Targeting skin discolouration

Discover expert treatments for pigmentation, acne, and tattoo removal, including advanced therapies like chemical peels, lasers, MNRF, and azelaic acid.

Pigmentation disorders are a universal concern, affecting individuals across all racial and ethnic backgrounds. With over 24.7 million dermatologist visits specifically for the management of skin discoloration, pigmentation issues are among the top 11 skin conditions seen by dermatologists. In the Indian context, three prominent types stand out: Post-Inflammatory Hyperpigmentation (PIH), melasma, and actinic pigmentation.

Technology advancement especially in social media networks alongside the culture of taking selfies has shifted patient attitude and expectation. Patients with pigmentation described feelings of shame or exposure, especially when in public places or gatherings. This has ensured that there are many patients with pigmentation seeking to get treatment for the blemishes on their skin.

Managing acne PIH

The causes of pigmentation are vast and varied, with many patients unaware of the factors contributing to their condition. For example, Dr Rupali Pavaskar, Dermatologist and Trichologist, Dr Rupali Pavaskar’s Clinic &Transforme Dermo-Cosmetic Center, shares a case of a young female patient presented with persistent acne and subsequent PIH. Despite controlling her hormonal acne, the PIH persisted, particularly around the perioral area – an unusual location for acne-related hyperpigmentation. “She did not give any specific history so I just did what needed to be done to control it. But when she came for the third time with the same type of macular scar, I insisted on her telling me what she had done. I would not have thought in a thousand years that this could lead to PIH.” The patient used to have someone come to her home for a facial treatment regularly because it gave her a noticeable glow. However, the treatment involved removing the epidermis, which led to post-inflammatory hyperpigmentation (PIH).

Dr Anju Methil, Celebrity Dermatologist and Cosmetologist, Skin and Shape Clinic, suggests, “I will suggest a benzoyl peroxide face wash or a salicylic acid face wash. This will help her in taking care of the PIH and the active acne.”

Another recommended treatment for pigmentation and acne is azelaic acid. Dr Sweta Nakhawa, Dermatologist, HL Aesthetic Skin Care Clinic, discusses the benefits of foam-based azelaic acid, which is particularly effective for acne due to its sebostatic properties.”I would rather use an azelaic acid using a foam-based preparation that would take care of the pigmentation and also the acne as well as it would be a sebostatic.”

However, some patients may experience irritation with azelaic acid, Dr Apratim Goel, CEO and Medical Director, Cutis Skin Solution, suggests counteracting this with proper hydration, “My goal is hydration. Hydration is the key for any of these patients who have come up with acne because of the products we use.

Dr Anju adds, ”I often alternate between retinoids and hyaluronic acid at night to ensure that we are treating the acne without causing excessive dryness or irritation.”

Chemical peels are often a first-line treatment for patients with pigmentation concerns. Dr Rupali expresses her preference for peels, especially for patients who can afford the downtime associated with stronger formulations. In cases where PIH is prevalent, she emphasised the use of stronger peels, such as TCA (trichloroacetic acid) or glycolic acid.

Treating body acne and pigmentation

Body acne and pigmentation present unique challenges, as the skin is thicker and less visible than facial skin.

Lasers have become a popular choice for treating PIH, particularly when peels alone are insufficient. Dr Rupali notes that Q-switched lasers, particularly those with 1064 nm wavelength, are often used for PIH. This wavelength is effective in targeting pigmentation without causing significant damage to the surrounding skin. She highlights that choosing the right laser setting, including spot size and fluence, is crucial for maximising results while minimising side effects. For stubborn pigmentation, combining treatments such as skin polishing, peels, and lasers can yield better results. «In some cases, we follow up skin polishing with Q-switched lasers and then apply peels.”

Dr Sweta, who also uses picosecond lasers, explains that these devices offer faster results with fewer side effects. «The picosecond laser, with a 10 mm spot size and low fluence, works wonders on pigmentation,» she says. ”While more expensive, it gives superior results compared to nanosecond lasers.”

Dr Rupali emphasises the need for priming the skin, particularly in cases where tanning or existing pigmentation is present. ”I always prime patients with topicals like azelaic acid or glycolic acid to prepare their skin before more aggressive treatments,” she says.

Additionally, Dr Apratim discusses the role of low-dose isotretinoin as an adjunct therapy during laser or peel treatments. Isotretinoin, originally designed to treat acne, can shrink sebaceous glands and reduce activity during the process. “Even in the absence of acne, I maintain my patients on a low dose of isotretinoin to suppress any sebaceous gland activity,” she adds.

Microneedling coupled with radio frequency (MNRF) has proved to be a preferred treatment because it is effective for patients with both active acne and scars. This procedure involves mechanical scraping, radio frequencies, and fine needles to enhance the skin texture, treat acne, and wound scars. Dr Rupali mentions that she uses MNRF in patients who have both pigmentation and acne scar because it is an added option for patients who are not candidates for peels or laser treatments.

