Updated: Sep 6, 2021
The major types of hyperpigmentation include age spots (also called sun spots or liver spots), Post Inflammatory Hyperpigmentation (PIH, or spots due to acne or post irritation), and Melasma.
Melasma is one of the more difficult types of hyperpigmentation to treat. Melasma (also called Chloasma when referring to hyperpigmentation on the face caused by pregnancy), is a form of hyperpigmentation that has strong genetic and hormonal influences. We'll talk about the prescription and non-prescription skincare options that actually work.
What Does Melasma Look Like?
Chloasma is referred to as the 'mask of pregnancy.' It tends creep up over time and begins looking like a soft shadow, usually around the center of the face (forehead, upper lip most common) or somewhat symmetrically on the sides of the face (cheeks). Melasma has characteristics similar to a cloud, or a shadow, while other forms of hyperpigmentation don't look as cloud or shadow-like.
Melasma often flares up in the hotter seasons. It may seem to get darker in the summer and lighter in the winter. Melasma is chronic, and does not have a cure, but can be controlled and managed by understanding influencing factors and treatment choices.
Why Do I Have Melasma?
The cause of melasma is not fully understood. There are said to be links to ethnic backgrounds of those who live in more warm, humid climates. Melasma most commonly occurs after a change in hormones, such as pregnancy or birth control.
Our skin cells responsible for creating pigment (melanin), or melanocytes, create pigment as a form of protection. It is the immune function of the skin to produce melanin. Heat to any area of the body can cause all melanocytes to become hyperactive, and be more likely to produce pigment as a form of protection. Sun exposure particularly irritates the skin.
How To Treat Hyperpigmentation
The first step to treating melasma and hyperpigmentation is by protecting the skin. Sunscreen must be worn at a minimum of SPF 30 applied every two hours. UVA/UVB refers to ultraviolet radiation, or sun rays that irritate the skin. Most SPFs have UV protection, but not all sunscreens have infrared (IR), or heat protection. With heat as a major influence on melasma, infrared protection is a must. If we cannot protect the skin from light (UVA/UVB) and heat (IR), we cannot treat the skin until protection is established.
My two favorite SPFs for melasma are Skin Medica's Total Defense and Repair, which comes in tinted and non-tinted, and ZO Skin Health's Sunscreen + Primer SPF 30. Both of these medical grade SPFs also have antioxidants to help the skin.
Exposure to irritants such as radiation, pollution, smoking, and normal processes of the body can cause free radicals. Free radicals have an uneven amount of electrons, and steal electrons, damaging healthy cells. The loss of electrons is called oxidation. Antioxidants do exactly what they sound like they do; Antioxidants are anti-oxidizers, and repair and prevent oxidative stress. When free radicals outnumber antioxidants, this can cause oxidative stress. A healthy diet can be a source of antioxidants. Many skin care products also contain antioxidants.
Vitamin C is a common antioxidant that works as a tyrosinase (melanin production stimulator) inhibitor. Vitamin C itself can oxidize and be more unstable, hence more affordable Vitamin C products tend to not work as well. My favorite Vitamin C product is SkinCeuticals C E Ferulic.
Retinoids are Vitamin A derivatives. Prescription retinoids like tretinoin or non prescription like retinol or adapalene help facilitate skin cell turnover. I like to think of retinol for hyperpigmentation as shedding the most pigmented cells. Bakuchiol is an alternative to retinoids, though less studied, may also yield less irritation. Drugstore retinoids include ROC Retinol and Differin gel. Generic versions are also available at certain drugstores. My favorite retinoids are Skin Medica 0.5 or ZO Skin Health Retinol Skin Brightener 1% for more aggressive skin cell turnover, or Naturium Vitamin C Super Serum Plus that contains Vitamin A for more sensitive skin types. SPF is so important to protect the cells that have been exposed due to facilitating skin cell turnover.
Niacinamide is a great antioxidant for sensitive skin types that can be combined with chemical exfoliants. Paula's Choice and Naturium are some brands that offer niacinamide. Keep in mind, a higher percentage does not necessarily equate to greater efficacy.
Resveratrol has anti oxidative effects and works against UV irritation. It can calm red skin and brighten skin. It helps protect the skin barrier. SkinCeuticals is a highly trusted brand that has an advanced resveratrol. The Ordinary and Paula's Choice also offer resveratrol containing products.
Glutathione is a powerful antioxidant that brightens the skin. This is best delivered intravenously, or as an IV weekly. It tends to take about two months of weekly IV gluta to start to see skin brightening effects.
Hydroquinone, or HQ, is the gold standard in dermatology for melasma. Hydroquinone works by turning off the hyperactive melanocytes as a tyrosinase inhibitor. Prescription 4-8% Hydroquinone is ideal for melasma. Hydroquinone can only be used for three months at a time, then a three month break is necessary to prevent an opposite effect of creating a black-blue hyperpigmentation. Hydroquinone is the most reliable and effective agent in my opinion to treat melasma.
Alpha-arbutin, or arbutin, is an alternative to hydroquinone. It is a derivative of Hydroquinone. Arbutin is found in bearberry and mulberry. It has antioxidant and antibacterial properties. Naturium, The Ordinary and The Inkey List both offer affordable arbutin for skin.
Kojic Acid is derived by fungi, and function as a tyrosinase inhibitor. It has antioxidant and antimicrobial properties. You may not see an effect with 1% or less.
Tranexamic Acid (TXA) has hypopigmentory effects. TXA is most commonly used for melasma topically, but can also be prescribed orally by dermatologists with experience with this newer medication for pigment that is used for blood clots. Melanin synthesis is influenced by arachidonic acid and alpha-melanocyte stimulating hormones due to plasmin activity. TXA works against plasmin. Lytera 2.0 is an amazing product that includes TXA that many patients with melasma swear by.
Chemical exfoliants are used to lighten pigment spots. Alphahydroxy acids (AHA) are used more often for pigment of all causes, such as post-inflammatory pigmentation from acne. Glycolic acid works more aggressively, azelaic acid in between, while lactic acid works more gently, along with mandelic acid that serves as a favorite for skin of color.
How to Implement Hyperpigmentation Regimen
With melasma, most physicians will prescribe topical steroids to fight inflammation, retinoids, and hydroquinone. Most aggressive agents will be used at night, such as retinol, HQ, and chemical exfoliants. If our skin is sensitive, it is a good idea to start with one product at a time and take it slow. If irritated you can take a break and use gentle cleansers and moisturizers, but consistency can result in less irritation over time. Some dermatologists recommend pushing through the irritation, as long as the skin is protected. If your skin is not as sensitive, you can start to layer more products or rotate through different products.
In the morning or daytime, antioxidants can be utilized, followed by SPF always. We can absolutely use retinol and chemical exfoliants during the day, but when we sleep the body repairs itself and works better with our 'heavy lifters.' We don't want to use more irritating products during the day (or at night) if our skin is not adequately protected.
Pigment takes a long time to change. Even with the most aggressive agent, hydroquinone, it still takes at least one to three months to start to see spots lighten. Be patient and most importantly, be consistent.