Hyperpigmentation

Hyperpigmentation is a common skin condition that affects 1 in 3 people in the UK, mostly those over the age of 35.

Women are more likely to be affected by hyperpigmentation than men.

Darker skin tones are more likely to develop hyperpigmentation, although it also significantly impacts lighter skin tones.

The symptoms of hyperpigmentation are spots or patches of skin that are darker than the surrounding area.

The face is most affected by hyperpigmentation. It also impacts 20% of people on the neck and chest, 10% on the shoulders and back, 30% on the arms, while 10% develop it on the legs.

Hyperpigmentation consists of 3 subtypes:

Subtype	Description	Common Areas
Solar Lentigines (age, liver, or sun spots)	Clustered, flat, brown, or black spots	Face, neck, arms, and legs
Melasma (chloasma or the mask of pregnancy)	Symmetrical, flat, brown, or grey-brown patches	Face, neck, and torso
Post-Inflammatory Hyperpigmentation (PIH)	Raised, red, brown, or black spots, or patches	Injured areas of the body

Around 50% of people with hyperpigmentation have solar lentigines, 25% present with melasma, and 50% suffer from post-inflammatory hyperpigmentation.

The term “hyper” refers to more, whereas “pigment” denotes colour.

Hyperpigmentation is caused by an overproduction of melanin, the pigment that is responsible for the colour of the hair, eyes, and skin.

The causes of hyperpigmentation include:

Cause	Description
Photoageing	Photoageing, caused by prolonged and unprotected exposure to ultraviolet (UV) radiation, is the leading causes of solar lentigines. While primarily resulting from sun exposure, artificial UV sources like tanning beds can contribute. Over time, cumulative UV radiation stimulates melanin production in areas most frequently exposed to the sun, such as the face, arms, and hands, leading to the formation of sun spots
Injury	Injury to the skin, whether from acne, eczema, burns, or wounds, causes inflammation. As the skin heals, it can produce excess melanin, which gets deposited in the injured area, resulting in dark spots or patches that can appear red, brown, grey, or black, depending on the person’s skin tone. Further irritation, like rubbing or scratching the area, can worsen this post-inflammatory hyperpigmentation. Additionally, fungal, viral, or bacterial infections may contribute to hyperpigmentation during the healing process

Several other factors can influence the development of the condition. This includes:

Contributor	Description
Genetics	Genetics play a big role in hyperpigmentation, with some people naturally more predisposed. For example, freckles are usually inherited and more common in people with lighter skin. Melasma often runs in families, while certain spots can be linked to rare genetic conditions. Some birthmarks, are more common in specific ethnic groups. People with darker skin are more likely to get dark spots after skin irritation because their skin naturally produces more pigment.
Hormones	Hormones can make the skin darker by increasing pigment. For example, oestrogen and progesterone, particularly during pregnancy or from birth control can cause melasma. Stress can also raise pigment levels. Conditions like Addison’s disease can cause dark spots due to hormone changes. Thyroid issues or insulin resistance can lead to darker skin patches, like those seen in acanthosis nigricans.
Medications	Medications can influence melanin production and result in pigment deposition in the skin, leading to changes in pigmentation. For example, some antibiotics can cause dark spots, especially on skin exposed to sunlight. Hormonal treatments, like birth control pills or hormone replacement therapy, can lead to conditions like melasma. Other medicines for inflammation, heart problems, or nerve conditions can also cause pigmentation changes.

Hyperpigmentation is common on darker skin tones, which already have a higher melanin content.

A doctor, pharmacist, or nurse can diagnose hyperpigmentation by performing a physical examination to assess the extent and severity of the affected areas, and reviewing the patient’s medical history.

Its clinical manifestations can vary widely, and diagnosis relies on recognising characteristic patterns and understanding potential contributing factors.

The severity of hyperpigmentation can range from mild, localized discoloration to extensive, darker patches.

Severity	Distribution	Characteristics
Mild	1-19%	Localised areas on sun-exposed areas
Moderate	20-49%	Noticeable patches of darker skin, more frequent, and larger spots
Severe	>50%	Deep, dark patches, extensive uneven skin tone

When diagnosing hyperpigmentation, it's important to consider other conditions that may present with similar symptoms:

Condition	Description
Acanthosis Nigricans	Acanthosis Nigricans manifests as dark, thick, velvety patches in skin folds like the back of the neck, armpits, and groins, and is often associated with insulin resistance, obesity, or hormonal conditions like PCOS
Addison's Disease	Addison's Disease leads to generalised skin darkening, particularly on pressure points and skin folds, due to adrenal dysfunction, and is usually accompanied by fatigue and low blood pressure
Erythema Dyschromicum Perstans	Erythema Dyschromicum Perstans is characterised by greyish or ashy patches on the face and neck, frequently linked to genetic and environmental factors, and is more common in darker skin tones
Hemochromatosis	Hemochromatosis results in bronzed or darker skin due to excess iron deposits, typically accompanied by liver disease and joint pain
Lichen Planus Pigmentosus	Lichen Planus Pigmentosus causes dark patches on the face and neck, is often linked to autoimmune conditions or sun exposure, and is more common in darker skin tones
Lupus Erythematosus	Lupus Erythematosus often leads to dark spots following a red rash, especially on sun-exposed areas like the nose and cheeks, and is associated with joint pain and fatigue
Peutz-Jeghers Syndrome	Peutz-Jeghers Syndrome presents with dark spots around the mouth and fingers, which are frequently associated with gastrointestinal polyps and an increased cancer risk
Tinea Versicolor	Tinea Versicolor appears as fungal infection-induced patches of lighter or darker skin, commonly on the chest or back, affecting melanin production

A skin biopsy may be necessary to rule out another condition. This information is for informational purposes only. For specific concerns, please consult a healthcare professional.

If the skin has not responded to over-the-counter products or is at risk of complications, Monderma may recommend a treatment plan.

This may contain up to 3 of the following ingredients:

Topical	Properties
Retinoids	Regulate the growth of cells on the skin to improve its texture and tone
Lightening Agents	Reduce the production of melanin to lighten patches of darker skin
Anti-Inflammatories	Inhibit the production of inflammatory-causing molecules to reduce redness and irritation
Corticosteroids	Inhibit the production of melanin to reduce swelling and inflammation
Antioxidants	Eliminate free radicals by repairing and strengthening the barrier function of the skin, improving hydration

Treating ageing skin topically must include adopting daily use of broad-spectrum sunscreen of SPF30 or higher.

It can take 8 weeks or longer to see lasting results, so it is important to be patient and follow your treatment plan.

Information on these ingredients, their directions for use, safety information, storage, potential side effects, and reporting can be found in the information leaflet

People with hyperpigmentation that changes colour or does not improve with treatment should consult a doctor, chemist, or nurse. They will conduct a more thorough examination of the condition and, if necessary, perform a skin biopsy.

The complications and challenges associated with hyperpigmentation include:

Complication	Description
Recurrence	In cases of post-inflammatory hyperpigmentation (PIH), ongoing skin inflammation can result in pigmentation to persist and worsen over time. Even after successful treatment, hyperpigmentation may reappear if the underlying cause is not addressed and proper sun protection practices are not followed
Scarring	Scarring can occur, primarily as a result of post-inflammatory hyperpigmentation. When the skin is repeatedly injured, irritated, or exposed to sunlight without protection, the risk of deeper and longer-lasting pigmentation rises, resulting in uneven skin texture and tone. In some cases, this could be more difficult to treat than the original hyperpigmentation. Acne-related hyperpigmentation may indicate deeper scarring, requiring more intensive treatment
Texture Changes	Texture changes in hyperpigmentation occur when the skin becomes uneven, rough, or raised as a result of inflammation or injury. These changes often accompany dark spots, particularly when the healing process is hampered by factors like picking at wounds or sun exposure. The combination of discolouration and irregular texture can make hyperpigmentation more visible
Treatment-Related	Treatment like microdermabrasion, chemical peels, and laser therapy carry risks such as scarring, infection, or worsened pigmentation if not performed correctly or without proper aftercare. Furthermore, if applied inconsistently or without professional guidance, both topical treatments and procedures can result in uneven skin tone, and allergic reactions to topical ingredients can aggravate the skin, exacerbating hyperpigmentation
Underlying Health Conditions	Underlying health conditions can be associated with a variety of pigmentation changes, most notably disruptions in melanin production. Inflammatory conditions such as acne, eczema, and psoriasis can cause post-inflammatory hyperpigmentation. Hormonal imbalances, such as those seen during pregnancy or with the use of birth control, can result in melasma. Addison's disease, a disorder of the adrenal glands, causes widespread skin darkening due to increased adrenocorticotropic hormone (ACTH). Insulin resistance in polycystic ovary syndrome (PCOS) can cause dark patches, particularly on the neck and armpits. Furthermore, certain metabolic or genetic conditions, such as hemochromatosis or Peutz-Jeghers syndrome, can cause an increase in pigmentation
Psychosocial	Psychosocial impacts of hyperpigmented areas, particularly those that are prominent or widespread, can lead to feelings of self-consciousness and low self-esteem. People may experience anxiety, depression, or emotional distress as a result of how their skin appears. Some people may avoid social situations, outdoor activities, or wearing clothing that reveals the affected areas, which can reduce quality of life and self-expression

Addressing hyperpigmentation early and adhering to sun protection measures are key steps in minimising the risk of complications and improving skin appearance and overall wellbeing.