Five Tips to treat hyperpigmentation on black skin

In West Africa, the most common complaint that plastic surgeons or dermatologists find is related to acquired pigmentary changes.  Among them, postinflammatory hyperpigmentation and melasma are the most frequently seen. 
 
Introduction and Definition
 
Postinflammatory hyperpigmentation, also called postinflammatory melanoderma, is an excessive pigmentation of the skin produced by a previous irritation.  Skin damage that results in inflammation can induce postinflammatory hyperpigmentation.  Common triggers are acne lesions, allergic or irritant contact dermatitis, folliculitis caused by ingrown hairs, scratches, insect bites or trauma.  Hyperpigmentation can also develop after cosmetic procedures like chemical peels, hair removal or laser resurfacing.
 
Melasma is a hyperpigmentary disorder that occurs typically as symmetrical lesions on the face.  The cheeks, forehead, upper lip, nose and chin are commonly involved.  It affects primarily darker skin type females at puberty or later in life.  It is known both for causing significant psychosocial stress and for its difficulty to treat.  There is a hormonal component, since episodes of melasma are associated with pregnancy and the use of hormonal birth control.
 
There have been described several mechanisms that produce hyperpigmentation.  Among them is the stimulation of melanocytes by inflammatory mediators (IL-1-alpha or ET-1).  Other known stimulators of melanocytes are superoxide and nitric oxide generated in damaged skin.
The melanin produced during inflammation can also enter the dermis, be phagotised by macrophages and retained in the upper dermis for a long time, since the removal of dermal melanin is a very slow process.
 
The use of hydroquinone has been the first-line treatment for hyperpigmentation.  Hydroquinone 1,5 to 2% is available over-the-counter and preparations with higher concentrations have to be prescribed by physicians.  The mechanism of action is the suppression of melanin formation by the reversible inhibition of tyrosinase (the main enzyme involved in the conversion of tyrosine to melanin) and the selective damage to melanosomes and melanocytes.  Therefore, the mechanism of action of topical hydroquinone is through prevention of new melanin production. 
 
Tip 1. Prevention, prevention and prevention
 
The most important advice for our patients is always prevention.  They must avoid all the known triggers that cause hyperpigmentation.  The importance of daily sun protection can’t be stressed enough.  It not only plays an important role in the prevention and treatment of pigmentary disorders, the use of sunscreen strongly decreases the rates of skin cancer and photoaging.  Still, many patients with skin of color assume that due to the darker skin tone, they can skip sunscreen altogether.
 
Tip 2. Find the underlying problem
 
A common mistake among many patients suffering from hyperpigmentation disorders is self-medication without treating the underlying cause.  It is imperative to conduct a thorough initial consultation and health history to determine the exact cause of the disorder and establish an early intervention.  When the cause is explained to the patients, their compliance with the therapy will increase.  We have to inform the patients that in cases of dermal pigmentation, the treatment will be challenging and that perseverance and patience will be imperative.
 
Tip 3. Combined therapies work better
 
Multiple studies show that combination therapy is more effective than single agents used alone.  Different therapies acting at different stages of pigmentation can produce better clinical results than a single therapy acting at a single stage.
The most used combination therapy for melasma has been the Kligman formula, which combines hydroquinone 5%, tretinoin 0,1% and dexametasone 0,1%.  More recently a new combination of hydroquinone 4%, tretinoin 0,05% and fluocinolone 0,01% has been commercialised  proving better than any other combination, with 77% of patients showing complete or almost complete clearing.
 
Tip 4. Use chemical peels with care
 
Superficial chemical peels are an attractive option because of their few side effects and minimal recovery time.  The burning sensation associated with superficial chemical peels is mild, not requiring the use of topical or local anesthetic.  Nevertheless, these therapies require extensive experience in its use to prevent the development of irritant dermatitis.  In patients with ethnic skin, irritant dermatitis can lead to postinflammatory hypopigmentation or hyperpigmentation.
A clinical trial showed the safety and efficacy of glycolic acid peels on postinflammatory hyperpigmentation in dark skin individuals.  The treatment consists in the application of a 2% hydroquinone/10% glycolic acid gel plus the application of six serial glycolic acid peels (68% maximum concentration).  This study demonstrated a more rapid and greater improvement with minimal adverse effects.
 
Tip 5. Use laser only in non-responding cases
 
The challenge of the use of lasers in patients with dark skin is to achieve effective treatment with minimal complications.  We have to be conservative, with low energy settings, appropriate wavelengths and cautious with the use of cooling techniques.  The use of lasers should be restricted to cases unresponsive to topical therapy or chemical peels and an appropriate maintenance therapy should be selected to avoid relapse when treating melasma. 

If we decide to proceed with the use of laser devices one of the best option is a Q Switch Nd: Yag laser.  It is critical to use at least a SPF 30 sunscreen before and after the laser treatment and it is also advisable the use of hydroquinone and tretinoin during the treatment.
 
Dr. Juan Aguiar
 
Dr. Juan Aguiar is a certified plastic surgeon, member of the International Society of Aesthetic Plastic Surgery, the Spanish Society of Plastic and Reconstructive Surgery, and the Skin of Color Society.
 
He received his training at Vall d’Hebron Hospital, one of the top institutions in Barcelona and completed his cosmetic training in Brazil, Singapore and the USA.
He has more than 10 years of experience in the field of cosmetic surgery and since 2014 he has been in charge of the department of plastic surgery at Hospital La Paz in Malabo, Equatorial Guinea.
 
Dr. Juan Aguiar, MD
 
Hospital La Paz
Malabo, Equatorial Guinea
+240 556 666 160
 
info@doctoraguiar.com
 
www.doctoraguiar.com