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How to Fade Stubborn Pigmentation and Brighten Up Your Skin:

The State-of-The-Art Part I of III
The Nature of Melasma and Post-Inflammatory Hyperpigmentation

Tired of uneven skin tone? Bothered by the brownish patches developed after your pregnancies? Troubled by your skin’s persistent darkening after your acne, laser or chemical peel treatments?

If you have stubborn pigmentation on your face, you may have melasma and/or post-inflammatory hyperpigmentation. Especially for Asians or darker skin individuals, these skin conditions are two of the most commonly seen acquired hyperpigmentary disorders.

If you wished that you had brighter looking skin with even skin complexion, then this particle is for you. This three-part series discusses the nature of melasma and post-inflammatory hyperpigmentation, their prevention, and innovative state-of-the-art solutions to these common bothersome skin conditions.

In order to better understand the solutions, let’s first discuss the nature of these conditions first.

Melasma: The Mask of Pregnancy

Imagine the following scenario. You have just given birth to your lovely baby and now you noticed that you can’t lose the extra fat and your skin tone especially on your cheeks is not as even or as bright as before.

You may have melasma now, the so called “mask of pregnancy’.

For your information, this melasma condition is an acquired hyperpigmentation disorder which often presents as symmetrical but irregular brownish patches with cloud like and diffuse pigmentation on the face around the cheeks, forehead, temples and even the lips areas.

Many women of Asian descent or darker skin type develop this unsightly pigmentation. While there may be a genetic deposition, the true causes of melasma remain unclear.

There are many well known factors associated with melasma. The closest connection is with hormones. Hormonal conditions accompanying the development of melasma include pregnancy, as previously mentioned, menopause, and low thyroid function.

Melasma is also known to be associated with use of certain medications such as birth control pills, hormones, or photosensitizing drugs. Individuals who frequently use fragrant cosmetics may also develop more melasma. In my experience, patients with low antioxidants in their diet also seem to develop more melasma as well.

Certain other factors definitive worsen melasma. Sun light exposure, for example, significantly worsens the condition. Over the years, I have known numerous patients with melasma which got much worse after their vacation in sunny places during the summer. And indeed, in my experience, any inflammation which results in excessive or prolonged redness also exacerbates melasma as well.

Melasma is the most stubborn pigmentation of all. Melasma in the superficial layer of the skin called epidermis is much easier to treat, while melasma in the deeper layer called the dermis is much more difficult to improve. As we shall discuss later, treatment rely on state-of-the-art prevention and reduction techniques.

So when you have another child again, begin to take birth control pills, or you are approaching menopause, take aggressive steps, as we shall discuss later in preventing in melasma.

Post-Inflammatory Hyperpigmentation (PIH): The Curse of Inflammation

Does your skin get easily hyperpigmented after an injury? Look at your old scratches or acne and if they stay dark for long time then your skin is prone to PIH.

Darker skin type can easily develop PIH from any inflammation. As such, any conditions which produce inflammation can cause PIH. The causes are obviously numerous. Some of the most common ones include acne flare-ups, allergy, irritation from any source including harsh lasers and peels. And just like melasma, both UV irradiation and certain drugs(for example, tetracycline) worsens this condition as well.

Facial post-inflammatory hyperpigmentation is also challenging but seems to easier to treat than melasma. Just as in melasma, however, epidermal PIH is much easier to treat, while dermal PIH is much difficult to improve.

So next time you get laser and peel without proper sun protection and skin products preparation, watch out for PIH and think of prevention first!

Combination of Melasma and PIH

Both melasma and PIH can co-exist, since many of the aggravating factors are the same. This scenario makes treatment even more challenging.

In summary, melasma and post-inflammatory hyperpigmentation are unsightly challenging skin conditions. In this present day culture of pursuit of beauty whitening, many women desire modern and better solutions to their skin concern.

Stay tuned for the next articles, as we shall discuss state-of-the-art ways both to prevent and to fade pigmentation so that you can have brighter looking skin!

George Sun, MD

The Nature of Melasma and Post-Inflammatory Hyperpigmentation

How to Fade Stubborn Pigmentation and Brighten Up Your Skin:

The State-of-The-Art Part II or III

To fade your stubborn melasma and pigmentation, have you tried one or more of the following?

  • You tried the most expensive cosmetic products from the department stores only to find them to be minimally helpful after a few weeks of use.
  • You want the natural way so you took multivitamins only to realize these simple supplements don’t work as well as miraculously claimed.
  • You liked the gentle pampering from facials but don’t get any improvement from them.
  • You were inpatient and wanted instant whitening so you sought aggressive laser and peels only to find your skin became drier and pigmentation worse.

