Getting to know your skin pigments

Dr. Vivien, Medical Aesthetic and Skin Physician

Hyperpigmentation disorder on the face is a common complaint seen in skin and aesthetic clinics all over Malaysia. The main cause of this problem is our constant sun exposure due to our sunny tropical climate, and a lack of sunscreen awareness among our population. Also, certain hormonal influences and the general ageing process do have their roles to play in causing hyperpigmentation as well.

However, these different causes lead to distinctive forms of hyperpigmentation, with some people having different mixtures of hyperpigmentation. This makes treatment more challenging, as each individual type of hyperpigmentation requires different forms of treatment. Therefore, it is important to understand the various conditions, before discussing pigmentation treatment options available in Malaysia. So, what is hyperpigmentation exactly, and why are some of them so hard to treat?

The most common type of hyperpigmentation is melasma. They are described as darkened patches that gradually worsens, usually seen over the cheeks, nose and forehead, and appears in various shapes and sizes. They typically affect middle-aged women of darker skin types. There are a number of factors that trigger melasma development. It is mainly due to excessive sun exposure, the ageing process and hormonal changes, such as pregnancy and menopause. Genetic predisposition also accelerates the formation of melasma. Pigments can be found either in the outer skin layer (epidermal melasma), the inner layer (dermal melasma) or in both layers simultaneously (mixed melasma). The location of these pigments would directly influence the efficacy of treatments chosen. Naturally, the deeper the layer, the harder it is to treat.

Melasma

Next, on the list are freckles. This is a fairly common problem, especially among the younger, fairer skinned population. Freckles are tiny brown spots, commonly distributed over the cheeks and nose area. They are generally related to genetic predisposition and regular sun exposure. The pigments are largely found in the epidermal layer, allowing this condition to have better treatment outcomes.

Solar Lentigo

Another commonly seen condition is solar lentigo. They present as flat brown spots on the skin, usually roundish in shape and are uniform in color. They affect both men and women equally and are frequently seen in both fair and darker skinned individuals. As its name suggests, solar lentigo develops due to excessive sun exposure, and its pigments are ordinarily found in the dermal layer, making them less responsive to topical treatments. However, this benign skin condition has a similar looking, but more sinister, twin. It is very important to distinguish a benign solar lentigo lesion from melanoma in-situ, a type of malignant skin cancer. Treatment options vary greatly, depending on the malignancy of individual lesions.

Ota Nevus

Next comes a group of skin hyperpigmentation that is purely genetic in origin, and frequently affects Asian women in general. They are perceived as a cluster of slate-brown or blue-grey discoloration of the skin and are termed nevi, otherwise known as birthmarks. These nevi are differentiated according to their location. The nevus of Ota is distributed over the forehead, around the eyes and may affect a part of the eye. Nevus of Ito is seen over the shoulder and upper arm areas, while the nevus of Hori is scattered over both sides of the cheeks or face. These nevi have their pigments deep within the dermal layer of the skin, making complete eradication a challenge.

Post-inflammatory hyperpigmentation, or more commonly known as PIH, is also often seen among Malaysian patients, particularly those with darker skin types. These hyperpigmented spots usually appear after the skin has undergone any form of injury or inflammation, such as patients with acne problems, eczema, or skin dermatitis; patients who develop an allergic reaction to certain products or cosmetics used; or other any other forms of underlying skin disorders. These pigments may be found either in the epidermal or dermal layer, depending on the depth of injury and inflammation. Post-inflammatory hyperpigmentation may mimic other types of hyperpigmentation conditions, so a detailed history is important when trying to reach an accurate diagnosis.

Seborrhoeic Keratosis with Melasma

Lastly, there is a hyperpigmentation condition that regularly affects the older population. It is called seborrheic keratosis. They are harmless warty spots that look like they are stuck on to the skin, and can appear anywhere on the skin, except the palms and soles. They are generally related to skin aging, hence the prevalence among the elderly. Some may have only a few spots, while others may develop hundreds of them. This is usually due to a genetic predisposition. These warty spots have their pigments in the epidermal layer and are generally easily removed. However, it is important to rule out any malignant changes, as it does occasionally occur within the lesion.

In conclusion, it is important to know your diagnosis before launching into treatment options. Also, one needs to be vigilant in differentiating these benign lesions from their malignant counterparts. Although less common among Asians, the risk of developing malignant hyperpigmented skin diseases, such as melanoma and pigmented basal cell carcinoma, are still present. Hence, it is always better to be safe than sorry. Seek medical advice from a properly licensed physician before deciding to just laser off lesions from your skin.

Dr Vivien See Kai Ying, Skin & Medical Aesthetic Physician, Klinik Dr. Ko – Johor Bharu
Medical Degree, Kursk State Medical University, Russia
Letter of Credentialing & Privileging of Aesthetic Medical Practice, Malaysia
Master of Science (Anti-aging, Regenerative Medicine and Medical Aesthetics), UCSI University
Diploma in Dermatology, AFPM, Malaysia
Diploma in Aesthetic Medicine, AAAM, USA

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