Hyperpigmentation: how to get rid of it?

You come back from your holiday tanned and happy. September goes by, the tan fades — and then something is left on your cheeks that was not there before. A brown patch. Then another one.

Or the other version: you have changed nothing in your skincare, and a diffuse brown smudge appears on your forehead and above your upper lip.

These are two completely different stories. And — most importantly — they are treated differently.

Where brown patches come from

Skin tone is governed by melanocytes, the cells that produce melanin. Ultraviolet radiation disturbs their work. Some melanocytes start producing too much melanin, and it builds up in one spot — and that is how a dark patch in one of the shades of brown is formed.

That is why pigmentation appears where the skin sees the sun most often: on the face, the décolletage and the hands. On the face most often on the forehead, cheeks, chin and around the mouth.

The sun, however, is not the only culprit. The formation of patches can also be linked to:

• hormonal changes — during pregnancy, for example,
• autoimmune diseases, particularly of the thyroid,
• the use of hormonal preparations,
• photosensitising medicines and supplements — here pay particular attention to preparations containing St John's wort.

Not all pigmentation is the same

This is the most important part of this text. Because everything else — the method, the treatment time and what you can realistically expect — depends on the type of pigmentation you are dealing with.

• Freckles — A genetic predisposition plus sun exposure. The first ones appear as early as childhood · Small, numerous, darker in summer.
• Melasma (chloasma) — Hormones, sun and genes together. Pregnancy, hormonal changes, oral contraception · Diffuse brown patches on the forehead, cheeks and around the mouth. Appears suddenly and darkens in the sun.
• Post-inflammatory hyperpigmentation — Damage to the skin: acne, mechanical injury · Exactly where the inflammation or injury was.
• Age spots — Years of sun overexposure, showing up at an older age · Patches larger than freckles.
• Toxic and chemical pigmentation — The use of certain cosmetics · Varies, depending on the cause.

Melasma is a separate matter — and it is worth knowing that in advance

Freckles, sun spots and post-acne pigmentation usually respond well to treatment with light. Melasma is sometimes qualified differently.

In our clinics we direct melasma primarily to depigmentation therapy. If a laser comes into play, we consider the 1927 nm thulium laser.

And a sentence there is no getting around: the choice of method is made by the doctor during the consultation. Melasma is a capricious condition, and what works brilliantly on a sun spot is not always the right choice for it.

If you searched the internet for "chloasma" or "melasma" and came across a list of universal treatments "for pigmentation" — treat it with caution. This type of change requires individual qualification. We have in fact devoted a separate article to melasma — there you will find a full explanation of why it is treated differently.

Medical peels: a spectacular result, but with one "but"

For severe pigmentation, depigmentation therapy gives good results.

There is, however, one serious side effect you need to know about before the treatment, not after. For at least a week the skin of the face is irritated and flaking. For many people that means having to take time off. Not everyone can afford it — and that is a fair reason to talk about an alternative.

The second thing: a medical peel is only the beginning. The course of treatment is continued at home, with daily skincare, for many months. Without that the result will not last as it should.

When the pigmentation is milder and the patches less visible, you can reach for gentler peels — including acid-based ones. They work far more gently, but you pay for that gentleness with the number of repetitions.

Light and lasers — why autumn is their season

Lightening the skin with light, including laser light, at the same time stimulates collagen renewal. It is a method that is minimally invasive, with no long convalescence and with a quickly visible result. The treatment causes little pain and along the way often firms and rejuvenates the skin.

How does it work? Light destroys cells with an excess of melanin. After the treatment the patches first darken and then flake off. Usually the treatment has to be repeated several times to lighten the pigmentation noticeably. And one thing worth knowing from the start: patches — and melasma especially — can come back, which is why after the series we plan a maintenance routine, that is, skincare and consistent protection from the sun.

What we do in our clinics:

• Depigmentation therapy — A medical peel plus many months of home care · Severe pigmentation. First choice for melasma (chloasma).
• Laser treatment of pigmentation and redness — Light destroys cells with an excess of melanin; it also reduces redness and closes superficial vessels · Sun spots, freckles, pigmentation coexisting with redness.
• 1927 nm thulium laser — A non-ablative fractional treatment that evens out the skin tone · Considered for melasma, after medical qualification.
• Laser wrinkle reduction (Nd:YAG, Q-Switch mode) — Non-ablative action with no convalescence · Pigmentation coexisting with fine wrinkles.
• Skin renewal programmes — Courses of medical peels selected after a consultation · Milder pigmentation, working in stages.
• 3-in-1 skin revitalisation — Exfoliation, oxygenation and nourishment of the skin in a single treatment; the whole thing in up to 30 minutes · When you do not want intensive flaking — it brightens and adds glow and smoothness.

That last treatment is a good choice before a "big night out": non-invasive, pleasant, with no marks on the face the next day.

Honestly about the risk: in some people, especially those with a darker skin tone, the laser can make the discoloration worse instead of removing it — this is what is known as post-inflammatory hyperpigmentation. That is why before a series we prepare the skin with skincare, start with lower settings and, when in doubt, do a test on a small patch. And that is why with melasma the laser is not the first choice, only an option for resistant cases.

What not to do at home

Lemon juice. Baking soda. Home "bleaching" of patches.

Patients come to me after such experiments regularly and the result is usually the same: the pigmentation stays, and irritated skin is added to it. With melasma, irritation can actually make things worse.

Home care is indispensable in the treatment of pigmentation — but the kind chosen by a doctor. A common choice is azelaic acid, often prescribed by dermatologists, which works not only on pigmentation but also has an anti-acne effect. As support, people reach for creams and serums with vitamin C.

Without sunscreen none of this makes sense

I always start the conversation with a patient who has pigmentation in the same way. Removing the patches that are already there is not enough. If you do not protect your skin, new ones will form — and we will be back where we started.

Four rules that really make a difference:

1. A broad-spectrum sunscreen, SPF 50+ — and with pigmentation, preferably a tinted one, with iron oxides. The SPF number alone tells you only about protection from UVB, while the patches are also deepened by visible light; the only thing that protects against that is the pigment in the cream, that is, a lightly covering cream.
2. Apply it to everything that is exposed. Not just the face and shoulders. In summer the neck, hands and feet are exposed almost non-stop, and they are the ones most often skipped.
3. Reapply during the day. A product applied in the morning does not protect you until the evening — especially after swimming or drying your skin with a towel. Reapplication is usually recommended after two hours.
4. Stay in the shade between 11.00 and 15.00 and cover your skin with light, airy clothing.

I do it myself. Whatever the weather and whether I am on the beach, in the car, in the city or in the office.

Aesthetic medicine doctors are not fans of the sun or of tanning — even though both of them mean we never lack patients.

In the fight against pigmentation what counts is a comprehensive approach: prevention, a properly chosen treatment and skincare kept up after the course has finished. A well-chosen sunscreen — broad spectrum, high SPF, preferably tinted — is not an add-on to the treatment. It is its precondition.

For persistent pigmentation and melasma our clinics use depigmentation therapy, and individual sun spots we reduce with laser treatments. The choice of method depends on the type of pigmentation — we establish that at the consultation.

This article was prepared by Joanna Kuschill-Dziurda, MD, PhD.