Despite your age, colour, and skin type, pigmentation may affect you at some point in your life. Everyone’s skin possesses a brown pigment – melanin, and it’s deposited by pigment-producing cells called melanocytes. Melanin is a natural protective mechanism of the skin and is largely dependent on ultraviolet (UV) or sun exposure.
When the production and deposition of melanin by these cells become abnormal, it causes an excess of skin pigmentation, hence the appearance of brown or darker spots that can be seen on the skin surface.
Undoubtedly, there are numerous skin pigmentation treatments out there in the market today, both invasive and non-invasive. However, most of these treatments are deemed to fail. Why is that the case?
Reason 1: Incorrect Diagnosis of the Pigmentation
The cause for excessive skin pigmentation or hyperpigmentation is generally due to exposure to UV rays from the sun. This form of radiation stimulates a rise in melanin production and can be focused on an area of the skin.
Sun Spots or Solar Lentigines in medical terms are brown spots of varying sizes that tend to occur on the sun-exposed parts of our skin. They usually first appear on the cheeks, sides of our face. The skin of our hands can be involved as well.
Melasma is another form of hyperpigmentation and is a result of a combination of factors including genetics, UV radiation, and hormonal aspects. Women tend to be more susceptible to this condition than men due to the overstimulation of melanocytes by the female hormone – estrogen. Pregnant women are generally more affected as well, especially when they are more exposed to sunlight on a daily basis.
Hori’s Nevus is an acquired pigmentation condition that tends to affect both sides of the face symmetrically. There are other types of acquired pigmentary conditions common in this part of the world. Interestingly, this pigmentation is NOT due to sun exposure. Nevertheless, the appearance of Hori’s Nevus can be quite distressing for the individual patient. It is often confused with melasma.
Freckles are also caused by UV radiation and can lighten or darken depending on the amount of sunlight one is exposed to. Its age of onset is much earlier, and patients usually start noticing the freckles in their teenage years.
Moles are not exactly a kind of pigmentation, but a form of pigmentated growth and are defined by an abnormal cluster of pigment-producing cells in the skin. Moles need to be monitored closely as they may evolve in colour and size over time.
The above are some of the common pigmentation conditions that are encountered in the clinical practice. Each of the condition requires different treatment approaches. I have seen patients with acquired pigmentation conditions like Hori’s Nevus and other types of acquired pigmentation conditions being diagnosed and treated as melasma!
Caveat: The most important step to a successful pigmentation treatment lies in the CORRECT DIAGNOSIS. Get this step wrong, and the appearance of the pigmentation may not ever improve.
Reason 2: Insufficient Knowledge of Other Treatment Options Besides Laser.
Yes, we have all heard about lasers. But do you know about the other treatment options that are available that can treat pigmentation as well? There are many that have been shown to work, and I will just list down some of them:
- Hydroquinone. Hydroquinone is a compound that inhibits tyrosinase, the enzyme responsible for melanin synthesis. It is used as a topically applied cream to treat areas of uneven skin tone and pigmentation such as melasma, freckles, solar lentigines, and even post-inflammatory hyperpigmentation. Multiple studies have shown that the best results occur when using hydroquinone as a combination therapy together with retinoid and corticosteroid . In Singapore, these combination creams require a doctor’s prescription. Usage of hydroquinone has to be under a doctor’s orders and the patient has to be followed up closely by a doctor during the course of hydroquinone usage. Adverse effects may include irritation, redness, stinging and even ochronosis, a grey-blue discolouration of the skin.
- Cysteamine. This product is a natural molecule with a well-known anti-melanoma, anti-mutagenic, and anti-carcinogenic effects. Its application in pigmentation is quite new, only in the last few years, but has shown considerable promise. In some recent studies, cysteamine has been shown to be effective in decreasing melanin content of lesions, successfully treating patients with epidermal melasma and uneven skin tone . Cysteamine is available in Singapore as a 5% cream, under the brand name Cyspera.
- Vitamin C. There is considerable evidence that shows that this Vitamin C has skin lightening effects and antioxidant properties. It has demonstrated efficacy in reducing melanin synthesis, as well as counteracting the effects of UV-induced skin damage. Vitamin C is an unstable compound, and important characteristic to note in formulations, and also the reason why most Vitamin C products do not work as well as they claim . They get oxidised even before being absorbed by the skin. Vitamin C serums that include compounds like Vitamin E in their formulations are more stable and are more effective in treating hyperpigmentation.
