The appearance of hyper pigmentation or brown spots on the face is one of the earliest forms of skin ageing. Research shows that there are 2 distinct types of ageing. Ageing caused by the genes we inherit is called intrinsic ageing. The other type is called extrinsic ageing and is caused by environmental factors like sun, pollutants etc. Melasma, Freckles, Lentigenes or age spots, spider veins, fine wrinkles, blotchy complexion are all signs of skin ageing. They are collectively called Photo-ageing. They may slowly evolve over years or develop suddenly. With repeated exposure, the skin loses its ability to repair and the damage accumulates.

1) THE BUTTERFLY SHAPED PIGMENTATION

2) FRECKLES

3) SOLAR LENTIGENES

4) POST INFLAMMATORY PIGMENTATION

5) SEBORRHEIC MELANOSIS

6) ACANTHOSIS NIGRICANS

7) LICHEN PLANUS PIGMENTOSUS

What is melasma?

Melasma is characterized by irregular, dark, hyper pigmented patches that occur symmetrically on both sides of the face.

Who gets melasma?

While melasma can affect both men and women, it is primarily seen in women. It is found in the age group of 20 to 50 yrs. People with darker skin are more likely to get melasma because they have more active melanocytes than those with lighter skin. People with a family history are much more likely to get melasma.

What are the types of melasma?

• Epidermal melasma – in this type there is presence of excess melanin in the superficial layers of skin.

• Dermal melasma – is characterized by the presence of melanophages (cells that ingest melanin).

• Mixed melasma – includes both the epidermal and the dermal type.

• Deep dermal melasma – is characterized by excess melanocytes and is commonly found in dark skinned people.

What causes melasma?

Melasma is caused when the pigment-producing-cells called the melanocytes become overactive and secrete excess melanin. The excess melanin gets deposited in the outer layer of the skin causing the appearance of dark patches on the surface. It is caused by a varying combination of factors like –

A change in hormones – Melasma could be triggered by hormonal changes like pregnancy, menopause and hormone replacement therapy. The pregnancy induced melasma is called chloasma or the mask of pregnancy and is largely caused due to high levels of progesterone. People suffering from thyroid disease or polycystic ovarian disease also have a greater chance of developing this condition.

Genetic – People with a genetic predisposition are at an increased risk of developing melasma. Skin pigmentation is originally caused by the UV rays from the sun. Normally the skins natural protection is able to resist the UV rays, but as people grow older, the immunity of the body reduces. This makes it possible for the years of accumulated sun exposure to take its toll on the skin. When this happens, it causes some genetic mutations of the genes that are responsible for the formation of skin color melanin. The genetic mutation experienced in such people can be passed on to their offspring’s and the cycle continues.

Sun exposure – ultraviolet light from the sun stimulates the melanocytes. Even a minimal amount of sun exposure can make melasma relapse. Most people find their melasma worsening in summer.

Stress – Recent research has established a link between stress and melasma. Stress can activate the propriomelanocortrin gene that prompts the cells to produce more pigment.

Cosmetics – skin care products that irritate the skin may trigger or worsen melasma.

What is the psychological impact of Melasma?

Melasma often has serious psychological effects on the persons self esteem. Some sufferers avoid social contacts with friends and family as they feel ashamed of their skin.

How is melasma diagnosed?

Melasma can be easily recognized by the characteristics of the pigmentation and its distribution on the face. A woods lamp examination is used to determine the depth or the number of layers that are affected by melasma.

How is melasma treated?

Treating Melasma is not like treating just any other form of pigmentation. When it comes to treating Melasma, it is recommended to avoid overly-aggressive treatments. The common notion is that an acid peel or a laser therapy will just peel off the pigmentation from the skin surface leaving behind a fair and glowing skin. However, irritation due to procedures like chemical peels and derma-abrasions can only make Melasma worse. Melasma responds best to non-invasive methods.

