that niacinamide interferes with the cell-signaling pathway between keratinocytes and melanocytes. In a clinical study of light-skinned individuals, topical niacinamide showed efficacy alone and in combination with N-acetyl glucosamine for the treatment of hyperpigmentation.3
Makeup and cosmetic camouflage are useful in concealing skin concerns related to hyperpigmentation. This offers instant coverage that can help to alleviate appearance-related distress and significantly improve self-esteem and quality of life (QoL). Good coverage must be light, long-lasting and provide a natural appearance. It also must be matte, waterproof and non-comedogenic. Due to the facial location of PIH, consumers require solutions that are easily applied and re-applied throughout the day.
Initiating the three-step routine of protecting, treating and concealing PIH early4 seems to speed its resolution and prevent further darkening due to persistent or recurring skin inflammation. Without treatment, it can take years to resolve the condition, much to the detriment of the consumer’s perception of attractiveness and self-esteem.
- B Fink, K Grammer and PJ Matts, Visible skin color distribution plays a role in the perception of age, attractiveness and health in female faces, Evolution and Human Behavior 27(6) 433–442 (2006)
- T Hakozaki T et al, The effect of niacinamide on reducing cutaneous pigmentation and suppression of melanosome transfer, Br J Dermatol 147(1) 20–31 (Jul 2002)
- AB Kimball et al, Reduction in the appearance of facial hyperpigmentation after use of moisturizers with a combination of topical niacinamide and N-acetyl glucosamine: Results of a randomized, double-blind, vehicle-controlled trial, Br J Dermatol 162(2) 435–41 (Feb 1, 2010)
- EC Davis and VD Callender, Postinflammatory hyperpigmentation: A review of the epidemiology, clinical features and treatment options in skin of color, J Clin Aesthet Dermatol 3(7) 20–31 (Jul 2010)