Sounds familiar? This article is the second discussion in the continuing series on the nature of melasma and postinflammatory hyperpigmentation. In these remaining articles, we will discuss state-of-the-art prevention and reduction techniques to fade stubborn pigmentation and help to brighten up your skin.

For treatment approach to melasma, you will need to understand important key steps towards better and brighter looking skin:

  • Have realistic expectation and be patient.Improvement takes time, often months. Furthermore, while melasma can fade significantly, melasma is not entirely curable. Wishful expectation and scientific reality are often different. In my years of experience, some patients I encountered expect melasma would just disappear forever in a few weeks. This type of result has not been my experience. Skin biology dictates that skin renewal takes at least six weeks. The melanin in the bottom layer takes at least this amount of time to move to the top and shed naturally. As such, medicine designed to “bleach” the skin work primarily by slowing down the production of melanin. The existing pigment cells still need to desquamate naturally over six weeks. As such, brighteners will need to take two to three months to begin to work.Having realistic expectation is the first key to better outcome, and having patience is, after all, a virtue.
  • Medicinal approach is the foundation of all prevention and treatment of stubborn pigmentation.Optimal uses of medicine require using multiple skin actives orally, topically, and even intravenously, often on all three levels simultaneously.Oral skin actives: “Sun blocks” you can swallow? The correct natural way.

    Whereas everyone now knows the importance of topical sun blocks, oral photoprotection with skin actives is an emerging, novel, and advanced concept for the control of pigmentation.“Oral sun block” is not swallowing your sun block cream. Rather, oral photoprotection is consuming multiple high potency anti-inflammatories from food or capsules to improve skin defenses against sun induced inflammation. With these photoprotective “oral brighteners,” there is less inflammation, and pigmentation can be better prevented or minimized.When do you need to think about prevention? You should consider taking these oral photoprotecting supplements the next time when you have another child again, take birth control pills or hormones, experience menopause, or spent time outdoors especially during the summer time.Examples of food with natural anti-inflammatories include ocean fish and antioxidant-rich fruits and vegetables such as berries, grapes, artichoke, tomatoes, and pecans. On the other hand, capsules with concentrated anti-inflammatories are much more convenient for ingestion. These specialized supplements can significantly enhance your skin immunity, help prevent sun burn, reduce redness, and calms down the skin to prevent melanin hyperactivity.
    People have used vitamins for their skin for sometimes but these regular supplements, while helpful for your general health, lack the optimal combination of skin actives. Be sure to look for combination of multiple skin actives for best efficacy in your oral skin brightening supplements. Oral skin actives need to be combined, highly potent, and synergistic to achieve effects. As such, important synergistic ingredients include omega-3 fish oil or krill oil, lycopene, vitamin E, vitamin C, genistein, polypodium leucotomos, green tea polyphenol, and grape seed extract.
    An example of the combination oral antioxidants is the Oral Brightener, which consists of many of the above listed ingredients. When used before sun exposure, especially during outdoor activities and during the summer times, oral photoprotectors can be very helpful in pigmentation prevention and control.
    Intravenous skin actives: “Drip in” your fruits and vegetables with intravenous micronutrients.

    Just as oral consumption of micronutrients can be helpful, intravenous infusion of these same ingredients can work even better and faster. Intravenous infusion provides several important advantages over oral consumption. Intravenous micronutritional therapy reduces inflammation and provides rapid photoprotection and skin hydration, all helping to minimize pigmentation and help skin brightening.Why is intravenous infusion better and faster than oral ingestion? First of all, oral absorption can be limited, especially for water soluble skin actives. A perfect example is vitamin C, which when taken at high dose orally, can lead to diarrhea. On the other hand, intravenous form of vitamin C can be very well absorbed, without such gastrointestinal upset.Secondly, intravenous infusion can be absorbed much faster, delivered at higher concentration, and carry multiple synergistic micronutritional elements simultaneously. Common skin actives used include vitamin C ascorbic acid, minerals, vitamin B’s, minerals, trace elements, amino acids, carnitine, and the master antioxidant glutathione.A specialized and even more advanced version of intravenous micronutrient therapy utilizes low level laser to further activate phytonutrients in a photodynamic reaction to boost the brightening and hydrating effects on the skin. Not only is skin condition is improved, but also overall anti-aging energization is achieved.An example of this state-of-the-art technique for skin and body antiaging is called Photodynamic RejuvenationTM, or PDR. In my experience, PDR has been very helpful in brightening up melasma, moisturizing skin, enhancing collagen growth, and achieving better energy and sleep quality for many individuals.So, to control your pigmentaton, start by being vigilant and take your time. Enjoy your antioxidants, take your natural “oral sun blocks”, and get a boost of micronutrients with intravenous infusions. Next get ready for topical skin products and treatments!In the next article, we will be discuss many exciting topical skin actives and advanced yet gentle in-office treatments with nonacidic peels, low-heat lasers, and direct micronutrient skin infusions.Stay tuned!

