Thanks for returning to read more! I hope you found the previous posts helpful. I greatly appreciate feedback and questions, as I can use those for future posts. However, I am unable to really offer specific advice outside of the doctor-patient relationship. Sorry! Maybe I should set up virtual consults hah!
So, based on the initial round of questions, it seems like the big elephant in the room is …… pigmentation! Or was often asked in the thread, “dark spots But the thing is, not all dark spots are created equal- the basic pathophysiology of each kind of “dark spot” is vastly different and importantly, informs treatment choices.
So let’s talk about three “flavors” of dark spots:
Part 1. Postinflammatory pigment alteration (PIPA)
Part 2. Melasma
Part 3. Lentigos
Part 1.
You may be wondering, now, what in the world is PIPA and what did it do with my good friend PIH? Well, the terminology has changed and PIH is now RIP and we use the term PIPA to encompass all types of pigment alterations caused by inflammatory skin conditions. Of course, in reality, we are mainly talking about hyperpigmentation but there are instances where hypopigmentation occurs as well.
What causes hyperpigmentation? Well if you remember back to the intro section, I talked about melanin and how it generally lives in at the junction of the epidermis and dermis (you all remembered that right??? it’s also entirely ok if you skipped that part and went straight to the product section- no shame in that game, especially for us doc moms with limited time!). melanin lives in small evenly dispersed packets called melanosomes, but when irritated, this balance and organization can be disturbed.
When irritated, melanin will increase and disperse itself more widely, to protect the skin from the irritant. It can also become weakened and fall down into the dermis. Both of these processes can cause clinically visible hyperpigmentation.
What are these irritants? In the case of PIPA, these are typically hordes of inflammatory cells that rush to the skin (or are living there and get activated) during any inflammatory skin process. Examples include atopic dermatitis, psoriasis, acne, melasma (MUCH more on this later), cuts, and really anything that disturbs the skin. Because individuals with ethnic skin have more melanin, PIPA is an exceedingly common sequela of any type of inflammation.
When melanin gets disturbed by hordes of inflammatory cells, the melanin drops out of its packets and releases its contents into the dermis. Melanin is typically not meant to live in the dermis and causes the hyperpigmentation that we perceive after the inflammatory insult fades.
So what are the most common reasons I see people for PIPA? The top three would be for treatment after eczema, acne…. and acne!!! It is incredibly common for these inflammatory skin conditions to leave behind residual PIPA in our type of skin due to the increased melanin in our skin in general.
So thinking about the basic pathology of PIPA, in that it is post-inflammatory, I cannot stress enough that the best intervention is prevention! Or to use a sports metaphor, the best offense is a good defense. Inflammatory skin conditions should be treated immediately and appropriately, in consultation with your physician.
When it comes to eczema, that means being aggressive about utilizing appropriate therapy for those who suffer from this. On this note, regarding steroids, it may seem very counterintuitive to suggest potent steroids in inflammatory rashes. After all we know that steroids cause hypo pigmentation- I have innumerable patients who feel their child’s PIPA is from steroids. It is in fact the opposite!! Early and appropriately sequenced therapy with steroids and steroid sparing agents will PREVENT PIPA much more than the steroids causing hypo pigmentation. So that’s my two cents on steroids =)
When it comes to acne, that means identifying inflammatory acne and treating it appropriately and without delay. We will talk a lot more about acne and its treatment, but in my experience post acne PIPA is the most common concern I see in our population.
Part 2. Melasma
Melasma is a topic near and dear to my heart. Firstly, it disproportionally affects women and even beyond that, women with skin of color. It is also is not always adequately treated and there are a lot of myths surrounding those treatments. It’s also an area that we need a lot more research in, to better understand this process.
Melasma is an inflammatory skin condition characterized by muddy brown patches of epidermal and dermal hyperpigmentation typically on the face over the forehead cheeks and chin. I say typically because melasma can present atypically in non-facial regions and in other areas of the face. A common area I see in ethnic patients is actually the upper lip- perhaps exacerbated by threading and waxing, but not always wholly due to that.
It is important to highlight that melasma is a chronic inflammatory skin condition, not unlike eczema. It is not static hyperpigmentation, as we discussed in PIPA. It is a primary inflammatory skin condition and as such, can wax and wane. Unlike PIPA, which can often get better and stay away once treated, melasma can disappear and then re-appear many years later. Frustrating right?
Common triggers include birth control, hormone replacements, and various medications. I often will discuss the hormonal component but have found that most of my patients have already addressed this when they come to me. This leaves me to discuss the most important risk factor in my book, which is radiant and thermal energy, ie sunlight and heat.
I want to emphasize that not only can the sun worsen melasma, but even heat can do that. So this means, exercise, hot yoga, a hot day at the beach in full sunscreen- all of this can worsen melasma. There have also been studies suggesting that computer and phone screens can worsen melasma and there are special tints that can be placed to protect from that. So please don’t forget about all types of light and heat when thinking about controlling melasma- it all matters!
Importantly, not all brown discolorations on the face are melasma- this is another concern of mine, as i often see patients who clearly do NOT have melasma sent over as such. I have found discoid lupus, sarcoid, lichen planus pigmentosus and more, masquerading as melasma. This is why using a lightening cream without appreciating the underlying process can be very dangerous. Feel free to call your friendly board certified derm to ask and refer!
For those of you who have experienced or treated melasma, you may know how frustrating it is to treat! I believe this is due again to the basic pathophysgiology of the disease. The hyperpigmentation of melasma can be epidermal and dermal. Epidermal is vastly easier to treat that dermal hyperpigmentation- epidermal hyperpigmentation responds readily to peels, retinA, acids, lighteners and brighteners. Dermal hyperpigmentation, hiding deeper in the skin, is much harder to treat. It’s important to see a dermatologist who can distinguish between these two, as treating dermal hyperpigmentation with these measures will ultimately prove to be ineffective and can even damage the overlying epidermis.
Part 3. Lentigos
Lentigos are the most basic, in terms of pathophysiology, of the dark spot trio. Simply put, a lentigo occurse when melanin increases in amount and begins to clump together. This usually happens in defense to sun exposure, forcing the melanocyte to protect itself and your skin by increasing melanin defenses. This can also be driven by hormonal factors and genetics.
Not much else to say about lentigos- except that sometimes lentigo maligna can be hiding in these, especially if it appears at all irregular. Ask your friendly derm if you’re worried about this, though the vast majority are normal.
Management
So how do we treat all this? Well, there’s so much info that I’m splitting it off into another post! So stay tuned!!