Dr Anju supports the use of MNRF for patients with active acne, highlighting that the procedure can help treat both PIH and scarring simultaneously. “If there is active acne along with scarring, MNRF works as a good adjunct treatment.”

Dr Sweta further elaborates that some MNRF devices have antibacterial effects, which can particularly benefit patients with acne. “Certain devices not only help with pigmentation but also target the underlying bacteria responsible for acne, providing a comprehensive solution,” she explains.

Innovations in pigmentation treatments

Lichen Planus Pigmentosus (LPP) is a disease of chronic hyperpigmentation of skin regions affected by sunlight, and frequently it is difficult to treat.

Dr Sweta describes a patient who had a history of using topical steroids, but who only received moderate relief from the treatment. She then settled for a low-dose steroid and Biorepeel,

a skin-peeling product that facilitates the regeneration of skin. The patient had a significant improvement and observed that pigmentation was almost gone in about six months without having to use Q-switched laser treatments.

Dr Anju introduces another innovation in the treatment of LPP: Polynucleotides and polydeoxynucleotides. In her opinion, even though Polynucleotides may be primarily used to solve problems related to skin dehydrating and elastic fading, this medication might help to treat pigmentary diseases, including LPP. “I have tried Polynucleotides for several of my patients, and while it is not a treatment specifically for pigmentation, it hydrates the skin and has positive effects on pigmentation.”

For treating dermal melanosis, Dr Apratim emphasises the importance of using Q-switched lasers, particularly for conditions that involve deeper pigmentation. However, she warns about the possibility of post-inflammatory hyperpigmentation (PIH) following laser treatment, which often requires additional topical products. “Even though topicals do not directly impact deeper pigmentary issues, they help in preventing the epidermal injury that can result in PIH,” Dr Apratim notes. “We call it the freckle burst in our clinic. Post laser treatment, we use topical depigmenting agents from day three to reduce the chances of PIH.” She also enumerates the risks associated with non-branded creams saying that some creams promoted on social media are dangerous. “Some of these creams have ingredients such as steroids, arsenic and lead,” she cautions. She also points out the need for patient education and to increase their awareness to protect skin and avoid adverse reactions.

Freckles, lentigines, and tattoo removal

Freckles and lentigines are more or less aesthetic issues, but for the people who do desire treatment, Q-switched lasers are still the best option. Dr Apratim describes her approach: “For freckles, I recommend using 532 nm at small spot size. It might seem like you are not accomplishing much in the beginning but the effect is stunning.”

Dr Ajay Hariani, Senior Plastic, Cosmetic &Laser Surgeon, Hariani Plastic, Laser &Cosmetic Surgery Centre, Mumbai, shares insights into managing tattoos and their removal. He highlights the challenges of treating coloured tattoos and stresses the importance of patience and proper timing in the treatment process. “For professional tattoos, you may need multiple sessions and a combination of techniques, including CO2 lasers and cryotherapy,”

Dr Rupali points out that pre-existing damage from tattoos or other causes can complicate treatment. “When dealing with tattoos, especially in areas like the face, consider the potential impact on hair follicles and surrounding tissues,” she cautions.

Dr Ajay highlights the type of tattoo also affects the removal process. «Professional tattoos are particularly challenging due to the quality and depth of the ink. In contrast, amateur tattoos, such as those done with M.I.T.O. ink, are comparatively easier to remove.”

Dr Apratim elaborates on the importance of using non-invasive methods to reduce inflammation before engaging in more aggressive treatments. “In cases of severe inflammation, even shampoos can irritate the skin, so starting with a foam-based cleanser to reduce inflammation is essential,” she recommends.

Dr Sweta and Dr Anju share their techniques for enhancing tattoo removal. Dr Sweta incorporates cryotherapy, performed at three-week intervals, to aid in the removal process. This approach helps manage crusting and facilitates more effective Q-switch laser treatments. Meanwhile, Dr Anju uses a combination of different spot sizes in Q-switch lasers to handle stubborn cases, emphasising the importance of customising treatment parameters based on the tattoo’s characteristics.

Tackling pigmentation challenges

Pigmentation and acne continue to be significant dermatological concerns affecting a diverse population. Treatments such as chemical peels, Q-switched lasers, azelaic acid, and MNRF have proven effective in managing conditions like PIH, melasma, and body acne.

Experts stress the importance of individualised approaches, combining topical treatments with advanced therapies.

Hydration, priming the skin, and the use of isotretinoin is crucial in enhancing results while minimising side effects. Innovations like polynucleotides and bio-stimulating peels are emerging as promising solutions. Education on safe product use remains essential to prevent complications from harmful substances in non-regulated treatments.

The above article has been extracted with excerpts from the panel discussion on ‘Clinical strategies in pigmentation management based on real cases’ that was held at the Aesthetic Medicine India Conference 2024.