Caveat: Laser is NOT the only option you have to treat pigmentation, and sometimes it may not even be the best option. Your medical team should always provide a list of comprehensive treatment options and discuss with you the best-suited one for you.
Reason 3: Insufficient Pre-Laser Care
Some aesthetic treatments like high-concentration chemical peels and lasers for pigmentation are only performed in clinics for a reason: they can be strong to the skin and needs to be done under controlled environments. This also means that the patient’s skin must be able to go through the treatment without any complications. Let me give you an example. In our clinic, one central principle in all our laser treatment protocol is: “First do no harm”. Before performing any laser treatment on a patient, he or she has to be cleared of the following:
- Prolonged direct sun exposure (> 2 hours) in the last one week prior to treatment
- Visible sunburns
- Contact dermatitis or eczema flare
- Concurrent skin infections
- Light dermographism (a form of light allergy condition that affects the skin)
- No prior laser treatment in the last 7 days
Caveat: A safe treatment is an important factor of a successful treatment for pigmentation
Reason 4: Insufficient Post-Laser Care
The emphasis on sun protection must be highlighted even after treatment on a daily basis and it is essential that patients are educated on all forms of post-treatment care to avoid a recurrence or relapse.
In addition to sun protection through the use of sunscreens, doctors may prescribe other home-use topicals medications, and moisturisers to be applied by the patient after the laser procedure. These are usually part of the comprehensive treatment plan that can ensure effective clearance of pigmentation and in the meantime, reduce the rate of pigment recurrence, especially for UV-induced pigmentation.
However, it is not uncommon to see patients not abiding by sun avoidance advice. This is more so if the patient has a very active outdoor lifestyle and engage in sports like golf, tennis, fishing, or frequent overseas travels. Moreover, they may not have the discipline to stick with the topical regimen for medication and products, which lowers the success rates of pigmentation clearance or a longer treatment course.
Caveat: Lifestyle modifications can be one of the hardest to achieve, but if done well, it can lead to significant improvement in pigmentation clearance rates.
Reason 5: Inadequate Knowledge of Laser Operation
There are many laser clinics and even more laser machines out in the market, each with their own treatment protocol to treat pigmentation. When there are so many choices out there, two factors that differentiate these choices are price and efficacy. And the efficacy of the treatment is determined by the expertise and experience of the doctor.
Lasers, being highly effective in reducing dark spots, also generate certain risks. They work using a focused beam of light, targeting a specific pigmented area in the skin. There are many grades of heat generated at a session and it depends on each individual condition how much to vary. Moreover, each laser machine will have its own operating protocol. An experienced doctor should have substantial competency in operating different laser machines so that he/she customises a laser treatment plan for the patient.
If performed poorly, lasers can cause problems involving, but not limited to, the following:
- Post-injury hyperpigmentation (PIH)
- Hypopigmentation (white spots)
- Laser burns
- Failure of treatment
In some cases, one should only opt for laser treatments when other modalities have been proven unsuccessful, when an addition of a laser modality can increase the speed of pigmentation clearance, or when the patient is suffering from multiple types of pigmentation concurrently.
Caveat: Like a double-edged sword, laser treatments can enhance a pigmentation treatment, or can give its own set of problems. Please do seek out an experienced doctor and have your laser treatment done in a MOH-certified clinic.
With the explosion of medical and laser technology in recent years, there is a multitude of skin pigmentation treatments at our disposal yet it is still our responsibility as service providers to ensure the safety and success of these treatments before proceeding. The Ogee Clinic ensures that product standards and clinical safety processes are in place for each and every patient who walks through the door so consistency in treatment quality is maintained.
 Farshi S, Mansouri P, Kasraee B. Efficacy of cysteamine cream in the treatment of epidermal melasma, evaluating by Dermacatch as a new measurement method: a randomized double-blind placebo-controlled study. J Dermatolog Treat. 2018 Mar;29(2):182-189
 De Dormael R, Bastien P, Sextius P, et al. Vitamin C Prevents Ultraviolet-induced Pigmentation in Healthy Volunteers: Bayesian Meta-analysis Results from 31 Randomized Controlled versus Vehicle Clinical Studies. J Clin Aesthet Dermatol. 2019;12(2): E53–E59.
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