Pigmentation is the localized aggravation of pigmentation on the skin, and the formation of areas that are significantly darker than the surrounding skin tone. Some pigmentation is natural, some is acquired, some is related to sunlight, some has nothing to do with sunlight, some will recur, and some will be removed when removed. There are very many types of pigmentation, and dozens of them are included in “Pigmentation Increasing Skin Diseases” edited by Professor Chang Jianmin (@Dermatologist Chang Jianmin). In this article, based on some information I have read (especially “Treatment of Pigmentation” by Mr. Kenichiro Kasai and translated by Prof. Wu Suofan) and my personal understanding, I will elaborate on the classification of the most common pigmentation problems.
I. Pigment composition of pigmentation
The main composition of pigmentation is melanin. Melanin is mainly regulated by tyrosinase, while inflammation, sunlight, friction, stress, estrogen and some metal ions can promote the activity of tyrosinase, thus accelerating the synthesis of melanin.
The other constituent pigments in pigmentation are also worthy of attention, and I personally think the key ones include.
1. Hemoglobin: hemoglobin, when its oxygen is lacking, forms cyanosis, and after the death of red blood cells, it turns yellowish-brown. In post-inflammatory hyperpigmentation, chloasma, purpura and other problems, hemoglobin is an important constituent pigment;
2.Lipofuscin: The research on lipofuscin is not deep, and it is generally believed that it is related to the process of fat oxidation and exists not only in the skin, but also widely distributed in various tissues throughout the body such as cardiovascular and nerve.
3.Protein end glycosylation products (AGEs): the reaction between sugars and proteins (in the skin especially refers to collagen), forming initial glycosylation products, forming some strong oxidizing substances, and then further reacting with tissues to form yellow end glycosylation products, this reaction is irreversible.
4, pathological products: long-term exposure to hydroquinone (hydroquinone), mercury, lead, etc., will cause the skin to develop exogenous brown yellows disease, the cause of these products is not clear. Occupational exposure to polyaromatic hydrocarbons (benzene, quinone, anthracene, phenanthrene, naphthalene, etc.) can lead to melanosis. Polyaromatic hydrocarbons are mainly found in crude products of petroleum and coal tar, such as oil for fuel, heavy oil, lubricating oil, asphalt, etc. This occurs in chemical, rubber, petroleum, coal, metal cutting and other industries, which are relatively far from the daily life of ordinary people.
Second, the causes, characteristics and treatment of different types of discoloration spots
First of all, I hope to clarify: for every kind of spots, sunlight will aggravate them, therefore, the general rule of care for removing spots must include: sun protection.
Secondly, antioxidants and whitening ingredients are effective in brightening skin tone, reducing inflammation and even fading pigmentation, therefore, skin with spots can use such products, but they may not be 100% effective.
Pigmentation is inside the skin, and many times when it happens, we can’t see it with our naked eyes; when the naked eyes see it, it is already quite serious. Therefore, it is important not to pursue quick results for spot removal, especially not for skin care products, which can easily fall into the trap of illegal products. At the end of the article, I will highlight several risks of spot removal.
As laser therapeutic methods belong to medical aesthetics, it is necessary to determine what kind of laser and methods to use after the interview by laser aesthetic doctors.
1.Freckles/Ephelides
Freckles are widely believed to be a hereditary disease, the cause of which is unknown. Mr. Kenichiro Kasai believes that it is a pigmentation problem caused by a somatic pigmentation disorder.
Features of common pigmentation types and treatment of freckles: They appear in childhood, can worsen with age, and are aggravated by sunlight. Small scattered pigmented spots (less likely to fuse into patches), symmetrically distributed on the face, especially on the nose and sides, but also on the whole face, with brown color predominantly and generally darker. The histopathological manifestation is mainly the increase of melanin in the epidermis.
Prevention: Strict sun protection. Antioxidants such as vitamin C, B and anthocyanins that help to whiten the skin can be taken.
Treatment: Topical whitening skin care products may have a lightening effect, but cannot be completely removed; Intense Pulse Light (IPL) is an effective method, and results can be seen in about a week, but they usually recur over a longer period of time. Some Q-switched lasers also have good results. PS: IPL has many names in the commercial setting, probably the most commonly used is photorejuvenation. The fourth generation is called Optimized Pulsed Light Technology (OPT).
2. Acquired Dermal Melanocytosis (Acquired Nevus of Ota, Hori’s mother spot, brown surface nevus, Acquired Dermal Melanocytosis/ADM)
This is a skin problem unique to Asians, first reported in 1984, initially as a subtype of nevus of Ota.