External applications – For mild cases external applications consisting tyrosinase inhibitors are prescribed. They work by preventing pigment formation by inhibiting the formation of melanin by melanocytes. Apart from tyrosinase inhibitors, skin lightening agents also play an important role in fading away the patches.

Oral medication – Melasma patch is not like a banana skin that can be just peeled off from the surface. It is a much more stubborn, deep-seated pigmentation and is caused due to an overactive cell underneath which secretes excess melanin. Stabilizing this overactive cell is crucial in treating melasma. Oral medicines work by reducing the activity of the pigment producing cells. For severe cases a combination approach is generally more effective.

Sun protection – For those who suffer from sun allergies, a broad spectrum sunscreen usage is important for successful management of Melasma.

During the treatment, it is important to adhere to the three Ps for maximum results – Patience, Persistence and Precaution. Patience is necessary as melasma can be slow to respond to treatment, especially if it has been present for a long time. Persistence is necessary in the form of ongoing skin care to maintain the results of the treatment and prevent relapses. Precaution is the third important thing. Exposure to sun and harsh chemical peels need to be avoided as they trigger inflammation and worsen Melasma. Following the three Ps can help bring better results.

What are freckles?

Freckles, also called Plural Ephilides are caused due to localized accumulation of melanin in the keratinocytes.

What causes freckles?

 

Sun exposure – Freckles are triggered by repeated sun exposure. The UV radiation causes the melanocytes to secrete more melanin which can cause freckles to appear or become darker. The freckles usually darken in summer and appear lighter in winter.

Genetic – while any one can have freckles, they are genetic. So if your parents have freckles, there is a good chance you may have them too.

Fair skin – Freckles are more common in fair skinned people. People with fair complexion have less melanin in their skin. When sunlight causes their melanocytes to make more melanin, they develop freckles instead of a uniform tan seen in dark skinned people.

How are freckles treated?

Freckles are treated using skin lightening agents, antoxidants, and sun protection. In moderate to severe cases oral medication may be required to reduce the activity of the melanocytes.

What are Lentigenes?

Lentigenes or liver spots are benign spots that occur on the sun exposed areas of the skin. They are larger and more defined than freckles. They may slowly evolve over years or may appear suddenly and persist for long periods. They are commonly seen on the face and the back of the hands.

What causes Lentigenes?

Lentigenes are caused by marked increase in the number of pigment cells located in the superficial layers of the skin.

Sun damage – Exposure to UV light from the sun is one of the biggest causes. Lentigines are common in those with fair skin but are also frequently seen in those who tan easily or have naturally dark skin.

Ageing – The lesions tend to increase with age, making them more common among middle age and older population.

How are Lentigenes treated?

Lentigenes are harmless and treatment is often required only from the cosmetic point of view. Mild cases of Lentigenes are treated using skin lightening agents, antoxidants and sun protection. However in case of chronic and relapsing types, a combination approach involving external applications and oral medication is used. The combination approach helps to lighten the patch from the surface as well as reduce the activity of the melanocytes internally.

It is important to distinguish the harmless Lentigenes from early malignant melanoma. A biopsy should be considered if a lesion shows irregular border, changes in color or thickness.

What is Post Inflammatory Pigmentation?

Some people have an easy tendency towards pigmentation. In other words, anything and everything leaves a black mark on their skin. From a simple scratch or a pimple to sun allergies or infections, any inflammation leaves behind a blotchy mark which does not heal on its own. This is called Post Inflammatory Hyper pigmentation. It is located on the site of the original injury or inflammation. The pigmentation may be light brown to black in color and may become darker when exposed to sunlight.

Post Inflammatory Hyper Pigmentation Marks due to Acne

What causes Post Inflammatory Hyper pigmentation?

Post Inflammatory Hyper Pigmentation follows an inflammatory wound. It is the skin’s natural response to inflammation. It can be the result of simple wounds, acne, burns, friction or aggressive clinical treatments such as chemical peels, derma-abrasion, laser and IPL.

