Hyperpigmentation

What to know about hyperpigmentation

Hyperpigmentation causes patches of skin to become darker than the surrounding skin. It occurs when the skin produces excess melanin, the pigment that gives skin its color. It can affect any skin type and is more likely during pregnancy, with older age, or after an injury.

Hyperpigmentation is very common on the skin of color, as darker skin tones already have a higher melanin content. Burns, bruises, acne, rashes, or other trauma to the skin can cause it to produce more melanin and lead to dark spots.

Types of hyperpigmentation:

• age spots also called “liver” spots
• melasma
• post-inflammatory hyperpigmentation

Some medications and certain health conditions can also lead to hyperpigmentation.

In this article, find out about different causes of hyperpigmentation and the treatments available. We discuss these below.

Types and symptoms:

Sunspots are more common in areas with frequent sun exposure, including the face, arms, and legs.

Hyperpigmentation

Hyperpigmentation happens when there is an overproduction or uneven production of melanin. Melanin is a pigment produced by the basal cells of the dermis called melanocytes. These cells coexist with other cells called keratinocytes, which are the dead cells forming the stratum corneum or epidermis (top layer of the skin). Many factors can cause over or uneven production of melanin. These include birth control pills, pregnancy, hormone replacement therapy, sun exposure, and drugs containing phototoxic agents, abrasions, or acne.

Hyperpigmentation types include:

• Freckles: Most common form of hyperpigmentation which resembles a cluster of small brown spots, usually inflicting those with fair skin. Heredity influences freckles as well.
• Melasma: A form of large patches of hyperpigmentation more commonly found in women, caused by hormones, sun exposure, stress, and pregnancy.
• Post-inflammatory hyperpigmentation: Usually caused by trauma damage to the skin. Common traumas include acne, burns, and aggressive medical treatments.

Causes of Hyperpigmentation Hyperpigmentation is caused by an increase in the production of melanin, the substance that gives your skin its color. There are a wide range of causes (and some medical conditions) that may boost your body's production of melanin:

Excessive or repeated sun exposure

1. Aggressive skin treatments
2. Hot working environments
3. Acne or skin injury
4. Reaction to chemicals and fragrances
5. Genetics
6. Hormonal changes, often caused by pregnancy
7. Endocrine diseases such as Addison's disease
8. Certain medications such as antibiotics, anti-seizure drugs and hormone treatments

While anyone can develop hyperpigmentation, the condition tends to be more severe among individuals with Asian, Latin, or Mediterranean skin tones.

What causes hyperpigmentation?

Skin gets its color from a substance called melanin, which is made by skin cells. When those skin cells are damaged or unhealthy, they can produce too much?melanin. The melanin can clump, causing that area to appear darker.

Many things can lead to hyperpigmentation:

• Adrenal disorders?such as?Addison’s disease, when the body doesn’t make enough of a hormone called cortisol.
• Genetics, such as a family with freckles.
• Hormone changes, such as during puberty or pregnancy.
• Injury to the skin (for example,?acne, cuts, or burns), is sometimes called postinflammatory hyperpigmentation.
• Medications, such as?oral contraceptives (birth control pills)?and drugs that cause sensitivity to light.
• Melasma.
• Not getting enough of certain vitamins, such as B12 and folic acid.
• Sun damage?(these spots are often called solar lentigines).
• Thyroid disorders.

Does hyperpigmentation cause any symptoms?

Other than dark spots, hyperpigmentation doesn’t cause any symptoms. If you have spots on your skin with any other symptoms, talk to your primary care provider or a?dermatologist?(skin doctor).

How is hyperpigmentation diagnosed?

To diagnose hyperpigmentation, a healthcare provider may:

• Ask you about your medical history, including when the darkened skin started and what medications you’re taking.
• Do a physical exam to look at your skin.
• Examine your skin under a special ultraviolet light, called a?Wood lamp.
• Order blood tests to check vitamins, hormones, and iron, as well as?thyroid?function.
• Take a small sample of the skin for a?biopsy, which tests for any abnormal skin cells.

How is hyperpigmentation treated?

Depending on the reasons for hyperpigmentation, your healthcare provider may suggest some lifestyle changes:

• Avoiding sun damage by staying out of the sun, using sunscreen, and wearing protective clothing.
• Stopping any medications that may be causing it.
• Taking vitamins.