Characteristics: ADM is a pigmentation of unknown origin (this is nonsense, most pigmentation problems have unknown origin), unlike most pigmentation: its melanin is deposited in the dermis (in normal people, melanin and melanocytes are only present in the epidermis), and it often occurs after the age of 15 to 20, so it is considered to be acquired. Its occurrence is not related to sunlight and its color is grayish (this is important! The greenish-gray discoloration is usually located in the dermis, while the brownish-brown one is in the epidermis), often distributed along the nerves on the face, mostly symmetrically. Most of them are symmetrical. The most common sites are: the root of the nose, cheekbones, sideburns, and the inner part of the eyes. In 2005, the Murakami Research Group in Japan reported that people with severe hereditary atopic dermatitis are prone to develop ADM.
Prevention: Sun protection. The use of whitening products has some lightening effect, but it cannot be eradicated. Strictly speaking, since the mechanism of its occurrence is unknown, it cannot be effectively prevented for the time being.
Treatment: Laser. Once treated, recurrence is rare. Mr. Kenichiro Kasai recommends the Q-switched ruby laser in preference.
Note: ADM may occur in combination with melasma, etc., so the doctor needs to identify and decide which problem to treat first. Improper treatment can lead to aggravation of the problem (especially if the laser is performed in congested state, inflammation, or sensitive state)
3.PostInflammatory Hyperpigmentation (PIH)
If you say “post-inflammatory hyperpigmentation”, you may find it friendly – acne marks are a kind of post-inflammatory hyperpigmentation.
The typology and treatment characteristics of common pigmentation: After skin damage, such as infection, sunburn, allergy, man-made damage, medical art surgery, exposure to a large number of irritants, etc., the skin becomes congested and inflamed, and various inflammatory factors increase, resulting in active melanin cells, increased melanin production, mixed with the death of red blood cells to form hemochromatosis, which together form post-inflammatory hyperpigmentation. Fresh ones are red in color, and those that do not disappear over time are brown. The longer the time, the more difficult it is to eliminate.
Prevention.
1, can quickly stop the inflammatory process (anti-inflammatory, soothing, sedative), can largely reduce the occurrence of PIH, you can take high doses of vitamin C, B, drinking green tea, using licorice, horsetail-type ingredients to make a mask to relieve inflammation, when necessary to seek medical help; if there is an infection, be sure to deal with the infection at the first time (please seek medical help) ;
2, after the inflammation occurs to avoid friction, must be strictly sunscreen ;
3, fresh, red pimple marks, you can use Babu agent mask care, paste on the face before going to bed and take off when you wake up. Individual small pimples left behind can be cut into small pieces and pasted on top, which can fade to red and also stop melanin from increasing, with good results.
Key tip: If the skin is in the inflammation period and the redness is serious, you should avoid laser, dermabrasion and other medical cosmetic procedures, the possibility of PIH is high. You should first take precautions to restore the skin to normal before seeking medical help.
Treatment: Once PIH forms brown discoloration, it takes 2 years or more to fade naturally, provided that strict attention is paid to sun protection in the meantime. Otherwise, no improvement is possible.
Brown PIH can be treated quickly using medical cosmetic procedures such as fruit acid peels, dermabrasion and laser (after treatment should be prevented from re-occurring PIH as described before, please seek medical help); you can also use whitening products with strict sun protection to accelerate the fading with certain effect.
4.Seborrheic Keratosis (Seborrheic Keratosis/SK)
Also known as age spots or longevity spots, it will be seen as a symbol of longevity – in fact, it is a symbol of aging.
The typology and treatment characteristics of common pigmentation spots: middle-aged women/men who do not pay attention to maintenance will show faint traces around the age of 40, initially starting with a light brown color and smooth surface; as they grow older, the color deepens and becomes thicker, protruding from the skin surface. Usually the most selected area is at the temples, followed by the cheeks, back of the hands and back of the arms. They are usually about 25px in diameter and do not usually form patches.
It is a lesion of the stratum corneum, and the biggest trigger may be sun exposure (not one of them), which is manifested by severe thickening of the stratum corneum and highly active melanocytes.
Prevention: Strict sun protection and use of whitening products.
