Variation in skin tone is one of the prominent distinguishable features of human beings. Skin pigmentation in humans is variable and has evolved predominantly to regulate the penetration of light (UV levels). A direct correlation has been observed between the geographical distribution of UV radiation and skin pigmentation worldwide.
Some skin tones are more susceptible to pigmentation disorders than others, especially of Asia and India. Most of these disorders are attributed to or worsened by exposure of light (UV).In a study by Hourblin across four Indian cities revealed that more than 80% of the population present skin colour diversity on the face, irrespective of age and gender. This diversity mainly results from hyper-pigmented spots, melasma and dark circles.3 These disorders can cause distress and negatively impact the quality of life of an individual. Two important hyperpigmentary disorders in India, namely, melasma and post-inflammatory yperpigmentation (PIH) will be detailed below.
Melasma: an acquired pigmentary disorder, is identified by hyperpigmented brown to greyish brown spots on the face. It occurs mainly in women (90% cases) and 10% of males of all ethnic and racial groups. In India, 20–30% of 40–65 years old women present facial melasma.3 In India high incidence of melasma in high-altitude, sun-exposed environments is also seen due to high UV exposure.
While the exact cause of melasma is unknown, exposure to UV, increased estrogen levels (observed mainly during pregnancy or use of oral contraceptives), genetics and other factors like ovarian dysfunction, thyroid and/or liver diseases are also related to it.
Postinflammatory hyperpigmentation (PIH): PIH, an acquired disorder, occurs as a result of an inflammatory reaction, induced by skin diseases like acne vulgaris, atopic dermatitis, psoriasis, impetigo, lichen planus, irritant and allergic contact, photocontact-dermatitis and insect bites as well as a complication of laser therapy. In India, a majority of subjects with an acne history present pigmented post-inflammatory marks: More than 70% before 35 years old, both in women and men. This prevalence rapidly decreases with age to involve <10% of people older than 50 years.
Treatment: These disorders are challenging to treat. If hormonal factors are implicated, the use of the oral contraceptive pill or intrauterine devices should be discontinued. The other treatment options are Topical creams, Sun protection, Chemical peels, and Laser and light-based treatments.
Topical creams: Hydroquinone cream or lotion (2-8% either in a stand-alone formulation or mixed with other active ingredients) is the most widely used method to treat melasma. The higher the concentration of hydroquinone, the higher the incidence of irritant dermatitis (eczema). Hydroquinone should, therefore, be used for limited periods under the supervision of your dermatologist.
Vitamin A creams including tretinoin can be used as a stand-alone treatment or in combination with other agents. These can cause skin irritation so their use should be guided by a dermatologist and closely monitored. Ascorbic acid (vitamin C) is sometimes used in addition to other treatments such as hydroquinone.Azelaic acid (20%) has been reported to improve cases of superficial melasma.
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Combination topicals: Hydroquinone, retinoid and topical steroid combination creams are currently the best initial option for melasma management. Sun protection: Strict and absolute sun protection is essential with a broad-spectrum sunscreen (SPF 30+ or more). Sunscreens should be applied twice a day, 20 minutes prior to sun exposure. Broad brimmed hats should be worn when outdoors.
Chemical peels: Chemical peels have variable success in treating melasma. Multiple treatments are required to achieve modest benefits. They are best used in combination with topical creams.
Laser and light based treatments: Laser and light based treatments should only be used in severe cases for which the abovementioned therapies are ineffective. The risk of complications is high and multiple treatments are necessary to see a noticeable improvement.
It should be noted that even if treatments of Melasma are effective, recurrence of the conditions is common.
- Jablonski NG, Chaplin G. J Hum Evol. 2000;39:57–106.
- Del Bino S, Bernerd F. Br J Dermatol. 2013;169(Suppl 3):33–40
- Hourblin V, Nouveau S, Roy N, de Lacharrière O. Indian J DermatolVenereolLeprol. 2014;80:395–401
- Ortonne JP, Passeron T, Srinivas C. In: Pigmentary Disorders, Prevention, Treatment and Cosmetics Contributions. Basic Science for Modern Cosmetic Dermatology. Srinivas C, Verschoore M, editors. New Delhi: Jaypee Brothers, Medical Publishers Pvt. Limited; 2015.
- Rendon M, Berneburg M, Arellano I, Picardo M. J Am AcadDermatol. 2006;54(5 Suppl 2):S272–81
- 102. Singh G, Chatterjee M, Grewal R, Verma R. Indian J Dermatol. 2013;58:107–12.
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