Your healthcare provider may also recommend a prescription or over-the-counter topical therapy (creams or ointments you put on your skin):

• Azelaic acid.
• Corticosteroids.
• Glycolic acid (alpha-hydroxy acid).
• Hydroquinone.
• Kojic acid is a chemical that can reduce the amount of melanin the body produces.
• Salicylic acid.
• Skin bleach.
• Tretinoin.
• Vitamin C or B3 (niacinamide).

Other treatments may include:

• Chemical peels.
• Cryotherapy.
• Laser skin resurfacing.
• Pigmented lesion laser.

How can I prevent hyperpigmentation?

Hyperpigmentation can’t always be prevented, but protecting your skin from the sun helps:

1. Apply sunscreen every day. Choose one that’s “broad spectrum” (blocks ultraviolet rays, UVA, and UVB) with an SPF of 30 or higher.
2. Avoid too much sun exposure.
3. Use physical blockers such as titanium dioxide or zinc oxide.
4. Wear protective clothing and hats.

How long will I have hyperpigmentation?

Hyperpigmentation is a lifelong condition. Treatments can help clear some dark spots and lessen others. But they might take a few months or a year to work. And other spots can appear over time, especially if you don’t protect yourself from sun damage.

How can I cope with age spots, sun spots, liver spots, and other forms of hyperpigmentation?

The appearance of hyperpigmentation can make you feel self-conscious.

1. Avoid sun damage.
2. Be patient with any treatments you’re trying, as they can take months to show improvement.
3. Don’t pick at any imperfections, such as pimples.
4. Reach out to others with hyperpigmentation through support groups or online chats.
5. Realize that many people have hyperpigmentation and other imperfections. You’re not alone.
6. Take care of your skin by washing, exfoliating, and moisturizing regularly to help it look as healthy as possible.

Should I ever seek medical care for hyperpigmentation?

You should see a healthcare provider, such as a dermatologist if your skin is:

• Red.
• Hot to the touch.
• Itchy.
• Painful.
• Leaking blood, pus, or any other substances.

A note from ( YOUR DENTAL & MEDICAL CENTER )

Clinical findings

Group 1: Serious causes of hyperpigmentation

The following are rare, but must not be missed:

Addison's disease

• Systemic features?include fatigue, weight loss, dizziness on standing, abdominal pain, vomiting, and psychiatric symptoms
• Hyperpigmentation?affects UV-exposed sites, palmar creases, buccal mucosa, gums, scars, hair and nails, and areas subject to friction. There is an accentuation of normally high pigmentation areas such as the areolae, axillae, genital skin, and umbilicus
• Investigations:
• Low serum sodium and raised serum potassium
• Serum urea and albumin are raised because of dehydration
• Serum cortisol level took ideally between 8-9 am (random measurements have a low sensitivity for Addison's disease due to the pulsatile nature and diurnal variation of cortisol secretion). If the level of?serum cortisol is:
• < 100 nanomol/L - adrenal insufficiency is highly likely (if the patient is not on oral or inhaled steroids)
• > 400 nanomol/L - adrenal insufficiency is unlikely (diagnosis not excluded if the patient is acutely unwell at the time since cortisol values may increase during illness)
• Between 100 and 400 nanomol/L - refer to a specialist for further investigations eg synacthen test

Haemochromatosis

• Systemic features?-?diabetes, cirrhosis, and cardiac failure
• Hyperpigmentation?- slate grey or brown-bronze with a predominance for the face and other UV-exposed sites
• Investigations:
• Iron levels - most people with hemochromatosis have elevated levels of iron in the blood
• Transferrin saturation - transferrin is a protein that binds iron and transports it between the tissues. This test is one of the most sensitive tests for detecting early hemochromatosis. A transferrin saturation greater than 45% should be investigated further
• Ferritin levels?- ferritin is a protein that reflects the body's iron stores. Blood ferritin levels increase when the body's iron stores increase; however, levels of ferritin usually do not rise until iron stores are high. Therefore,?ferritin levels may be normal early in the course of hemochromatosis.?Ferritin levels greater than 400 ng/mL support a diagnosis of hemochromatosis, however, ferritin levels can also be increased in other conditions

Group 2:?Postinflammatory hyperpigmentation (PIH)