George Sun, MD, FAACS

The Nature of Melasma and Post-Inflammatory Hyperpigmentation

How to Fade Stubborn Pigmentation and Brighten Up Your Skin:

The State-of-The-Art Part III of III

For treatment and product options for melasma and hyperpigmentation, the previous article has discussed oral and intravenous skin actives. This last and important article will provide insight into advanced skin skin actives and office-based solutions to restore clearer skin.

The following are continuing key steps towards better and brighter looking skin:

  • Learn the best skin actives, and understand how they need to work together.When you read product ingredient list, the ingredient with the highest concentration is usually listed first, followed by the next highest concentrated ingredient. Commonly for many products, water is often listed as the first ingredient. While water is important for the skin, water is not an active for pigmentation and is obviously not very effective for melasma! As such, skin products with true actives listed first on the label will be significantly more effective.Indeed, to be truly effective, topical skin actives need to be combined, highly potent, and densely concentrated. Yet at the same time, they need need to be gentle, hypoallergenic, non-acne flaring, and cosmetically elegant and luxurious for daily use.Generally, the best brighteners complexes consist of effective five components: sun blocks, exfoliators, bleachers, hydrators, and anti-inflammatories. Too many times, products solely devoted to bleaching are not adequate in dealing with melasma.Since melasma can last years, these clinical skin products need to be suitable for lifetime use and all skin types, especially darker skin individuals who are prone to postinflammatory hyperpigmentation.As such, cosmeceutical and/or clinical grade products used by skin physicians or specialists, especially under supervision, may provide a much more effective option than simple over-the-counter cosmetics.With the above understanding, it is no wonder that the most expensive cosmetics you bought at the department store may not be most effective choice for your melasma and PIH. Live and learn!Here is list of important ingredients and their functions:
    • Sun blocks:The best sun protection combines both sun shielding and photoprotection.Sun shield actives include chemical and physical sun block agents. Generally, compared to chemical sun block ingredients such as PABA and avobenzone, physical sun block agents such as micronized titanium oxide and zinc oxide have less potential for allergic and irritation potential and are therefore preferred in my experience.When sun shields are infused with phoprotecting agents, DNA is better protected and thus the sun protection is even better. Just as in oral photoprotection, these photoprotecting agents such as antioxidants and enzymes can enhance skin immunity and reduce DNA damage. Commmonly used photoprotective actives include DNA repair enzymes, vitamin E, vitamin C, beta-carotene, selenium, genistein, polypodium leucotomos, green tea polyphenol, and grape seed extract.Remember that sun blocks should have an SPF greater than 25, be liberally applied, used before sun exposure, and reapplied every two hours when outdoors.
    • Exfoliators:Exfoliators serve as penetration enhancers for other skin actives and help to shed pigment more rapidly. To minimize irritation and to enhance brightening, exfoliators always need to be used in conjunction with sunblocks, bleachers, hydrators, and anti-inflammatories.State-of-the-art exfoliator actives include: alpha hydroxy acids such as glycolic acid, mandelic acid, lactic acid, beta hydroxyacids such as capryloyl salicylic acid, gentle vitamin B3 niacinamide, the new hydrating polyhydroxy acid and bionic acid such as lactobionic acid and gluconolactone, and retinoic acid derivatives.
    • Bleachers:These actives primarily reduce the production of melanin. As such, they tend to work slowly by themselves over the course of six to eight weeks. The effect of brightener works much better especially when combined with exfoliators.The most commonly well known bleacher is hydroquinone; however, with the increasing controversy regarding the safety and irritation profile of hydroquinone, most cosmeceuticals are relying on other brightening factors. The best non-irritating brightening actives include both water and fat soluble ones: vitamin C, licorice derived glabridin, arbutin, azelaic acid, butylresorcinol, mulberry, aloesin, and niacinamide.
    • Hydrators:Hydrating agents by themselves do no brighten the skin directly, but they do help to restore the natural skin barrier so that other skin actives, especially strong exfoliators and bleachers can work more comfortably.The best hydrating actives include emolliment, occlusive , humefactant, and natural lipid resotoring agents. These actives proivdes both water soluble and oil soluble components.Emolliment agents fill thegaps in the desquamting cells to improve smoothness. An example is cetyl stearate. Occlusive agents prevent water loss and can include dimethicone and cyclomethicone to improve the slipperiness. Humefactant draws water into the cells and often include actives such as very low molecular weight hyaluronic acid, panthenol, sodium PCA, and glycerin. Important barrier restoration components include urea, ceramides, phospholipids, cholesterol, and linoleic acid.
    • Anti-inflammatories:Mostly botanical and some synthetic, anti-inflammatories serve numerous multiple functions. These actives not only reduce inflammation, improve antioxidants, rebuild skin barrier, provide uv protection, and even serves as brighteners themselves. Mostly importantly, anti-inflammatoires reduce the potential irritation from exfoliators and bleachers and allow greater use of all actives.Helpful anti-inflammatories include: ergothioneine, ethoxybenzaldehyde, niacinamide, parthenolide-free extract, oat avenanthramides, green tea, licochalcone A, gingko biloba, and allantoin.
  • When you want in-office treatments, go slow and gradual.
    • State-of-the-art treatment often require multiple, simultaneous, syngergistic approaches. Furthermore, treatments need to be minimally inflammatory, incremental and proceed gradually from gentle to more aggressive manners.Remember your last aggressive peel or laser which left you drier and perhaps worse pigmentation than before? Melamsa and postinflammatory hyperpigmentation loves redness and heat. When excessive inflammation occurs, skin melanin gets into hyper-production mode. Over the years, I have seen numerous patients who were impatient and sought instant improvement by getting aggressive peels and laser which left excessive redness behind and often exacerbated melasma.
    • Maintenace is absolutely required.As previously stated, since melasma can last a long long time and recurrence is easy, vigilance with maintenance is essential. Too many times, I have seen patients who have improved melasma only to forget diligent sun protection and then have melasma return with a vengence.For continuing home maintenance, daily use of topical agents and oral photoprotective antixodants are easy to administer. For office based treatments, selective routine maintenance in-office intravenous micronutrient deliveries, gentle peels, controlled exfoliations, low heat lasers, and skin infusions.
  • Consider combination minimally inflammatory treatment for best results.Over the years, to my surprise, I have learned that topical skin actives, peels, and even laser work almost all equally for melasma. Furthermore, combination treatment seem to work the best.Microneedling is a techniue to passively enhance absorption of water soluble skin actives by creating numerous micropunctures via microneedles. Compared to topical skin products, microneedling can provide better absorption. An enhanced version using motorized technique is called MotoRollerSM, which comfortablly introduces tens and thousands of numerous micropunctures with ease to allow passive diffusion of skin products.Direct skin active injection is a technque whereby skin actives can be manually injected into the skin, thus allowing active and better absorption of products than microneedling. In our clinic, an upgraded version using suction assitance is called Vaccum InjectionSM. This particular solution can adjust the depth of injection and can be admnistered more quickly and comfortably than manual injection.