Treatment: In early pale cases, the development process can be slowed down after paying attention to sun protection and whitening products; fruit acids and other methods can be used to make them fall off faster. When protruding from the skin surface and deep in color, it needs to be dealt with by medical cosmetic means, such as: laser, microdermabrasion, fruit acid peeling, or even direct peeling with a scalpel. Once treated, as long as attention to protection, rarely recur.
Special note: medical cosmetic surgery should be operated by regular skin hospitals and professional skin doctors, do not toss by yourself.
5.Melasma
Melasma is called “the king of spots”, it is a kind of colored skin, especially Asian people with high incidence of pigmentation, not common in Caucasians (black people may not see it even if it happens). Some data show that melasma occurs in about 70% of postpartum women.
Fractal and treatment characteristics of common discoloration: melasma is patchy, large in size, symmetrically distributed, and may range from yellowish brown, maroon to brownish brown, with irregular edges, and will be aggravated by sunlight, but sunlight is certainly not the cause of its occurrence. Melasma is non-hereditary and the cause of its occurrence is still unclear, but it is gradually approaching the truth. Mr. Kenichiro Kasai believes that frictional damage to the melasma skin is the possible cause, and he has found during his treatment that women with melasma usually pay special attention to their makeup and must be very clean in removing it. In some cases, after listening to his advice that “it doesn’t matter if you don’t wash so cleanly”, they have improved naturally.
It is believed that chloasma is caused by barrier damage, which leads to inflammation, and the inflammation process promotes melanocyte activity; the fragile rupture of blood vessel walls leads to the death of red blood cells, and blood iron flavin aggravates the pigmentation. He proposed the classification of vascular type, pigment type and mixed type, creatively proposed the slide examination method, and according to the examination results, anti-inflammatory, melanin reduction and laser treatment were given respectively.
The use of low-dose small spot instead of the previously widely used low-dose large spot treatment has significantly reduced the recurrence rate. Interesting to mention: after several times of low-dose small spot treatment, a certain pigmentation aggravation is induced first, which gradually fades until it is removed after continuous treatment, and very good results are achieved after two years
Prevention: sun protection, protection of skin barrier, avoid over-cleaning, rubbing the skin, supplementation of vitamin C, B, glutathione and other antioxidants, dipotassium glycyrrhizate anti-inflammatory, reduction of vasodilation with tranexamic acid. Personally, I believe that supplementing collagen to enhance vascular elasticity is also meaningful for prevention. Irritating skin care products should be avoided.
Treatment.
If it is only a melanin problem, it can be solved faster with laser, and then pay attention to post-laser repair to avoid PIH, which is more effective;
If it is a vascular type, it can be eliminated by anti-inflammatory treatment;
If it is a mixed type of vascular and pigmentation, anti-inflammatory treatment is needed first to stabilize the skin, restore the barrier, and normalize the blood vessels before using laser to treat the melanin. This is in line with Mr. Kenichiro Kasai’s first recommendation of tranexamic acid (tranexamic acid, agglutinative acid) as a conservative treatment, but it is of great significance because of a more in-depth explanation of the mechanism.
Before this, melasma was considered a no-go area for laser treatment, mostly because when inflammation was still occurring, blood vessels were dilated and inflammatory factors were active, which were stimulated after treatment with laser, and the pigment disappeared, but the inflammation was aggravated, and not long after, pigmentation appeared again. After performing accurate sizing and segmentation, these problems can be greatly avoided.
Considering the role of barrier damage, inflammation and vasodilation, and active melanocytes in the formation of melasma, Prof. Huimin Zhang of Shanghai Shuguang Hospital proposed the idea of using a bionic mask to continuously supply the skin with effective ingredients to take care of melasma. The idea was realized by Shanghai Yifei Biological, which is the first “Babu agent mask” in the world, turning the scope of mask upside down. I have shown my experience of using this mask on Weibo. It uses a polymer gel to form a bionic gel film with constant water content, and adds dipotassium glycyrrhizinate (anti-inflammatory), agglutinative acid (reduces vasodilation, anti-inflammatory and inhibits melanin) and ascorbyl palmitate (vitamin C derivative, reduces melanin, anti-inflammatory and repairs blood vessels) to the gel film to stop the generation of melasma from different aspects. Since the water content is constant, it can be left on the skin surface for a long time (6~8 hours) to continuously deliver the active ingredients, while keeping the skin moist with water and forming a better sebaceous film (the speed of tissue repair is increased by 2 times in the moist state). Clinical observation has been completed and the results are very good.