• PIH refers to the darkening of the skin that occurs after an?inflammatory eruption?such as acne, eczema, lupus, or following cutaneous injury. There may be a history of itch and/or signs of active skin disease such as erythema and scale. On?occasions, the skin can become hypopigmented
• As with many of the causes of facial hyperpigmentation, the incidence and severity of PIH are much greater in the skin of color
• Management:
• Treatment is of the primary disorder - the patient will develop less postinflammatory hyperpigmentation if the skin condition is treated promptly and effectively
• As with other causes of facial hyperpigmentation, it is important to consider the possibility of contact allergic dermatitis or a photo contact allergic dermatitis, referred to as?Riehl melanosis. Affected individuals usually have pruritus with mild erythema and scale. Patients should be referred for patch testing and sometimes photo patch testing
• Once the hyperpigmentation has developed the time taken for the affected skin color to lighten is highly variable and can take several years

Group 3: Drug reactions?

• Several medications can cause hyperpigmentation including phenothiazines (especially chlorpromazine), minocycline, phenytoin, antimalarial drugs eg chloroquine and hydroxychloroquine, busulfan and other cytotoxic drugs, amiodarone, anti-retroviral drugs and tricyclic anti-depressants (especially imipramine) -?the color change seen is likely to have a grey tone?
• Lichenoid drug eruptions, eg caused by gold, antimalarials, thiazides, ACEI, beta-blockers, and quinine, can also affect the face
• Photosensitive reactions?can arise from a number of medications including diltiazem
• After discontinuing the drug it can take many months, sometimes years, for symptoms to improve

Group 4: Melasma and other causes of more diffuse facial hyperpigmentation

Melasma (syn. chloasma)

• Symmetrical involvement, most commonly of the dentofacial, malar, and mandibular regions. The forearms can also be affected
• Light to dark brown patches - if?the excess melanin is in the epidermis the patches are brown and more well-defined, whereas, if the excess melanin is in the dermis the patches are more grey-brown with less well-defined margins. Mixed types occur. A Wood's light may be helpful as it will enhance the color of the pigment that is mainly epidermal (eg some cases of melasma, and post-inflammatory hyperpigmentation), but not if the pigment is in the dermis. Epidermal melasma is more likely to respond to treatment?
• For more information refer to the chapter?Melasma??

Maturational dyschromia

• Dyschromia?refers to skin discoloration or patches of uneven color resulting in temporary or permanent hyperpigmentation (increase in pigment production) and/or hypopigmentation (decrease in pigment production).?Mottling, or mottled skin, is another type of dyschromia in which changes in the blood vessels cause a patchy appearance
• Maturational dyschromia?is common. It is mainly seen?in mature patients with?skin of color. Maturational dyschromia causes?diffuse hyperpigmentation predominantly affecting the lateral forehead, temples, and?cheekbones, the margins are often ill-defined and the texture can be velvety.?Most patients are overweight and 70% have metabolic syndrome so it is worth testing for diabetes etc. Pressure?or trauma may contribute (eg lying on one side in bed)?but not UV-light?
• Refer to the section on management for more information

Lichen planus pigmentosus (LPP)

• An uncommon variant of lichen planus, the cause is unknown
• Affects predominantly young to middle-aged patients with skin of color
• Unlike classical lichen planus, LPP does not tend to itch
• Oval-shaped grey-brown to brown macules and patches mainly on the face, neck, and intertriginous areas, although can be more widespread. A minority of patients also have classical lesions of lichen planus
• Lesions can persist for many years
• Refer to the chapter?Lichen planus

Exogenous ochronosis

• Occurs secondary to the use of chemical substances applied to the face eg hydroquinone or resorcinol, often used by the patient to treat one of the conditions listed above. Such treatment may have been prescribed or used without the knowledge of a health professional
• Blue-black pigmentation of the face, sides, and back of the neck. It can also affect extensor surfaces
• The appearances can be similar to those of PIH or melasma and sometimes a biopsy is needed to differentiate. In exogenous ochronosis, a microscopic deposition of?ochre-colored pigment can be found in the dermis

Group 5:?Localised facial hyperpigmentation

Periorbital hyperpigmentation (syn. dark circles; periorbital hypomelanosis)?

• A?common condition?
• The cause may be multifactorial and include both genetic and environmental factors?
• Bilateral darkening of the orbital skin and eyelid
• The skin should be asymptomatic. If the itch is present, or there are other skin signs, consider a diagnosis of eczema/contact allergic dermatitis?

