Treatment options and combination therapy in everyday practice

Hyperpigmentation plays a major role in the daily routine of dermatologists. Solar radiation, stress and various noxae are regarded as triggers for skin aging and development of hyperpigmentation. PD Dr. Maurizio Podda, Darmstadt, explained in a symposium supported by Vichy at this year’s DERM in Frankenthal which different forms of hyperpigmentation can occur and which role the use of dermatocosmetics plays in the treatment.

“In hyperpigmentation we distinguish between two main groups,” Podda explained at the beginning of his presentation. The first group is so-called postinflammatory hyperpigmentation, which occurs as a result of inflammation or injury to the skin. These include acne, eczema or sunburn, for example. The second group is melasma-type hyperpigmentation, which is triggered by hormonal changes or genetic factors and usually occurs on the face. “So hyperpigmentation can have a wide variety of triggers,” Podda said. Due to the different possible causes, practitioners and patients are faced with major challenges in therapy, which require a thorough analysis to clarify the cause of the hyperpigmentation.

Postinflammatory hyperpigmentation – endogenous and exogenous triggers

“In postinflammatory hyperpigmentation (PIH), we are talking about epidermal or dermal hypermelanosis that results from endogenous or exogenous triggers after inflammation,” Podda explained. PIH are caused by two different mechanisms in the skin, which can also occur as a combination in some patients. Acne, lichen ruber, atopic dermatitis and lupus erythematosus are common endogenous triggers. A purely epidermal inflammatory response can activate the arachidonic acid cascade as well as the release of prostaglandins, leukotrienes, and chemokines, which alter melanocyte activity in addition to immune cell activity. This is followed by an increase in the synthesis of melanin and physiological pigment transfer to surrounding keratinocytes is increased. In this case, the increased stimulation and transfer of melanin cells leads to epidermal hypermelanosis. In other cases, disruption of the basal cell layer activates melanocytes, which release melanin pigment in the papillary dermis [1]. Exposomal factors such as environmental pollution, stress, UV light, and diet can also alter the skin barrier and lead to inflammation, promoting the development of hyperpigmentation and skin aging [2]. For PIH to be properly treated therapeutically, the trigger must be specifically defined [3] [4].

Melasma – characteristics and causes

Melasma represents another common form of hyperpigmentation that occurs in sun as well as exposomexposed areas. Melasma usually presents as symmetrically distributed patches that may be confluent, reticulated, or punctate. “The pathophysiology of melasma is multifactorial and unfortunately not fully characterized,” Podda explained. “A direct link to female hormonal activity appears to be present, as melasma is more common in women than in men during postadolescence. Half of melasma cases first appear during pregnancy. In addition, the use of oral contraceptives, photosensitizing drugs, and topicals or cosmetics can trigger or exacerbate melasma [3]. Similarly, the exposome plays a crucial role in the genesis of melasma. Since UV light induces the production of reactive oxygen species in the skin, thereby promoting melanogenesis, sun exposure in particular is a promoting factor in the development of melasma and is considered the most important cause of hyperpigmentation [1].

Dermatological treatment of hyperpigmentation

“For melasma, I recommend a combination of topical care and aesthetic treatments,” the expert emphasized. By using an IPL flash lamp, pigmentation and age spots can be treated and reduced superficially without injuring the skin. Further therapy possibilities, which can be combined in each case also, are for example fruit acid treatments or Microneedling.

As a basis for all treatment methods and for the prevention of further hyperpigmentation, the daily and sufficient use of a suitable sunscreen with comprehensive UVA and UVB protection is necessary above all. In one study, consistent UV protection showed the same effect as laser treatment [6]. “It is important to educate patients that hyperpigmentation can always recur. Therefore, a caring and preventive treatment of the skin by dermatocosmetics with suitable ingredients should be consistent and permanent” Podda underlined.

A current study has now shown the positive effect of niacinamide in the treatment of melasma. For this purpose, 27 patients with melasma were treated for eight weeks with 4% niacinamide cream on one side of the face and 4% hydroquinone cream on the other side. The results showed a comparable improvement in pigmentation under both treatment methods. However, side effects were noticeably higher with hydroquinone [7].

Dermatocosmetics against hyperpigmentation

For the treatment and prevention of hyperpigmentation, the use of dermatocosmetics with suitable ingredients, such as niacinamide, is of great importance. Vichy LIFTACTIV B3 pigment spot serum, for example, is suitable for this purpose. Its highly concentrated active ingredient complex with niacinamide and tranexamic acid helps to counteract hyperpigmentation. Niacinamide inhibits melanin overproduction in the skin. It calms the skin and helps reduce redness and skin discoloration [7]. Tranexamic acid controls the process of pigmentation by regulating the release of inflammatory mediators such as prostaglandins, which play an important role in melanogenesis [8]. Vichy LIFTACTIV B3 pigment spot serum combines both ingredients and is therefore suitable for use against hyperpigmentation as well as dark spots and can thus contribute to a more even skin tone. The peeling complex with glycolic acid, hepes and urea ensures faster renewal of the epidermis and can thus contribute to a radiant and even skin tone. The new Vichy LIFTACTIV B3 Anti-Pigment Spots SPF 50 cream complements the skin care routine. Niacinamide, which is also included, and a sun protection factor of 50 protect the skin from UV rays and, in combination with the ingredients, can prevent new pigment spots and soften existing ones.

Source: Symposium “Focus on hyperpigmentation: Worth knowing for everyday practice with exciting cases from practice for your successful practice”, DERM Frankenthal.

Literature:
1. Ortonne JP, Bissett DL. J Investig Dermatol Symp Proc 2008; 13(1): 10-14.
2. Krutmann J. J Dermatol Sci. 2017; 85(3): 152-161.
3. Sharad J. J Cosmet Dermatol. 2011; 10(4): 317-323.
4. Bailey AJM et al. J Am Acad Dermatol. 2022; 86(4): 797-810.
5. Passeron T, Picardo M. Pigment Cell Melanoma Res. 2018 31:461-465.
6. Halachmi S, et al. Lasers Med Sci. 2014; 29(2): 589-598.
7. Navarrete-Solís J et al. Dermatol Res Pract. 2011; 2011:379173.
8. Mechanism of Action of Topical Tranexamic Acid, 2022, School of Bioscience and Biotechnology, Tokyo University of Technology, 1404-1 Katakura, Hachioji 192-0982, Tokyo, Japan.