Due to the similarity of the mechanism of occurrence, I think this mask can also be used for first aid after skin allergy (to inhibit inflammation and prevent PIH), I have experimented myself and confirmed effective; perhaps it can also be used for red acne marks (to eliminate redness and inhibit PIH formation. But still need to experiment to confirm).
Special Note: Different spots are likely to occur in a mixture, for example, ADM mixed with PIH and mixed with melasma. This complex situation, with different solutions, requires an experienced doctor to make a differential diagnosis, treat them separately and improve them gradually, which usually takes one or two years or even many years.
6.Coffee spots
Characteristics: The incidence of coffee class in normal people is about 10~20%, like the color of milk and coffee mixed together, so it is called coffee spot.
The typing of common pigmentation and the reason of treatment: This is a hereditary problem, and the reason is still unclear. It appears in infants, at birth, and can occur in any part (mainly in non-exposed parts), with size from several millimeters to tens of centimeters, with clear borders and uniform color, and histopathological studies show that it is mainly in the basal layer of epidermis where melanocytes and melanin increase. When the diameter is >37.5 px and the number exceeds 6, there may be a combination of type I neurofibromas. There may be dermal fibroblasts involved in its formation process. Unlike freckles, freckles occur mostly on the face, in large numbers and small size.
Treatment: Laser. But the recurrence rate is higher.
7.Nevus of Ota (Nevus ofOta)
Cause: During the development of fetus, melanocytes “misplaced” and aggregated in patches along the nerve line (because melanocytes originate from nerve cells), forming cyanotic spots, which are more common on the face unilaterally and more frequent in the temple area around the eyes (the figure below shows before and after treatment).
Typing and treatment of common discoloration
Prevention: No method at the moment
Treatment: Laser treatment with good effect. Skin care products are ineffective.
8.Pigmented nevus (Mole)
Description: Also called nevus nevus (melanocyticnevi), it can be seen in any part of the body, with smooth surface and slow development, and there are various types of nevus such as junctional nevus, mixed nevus and intradermal nevus, etc. Generally, no treatment is needed, and there are few malignant changes. If treatment is needed, pathological examination is recommended and surgical excision is preferred. If laser treatment is not clean, melanocytes may be provoked and nevus may be formed.
Prevention and treatment of common pigmentation: There is no effective method. Pay attention to sun protection to prevent aggravation.
Common risks of blemish removal: 1.
1.Hg
Amino mercury chloride is a common prohibited added whitening ingredient, which has melanocyte toxicity and may cause a variety of adverse consequences such as depigmentation (similar to vitiligo-like manifestation), neurotoxicity, kidney damage, exogenous brownish yellow disease, skin damage and sensitivity. The high incidence area is the spot removal products from unknown sources, so when buying spot removal products, you must pay attention to their sources, inquire about their information, and even send them for testing if necessary.
2.Hormone
Some irregular blemish removal products may add glucocorticoid hormones, which may cause pigmentation, barrier damage, sensitive skin and hormone-dependent dermatitis after long use. The way to identify such products is: if the skin becomes very tender within a few days after use, the skin feels strongly uncomfortable after stopping use and must continue to use to feel comfortable (so-called “dependence”), after which the skin becomes thin, transparent and red, and the skin is dry, peeling, chapped and itchy after stopping use.
3.Inappropriate laser surgery
As mentioned before, different causes of pigmentation, different nature and distribution sites, and the presence of inflammation, etc. may form contraindications. Especially for melasma etc., it is important to pay attention to the condition of skin inflammation at the time of treatment, and to identify and step by step with other mixed occurrence of pigmentation, when it is very important to make assessment with Visia etc. Using laser under inappropriate circumstances may cause lasting PIH, melanocyte provocation, etc. Please choose a professional medical laser aesthetic institution and physician to deal with it.
IV. Summary
Pigmentation is a complex and not very well studied skin problem. There are many types and different ways to deal with them. This is the reason why I often get asked, “What should I do if I have a spot on my face?
Due to the special nature of pigmentation, the effect of topical spot removal products is not very obvious most of the time, so laser, surgical excision, peeling, intense pulse light and other treatments are needed. Depending on the type and location of each pigmentation, the type of laser, energy, wavelength, spot size, etc. and the surgical method chosen are many more things to be considered. Some can be treated completely, such as various moles and ADM, and some are prone to recurrence, such as freckles.
However, no matter what method has removed or reduced the pigmentation, attention should be paid to sun protection and topical whitening products to prevent or delay the recurrence of pigmentation.