Naevus of Ota

• Predominantly affects patients with skin of color, although it can arise in any skin type. The majority present either at birth, infancy, or around puberty
• Blue/grey to slate-brown patches of hyperpigmentation. The distribution of the pigment is usually unilateral affecting:
• Skin - the ophthalmic and maxillary divisions of the ophthalmic nerve
• The sclera can be involved, and sometimes other parts of the eye
• Occasionally the hard palate

Group 6: Hyperpigmentation of the neck

Poikiloderma of Civatte (POC)

• Refers to skin changes with thinning, increased pigmentation, and dilation of the small blood vessels (telangiectasia)
• The skin is red-brown with prominent hair follicles, affecting the?neck and lateral cheeks, characteristically with sparing of the shaded area under the chin
• The cause is unknown, however, there is an association with UV exposure and it is more common in patients with fair skin. An additional theory is the photosensitizing components of cosmetics and toiletries, especially perfumes, although many doubt this link
• Refer to the section on management for more information

Acanthosis nigricans (AN)

• Characterized by darkening, thickening, and hyperpigmentation of the skin, occurring mainly in the folds of the skin in the axilla, groin, and back of the neck. The face and other sites can be affected?
• Most?cases of AN are related to insulin resistance. Rarely is it associated with underlying malignancy, such patients have much more extensive skin thickening including of the palms and soles?
• Refer to the chapter?Acanthosis nigricans

Erythema dyschromia perstans (syn. ashy dermatosis)

• An asymptomatic, slowly progressive eruption usually presents during the second and third decade of life
• The majority of the patients are from Latin America. Males and females are equally affected
• Asymmetrical involvement of the trunk, neck, upper extremities, and sometimes the face with slate-grey to blue-brown oval, irregularly shaped macules and patches. In the early stages, lesions may have thin, raised, and erythematous borders

Dyskeratosis congenital (syn. the Zinsser-Engman-Cole syndrome)

• A group of genetic diseases that most commonly manifest with mucocutaneous signs, bone marrow failure, and/or lung or liver fibrosis
• There is considerable variability in the severity, age at onset, and organ involvement, even within individual families
• The classical mucocutaneous features are:
• Reticulate (lace-like) hyperpigmentation of skin creases, described as a?'dirty neck'
• Nail dystrophy with longitudinal ridging, loss of nails, or koilonychia?
• Oral leukoplakia
• Other cutaneous features include early hair greying or hair loss, sparse eyelashes, hyperhidrosis, and squamous cell carcinomas often arising at a young age (50% by 40 years)

Group 7: Lesional hyperpigmentation

Ephelides (freckles) and lentigines

• Are a common finding in white patients and less so in the skin of color

Dermatosis papulosa nigra (DPN) and seborrhoeic keratosis

• A common finding in African-American, Afro-Caribbean, and sub-Saharan black patient?
• Considered a variant of seborrhoeic keratoses, with an earlier age of onset in many cases, arising often in adolescence with lesions increasing in number and size after that
• Multiple 1-5 mm pigmented papules - lesions are distributed symmetrically across the malar eminences, forehead, and less often the neck, chest, and back

Hori's naevus

• A common finding in the Asian population, especially Chinese and Japanese patients aged 20-70 years
• Symmetrical blue-grey or grey-brown macules primarily on the zygomatic area, although can become more extensive?

Actinic lichen planus

• A rare photo-distributed variant of lichen planus, of unknown cause
• The majority of patients are of Middle Eastern extraction. It mainly occurs in children and young adults
• Tends to be worse in the summer and improves over the winter
• Lesions are photo distributed affecting the face, neck, and dorsal aspects of the arms, and present as annular, red-brown patches with a striking hypopigmented zone and fine scale?

