Our skin is a natural barrier protecting us against damage by the environment. It accumulates physical, chemical and solar damage over the course of our lives. Healthy and youthful skin is taut and has an elastic bounce. It has an intrinsic lustre and is devoid of irregular pigmentation.
In contrast, aged skin is characterized by wrinkles, appears dull, thin and crepe-like, and has irregular pigmentation. Irregular skin pigmentation is one of the early signs of skin aging and pigmentation removal is one of the most common clinical requests. Perimenopausal women often present with melasma, which are irregular dark patches initially arising in the cheeks, later involving the forehead, temples, and the upper portions of the nose.
Skin pigmentation is caused by melanin, which is produced by melanocytes, a specialized cell that resides within the skin. In youth, melanocytes are regularly distributed and produce an even amount of melanin and this manifests as beautiful skin with a homogeneous tone. Through the course of one’s lifetime, cumulative ultraviolet light damage stimulates irregular multiplication of melanocytes. The melanocytes produce melanin at different rates and deposit the pigment at the different depths of the skin resulting in irregular pigmentation. Pigment that is deposited more superficially appears darker, whereas pigmented deposited in the deep dermis appears faint. Progesterone is a female hormone that stimulates melanocyte activity and many women note significant increase in irregular skin pigmentation around the peri-menopausal years.
The optimal treatment modality is selected based on the depth of pigment. The various treatment options for pigmentation and melasma include sunblock, cosmeceuticals, pharmaceuticals, chemical peels and laser pigment removal. Combination treatment is often necessary for comprehensive pigment removal. Successful pigment reduction restores the appearance of youthful skin and improves the individual’s body image and self-confidence.
Preventive treatment is the first step in pigment reduction. Application of physical sunblock is the most effective method of blocking out UV light from the skin, and prevents conversion of pre-pigmented skin to pigmented skin. This is particularly important in Singapore where its tropical climate is associated with high levels of UV exposure throughout the year. Studies demonstrate that sunblocks rated SPF 30 and above are required for effective skin protection.
Cosmeceuticals are often used as adjuncts to other established treatment modalities for skin lightening. Carotenoids are plant pigments responsible for the color in many fruit and vegetables. They act as antioxidants in the human body. Carotenoids have also been shown to accumulate in the skin and inhibit melanocyte activity. The daily use of naturally derived oral carotenoids may be helpful in reduction of pigmentation.
Topical hydroquinone cream is a well-established and evidence-proven method of pigment reduction. Hydroquinone inhibits tyrosinase, an enzyme critical in the pigment-production pathway. It works well for pigment reduction in the superficial dermis but has less effect on deeper pigments due to limitation in its penetration depth.
Oral tranexamic acid is another treatment that reduces overall pigmentation levels and lightens melasma. It demonstrates effect on superficial and deep pigments and its efficacy is backed by peer-reviewed medical evidence. Both hydroquinone and tranexamic acid require treatment duration of at least 2 to 3 months before the effects are visible.
Chemical peels may be used to exfoliate the superficial layers of the skin together with the melanin pigment contained within it. Picasso Plastic Surgery uses a proprietary formulation for a chemical peel that stimulates this exfoliation. This is a simple treatment consisting of a peel applied in the clinic that is removed 4 to 6 hours later, followed by a daily recovery serum applied for a month following the peel. Chemical peels are an effective and safe method of removing skin pigmentation. Repeat treatments may be performed at 2 monthly intervals for optimal results.
Q-switched Nd:YAG laser is an effective and reliable of pigment removal. These lasers generate 532- and 1064- nm light wavelengths, which specifically target melanin in the mid- and deep dermis, leaving surrounding cells uninjured. The laser light is absorbed by the melanin and is converted to heat energy, which destroys the melanocyte. The pigment and cell remains are cleared by the body over the next few weeks.
Post-laser treatment care involves the use of recovery serums and sunblock for the prevention of recurrence. Mild redness may be visible following treatment, and the recovery time ranges from 24 to 48 hours. Repeat treatments may be performed at 4-week intervals for optimal results. Use of laser treatment alone may result in pigment recurrence and combination with other treatment modalities is frequently done.