    Peel is an under-utilized but expedient way to shed superficial pigmentation. Within one week to ten days, peel can quickly exfoliate melanin and create a more evened skin tone. For the purpose of melasma, the key to peel is repetitive peel with increasing intensity. A very specialized peel used in our clinic is called Glow PeelSM. Unlike most traditinoal peel, this peel is hardly acidic and produces no significant burning, redness, or aggressive peeling.

    Laser is the most high tech but is also probably the most commonly misused instrument for the treatment of melasma and PIH. Pigment laser s( q-switched ruby, alexandrite, and KTP) or even resurfacing laser(fracitonating CO2 or erbium laser) can cause significant redness, inflammation, and and consequently worsen pigmentation. Whole facial Laser is best use in a low heat, gentle manner for diffuse pigmentation and skin toning, while spot laser is best reserved for localized treatments for freckles and solar lentinges. An example of combing whole face with spot lasering is the DuaLaserSM, which uses two different frequencies in a low heat manner to target both diffuse pigmentation and spotty pigmentation.

    Often, combing microneedling, peel, injection, and laser produces the best effect. A proprietary combination treatment solution is called UltraClearSM. This techique first uses DuaLaser first, then Vacuum Injection, followed by Glow Peel. In this manner, the pigmentation can be fragmented by laser, infused with brightening skin actives, and be exfoliated rapidly. The results have been promising. Skin tone can be evened out quickly , spots cleared up better, with brighter and more hydrated skin within one week!

    So there you have it. Recognize that melasma and PIH can be stubborn, and as such, treatments can take time. At the very least, use clinical products with the right synergistic skin actives. And when you want further treatments with in-office treatment, consult with experienced facial medical specialist and consider minimally inflammatory combination treatment for best results.

George Sun, MD, FAACS



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