Group 8: Others - very rare causes of hyperpigmentation

Argyria

• Characterized by a metallic, slate-grey, or blue-grey pigmentation. Hyperpigmentation is most apparent in the UV-exposed areas of skin, especially the forehead, nose, and hands, as well as mucous membranes. Argyria results from prolonged contact with or ingestion of silver salts

Erythromelanosis follicularis faciei et colli

• Characterized by well-demarcated erythema, hyperpigmentation, and follicular papules. There are fewer than 50 reported cases, mostly from Japa

Post-chikungunya pigmentation

• Characterized by brown-black freckle-like macules, or less commonly slate pigmentation, mainly on the dentofacial skin. It occurs as part of Chikungunya fever, which is a febrile, mosquito-borne viral illness

A note from Dr. SHAYMAA ADIL

Hyperpigmentation

?is a common, usually harmless condition in which patches of skin become darker in color than the normal surrounding skin. This darkening occurs when an excess of melanin, the brown pigment that produces normal skin color, forms deposits in the skin. HypChanges in skin color can result from outside causes. For example, skin diseases such as acne may leave dark spots after the condition clears. Other causes of dark spots are injuries to the skin, including some surgeries. Freckles are small brown spots that can appear anywhere on the body but are most common on the face and arms. Freckles are an inherited characteristic.

Freckles, age spots, and other darkened skin patches can become darker or more pronounced when skin is exposed to the sun. This happens because melanin absorbs the energy of the sun's harmful ultraviolet rays in order to protect the skin from overexposure. The usual result of this process is skin tanning, which tends to darken areas that are already hyperpigmented. Wearing sunscreen?is a must. The sunscreen must be "broad spectrum" (i.e. it blocks both UVA and UVB). A single day of excess sun can undo months of treatment

repigmentation can affect the skin color of people of any race

How can I prevent the formation of hyperpigmentation?

Using broad-spectrum sunscreen every day can help prevent hyperpigmentation.

Sun protection is the most significant step you can take in helping to prevent hyperpigmentation in the first place. It’s important to remember that the sun’s rays affect skin even on cloudy days, so give your skin the daily protection it needs. As well as reducing hyperpigmentation,?protecting and preventing the formation of additional sun-induced pigment spots. Used in combination with the Dual Serum as part of a holistic skincare routine, you can help prevent and reduce pigment spots

Limiting skin exposure to the sun will also help to reduce instances of hyperpigmentation. Try to keep out of the sun during its most intense hours and wear protective clothing including sunhats and glasses whenever possible. When skin is exposed to the sun, apply and regularly reapply a sun protection product?with a suitable SPF level

Treatment

Face acids work well for mild hyperpigmentation on fairer skin tone.

Many face acids are available OTC at beauty stores and drugstores. Popular options include:

• alpha hydroxy acids , (such as glycolic, lactic, citric, malic, or tartaric acid)
• azelaic acid
• kojic acid
• salicylic acid
• vitamin C

A chemical peel?uses acids at stronger concentrations to treat the desired area of skin. They reduce the appearance of hyperpigmentation by removing the top?of?(the epidermis). Deeper versions may also penetrate the middle layer of your skin (dermis) to produce more dramatic results.

Chemical peels may work if you have:

• age spots
• sun damage
• melasma

They also work best for fairer skin tones, and they may provide faster results than face acid products.

A?laser peel ?(resurfacing) treatment uses targeted beams of light to reduce hyperpigmentation.

There are two types of lasers: ablative and non-ablative.

Ablative lasers are the most intense, and they involve removing layers of your skin. Non-ablative procedures, on the other hand, target the dermis to promote?collagen ?growth and tightening effects.

Ablative lasers are stronger, but they may cause more side effects. Both destroy elements in your skin to ensure that new skin cells grow back tighter and more toned.

Microdermabrasion ?is a clinical procedure used to treat hyperpigmentation that affects the epidermis only (superficial scarring).

You may need multiple sessions to achieve your ideal result.

Microdermabrasion works best on superficial scars.

It also works well for people with fairer skin

Lightening creams are over-the-counter (OTC) treatments that work with select ingredients to help decrease pigmentation. Many of these creams are available in stronger prescription forms.

They’re usually applied once or twice a day to help lighten the skin over time. Topical treatments for lightning also come in gel form.

Common ingredients found in OTC lightening products include:

• licorice extract
• vitamin B-3 (niacinamide )

A note from YOUR DENTAL & MEDICAL CENTER Clinic

Sometimes the skin produces extra melanin or pigment. That can create spots or patches that look darker than the surrounding skin. Hyperpigmentation may make you feel self-conscious, but it’s a common condition. Lifestyle changes and treatments may help. Avoiding sun damage is one of the best ways to prevent and reduce hyperpigmentation

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