So what to do about these marks?? First, we can acknowledge how unfair it is that these things follow us around, far after our eczema or acne years are over! (though for many women, those acne years hang around- more on that in another post). We already talked about the best defense is a good offense, ie treat early, appropriately and in consultation with a dermatologist.
Sunscreen is also a tremendous defense against of all types of dark spots. As we have discussed before, sunscreens that are broad spectrum, high SPF and mineral based are best. They are both preventative and therapeutic, as they allow the skin to heal while deflecting the sun from the skin.
1. exfoliation- retinoids A and acids
2. lighteners- hydroquinone
3. brighteners- natural and chemical products that do brighten the skin
Exfoliants are useful mainly in disorders of epidermal pigmentation. This means that these are useful for PIPA and sometimes for melasma but not often for lentigos and the deeper component of melasma.
Typical exfoliants include beta and alpha hydroxy acids. Typical alpha hydroxy acids are glycolic and lactic while a typical beta is salicylic. Both are very helpful in improving cell turnover, by exfoliating off dead keratinocytes.
Salicylic acid is particularly helpful in the management of acne PIPA, as salicylic acid concentrates in the sebaceous glands, where acne and its sequelae occur. Glycolic acid is particularly nice for the superficial component of melasma and provides general brightening of the skin.
Salicylic acid is available in washes and creams, and often just a low 2-5% concentration works well. I would avoid anything stronger than that in ethnic skin, as salicylic acid does cause irritation and high concentrations, and we don’t want anything to further worsen dark areas.
Glycolic acid is a great product and one that again is available in washes, creams, and peels. A note on glycolic acid is that it can be harsher than salicylic acid but is very good at PIPA and melasma.
And of course, our favorite exfoliant is tretinoin- as discussed before it has excellent anti-aging properties and helps to normalize keratinocyte turnover, slough off dead skin cells, and even lighten pigment in the skin. See our intro section for good tretinoin products.
The prototypical lightener is hydroquinone- you can look for any chemical that has “quinol” or “quin” and it usually will bear similarities to hydroquinone. Hydroquinone is a direct lightener and directly blocks tyrosinase, a key enzyme in melanin production (nerd alert: many forms of genetic albinism are related to tyrosinase enzymes!). By doing it, it blocks further darkening of the skin.
Hydroquinone is a mainstay of lightening creams, both over the counter and prescription. It is extremely useful when used correctly. What does correct use entail? Well, of course, firstly, working with a dermatologist who can select the right strength and formulation and frequency of use (that’s always my first answer isn’t it =) Depending on your skin tone, hydroquinone can range from 2% which is typically in over the counter products all the way to 12% in compounds. The higher you go, it can potentially become more irritating, and of course, the higher compounds must be used with a dermatologist overseeing its use.
A note on ochronosis- some of you may be familiar with exogenous ochronosis, in which prolonged use of high strength hydroquinone causes paradoxical darkening of the skin. This has been seen in some over the counter products found in other countries for the purposes of overall skin lightening. Use of an appropriate strength for a limited time with breaks will prevent this from happening.
Another fantastic lightener is azelaic acid, which is my personal favorite product. It is a true triple threat, with its ability to treat pigment, acne, and certain inflammatory conditions such as seborrhea. It inhibits tyrosinase and normalizes the skin bacteria and inflammatory mediators that play a role in acne. It is also safe in pregnancy, a time when many women are concerned about acne and melasma (we will have a pregnancy skin section too so more on that later). Azelaic acid is available by prescription and via compounding- ask your dermatologist, who should be very familiar with this option.
Brighteners do not typically function to break down pigment but rather to generally brighten skin. This means that applying to the regular skin can be helpful, not just to skin with pigmentary conditions.
A great example of this is soy. There is a bunch of research on the beneficial effects of soy on the skin, and Aveeno Positively soy makes a solid line of soy-based products that work really well, along with the above-mentioned exfoliants and lighteners.
Niacinamide, a B vitamin, is another great brightener. Look for this in moisturizers and sunscreens, as it really helps to brighten dull appearing skin. A good product for this is Cerave Pm (as mentioned before). A great combination product is La Roche Posay PigmentClar Darkspot serum, which contains niacinamide, salicylic acid, and other good ingredients.
There is also data for N-acetyl cysteine, which can be found in Olay Total effects, for some mild brightening effects.
Another nice product is kojic acid, which works really well with hydroquinone. Usually, these are compounded under a dermatologists guidance. Again, La Roche Posay makes a nice product called La Roche Posay Mela-D pigment control with kojic acid.