Who gets Post Inflammatory Hyper pigmentation?

Post Inflammatory Hyper pigmentation can occur in anyone, but it is more common in dark skinned people. The pigmentation is likely to come up on sun exposed areas. Certain antibiotics and anti-malarial drugs may also cause it.

How is post inflammatory hyper pigmentation treated?

In case of PIH, the original injury or inflammation is already cured and what remains is just to get rid of the pigmentation. Therefore skin lightening agents form the mainstay in treating post inflammatory pigmentation. In chronic and long standing cases involving extensive areas of the skin a combination of treatments which includes external and internal medication may be required. If the pigmentation is on an exposed site, sun protection is very essential.

What is Seborrheic Melanosis?

Seborrheic melanosis is pigmentation that is seen on folds of skin like the nose corners, around the mouth, under the lower lip and arm-pits.

Seborrheic Melanosis on nose and mouth corners

What causes Seborrheic melanosis?

Seborrheic melanosis is caused due to a yeast infection called Seborrheic Dermatitis. People with oily skin are more prone to developing it. Sun exposure and friction from jewelry and clothing can further darken the pigmentation. It can be worse if the person is overweight. The darkening can also result due to profuse sweating. Use of Deodorants and anti-perspirants can also trigger it.

How is Seborrheic melanosis treated?

Seborrheic melanosis is secondary to seborrheic dermatitis. Therefore treating seborrheic dermatitis is important to get rid of the pigmentation. The triggers are to be identified and avoided. Once the seborrheic dermatitis is treated, the pigmentation is treated using skin lightening and exfoliating treatments.

What is Acanthosis Nigricans?

Some people develop darkened and thickened skin around joints and body folds like neck, armpits, elbows and knees. This is called Acanthosis Nigricans. The skin usually stays soft, which is why the word “velvety” is often used to describe the symptoms of Acanthosis Nigricans.

Acanthosis Nigricans around the neck

What causes Acanthosis Nigricans?

People who are overweight or obese are more likely to develop Acanthosis Nigricans. Certain hormonal medications can also cause it. Acanthosis Nigricans is found in people who have type 2 diabetes or those who are at a greater risk of getting diabetes.

How is Acanthosis Nigricans treated?

By itself Acanthosis Nigricans is not harmful or contagious. Many people who have it have no other symptoms and are otherwise healthy. Often, Acanthosis Nigricans can be a sign of diabetes or other medical conditions. In such cases superficially treating the pigmentation may not yield the desired results, finding and treating the health problem is necessary. Therefore in cases with diabetes or obesity, getting sugar levels and weight under control can help to clear up the pigmentation.

What is Lichen Planus Pigmentosus?

Lichen Planus Pigmentosus is a grayish-black pigmentation commonly seen on sun exposed areas like the face, neck, chest and arms. It is also found in places where two areas of the skin touch or rub together (like armpits and groin). The pigmentation may develop slowly or have a sudden onset.

Lichen Planus Pigmentosus on face and neck

What causes Lichen Planus Pigmentosus?

It is caused due to a hypersensitive reaction to unknown antigen leading to excessive production of melanin. Viral infections, UV light, certain hair dyes (even those which are henna based) and application of mustard or amla oils on the hair or skin are some of the known triggers.

How is Lichen Planus Pigmentosus diagnosed?

Lichen Planus Pigmentosus is diagnosed on the basis of its characteristic signs and symptoms. However in atypical cases a skin biopsy may be advised.

How is Lichen Planus Pigmentosus treated?

It is a chronic relapsing condition with periods of exacerbations (worsening of symptoms) separated by periods of remission (disappearance of symptoms). The condition if left untreated can run a long and progressive course. Therefore early diagnosis and damage control is the best solution. The treatment protocol is usually customized depending upon the extent of the disease and the response to previous treatments.