Treating Pigmentation in the Autumn

We spoke to two cosmetic doctors about their recommendations for treating two stubborn types of pigmentation, and why the colder months are the best time to do it.

 

Any aesthetic practitioner worth their salt knows that pigmentation issues shouldn’t be addressed during the spring and summer months. However, patients are often unaware of the reasons why pigmentation treatment programmes should be started in autumn or early winter and can actually be surprised to learn that it can take more than a serum and a few in-clinic peels to clear it. Treating pigmentation in the winter is beneficial and preferable for a few reasons. As sun exposure is a major factor that exacerbates many types of pigmentation, the shorter days, lower sun positioning and cooler temperatures of autumn result in decreased sun exposure, which in turn prevents further darkening of the affected pigmented areas.

 

Less intense UV radiation is also key, as when the sun’s ultraviolet radiation is weaker during the winter months, patients are less likely to trigger additional pigment production due to UV exposure when they are outside, and we know that UV radiation is a major contributor to skin damage and pigmentation problems. In addition, many pigmentation treatments involve the use of products or procedures that can make skin more sensitive to sunlight and therefore uncomfortable (in varying degrees depending on the depth of treatment). 

 

Treating pigmentation during the winter can make the process far more comfortable for patients, as they’re less likely to feel the heat and discomfort associated with certain de-pigmenting treatments compared to during the warmer, more humid summer months. Less sun exposure and cooler temperatures also mean that the skin has a better chance of healthy and accelerated healing from more aggressive treatments, as patients tend to have quieter social lives and are less inclined to be out about and about when they should be engaging in all-important downtime. By treating pigmentation in the second half of the year, the skin has a head start in terms of improvement so that by the time spring rolls around, patients’ skin health will hopefully be in a better condition and less prone to flare-ups or developing more pigmentation when exposed to higher levels of UV radiation once again. 

 

As we prepare to move into autumn, we asked aesthetic doctors Dr Catharine Denning and Dr Manav Bawa for their suggested treatment plans for two stubborn types of pigmentation - acne scarring and melasma. 

 

“There are three visible skin changes that can occur following acne. One is scar tissue formation and the other two are skin colour changes that can occur with or without the presence of scar tissue,” explains Dr Catharine Denning, who practises from The Light Centre in London. “The first skin colour change is post-inflammatory erythema (PIE); in light skin, this presents as pink or red where trauma has occurred, while the second is post-inflammatory hyperpigmentation (PIH), which tends to be brown in colour and more likely to occur in those with darker skin types. PIH is similar to other forms of hyperpigmentation in that it is caused by the stimulation of melanocytes to make the skin darker, resulting in more highly melanated areas of the skin localised to where the inflammatory changes have occurred. The difference between PIH and other forms of pigmentation is that in acne, these melanocytes are stimulated by cutaneous inflammatory mediators following trauma or infection rather than other factors such as age or changes in hormones,” says Dr Denning. 

 

“Depending on the severity of the residual skin marks, treatment may differ, but all would require good at-home skincare as a bare minimum, along with in-clinic treatments to resurface the epidermis,” says Dr Denning. And sunscreen is an absolute must.

 

Scar tissue — “This can be broken down and remodelled using in-clinic treatments such as microneedling or ablative lasers like CO2, while subcision can help reduce any deeper tethering of the skin, which gives an uneven appearance.”

PIE — “Aim to target the inflammation and broken vessels that cause the pink colour. In-clinic, this could be via microneedling or lasers such as IPL or pulsed-dye laser. At home, patients should use targeted, prescribed products containing ingredients like niacinamide, azelaic acid, vitamin C and tretinoin.”

 

PIH — “Aim to both reduce melanocyte activity as well as remove existing pigment in the skin. In-clinic options include chemical peels (to help take off the top layers of pigmentation and reduce its appearance) and Nd-YAG laser. Blue-light therapy can also break down and reduce pigment patches. In terms of home care, patients should be advised to downregulate the melanocyte activity with depigmenting topicals such as hydroquinone, arbutin, kojic acid or tretinoin, as well as resurfacing treatments such as exfoliating acids like glycolic,” says Dr Denning. 

 

Acne scarring becomes more difficult to treat if the patient is also dealing with active acne. In this instance, Dr Denning advises focusing on the treatments and ingredients that tackle both scarring and active breakouts. “There is a difference in approach between treating active acne and resulting scarring, but there is some overlap in ingredients — especially retinoids and exfoliating acids — and in-clinic treatments such as peels and LED therapy can be effective at treating both the acne itself and its resulting post-acne skin lesions,” she says. “I would, however, avoid the use of microneedling or subcision in active acne, as this can spread infection.”

 

Though the scarring following acne often does not completely clear up and the associated pigmentation is often very stubborn, Dr Denning says that on a treatment plan like this, it should minimise significantly, depending on severity. “Skincare alone can help minimise PIE and PIH over the course of a few months (on average, six), whereas in-clinic laser and peels often require a course of treatment but can be effective as soon as the subsequent few days after the initial treatment,” she says. In terms of the specific products that she finds success with, Dr Denning prefers stronger, prescribed topicals for acne scarring. “I like the acids and retinoids in the ZO and Obagi Nu-Derm ranges, prescribed azelaic acid, tretinoin and hydroquinone,” she says.

 

 

“Melasma is an acquired condition of the skin, which usually presents as patchy pigmentation in a symmetrical pattern across both sides of the face. It is common on the forehead, front of cheeks, upper lip and chin,” explains Dr Manav Bawa, medical director of Time Clinic in Chigwell, Essex. “Other types of pigmentation can appear anywhere without a typical pattern, and are usually caused by UV radiation and trauma, as well as the natural ageing process.” Instead, melasma is linked to hormones, and is much more common in women between the ages of 20 and 40, with a higher incidence in pregnancy,” says Dr Bawa. 

 

“There are links to hormonal changes, however it can still occur in men, albeit more rarely. It is more common in skin types who tan easily, as well as patients with brown skin (Fitzpatrick 3 and 4). Sometimes we don’t know the cause, and other times it could be a genetic component.” Despite this, melasma can still be triggered by sun exposure, so autumn and winter are the best times of the year to embark on treatment for the most success. “Patients can start treatment any time of year, but during the summer months it will be harder to reduce the activity of the melanocytes due to the stimulation from the sun,” says Dr Bawa. 

 

“I would always start with a thorough consultation to find out how the patient rates the severity of the melasma, and how it impacts their lives. What would be important is finding out what they have used in the past, as well as if they can tolerate any downtime. Their social history is of importance, such as their job (client-facing, as an example) because these factors may change the treatment plan,” advises Dr Bawa. “I would start with basic recommendations such as camouflage make-up and blood tests to check whether there are any other causes.” 

 

“Home care should include products to be used on a day-to-day basis, such as a hydroquinone-based product, vitamin C to help brighten and of course, medical-grade sunscreen to prevent the melasma getting worse. In-clinic treatments could include peels to really help boost the results of the skincare regime,” he says, adding, “Other treatments can include steroid cream and tranexamic acid tablets, while lasers can also play a part in treatment.” Dr Bawa favours hydroquinone in the treatment of melasma (pending potential contraindications), and he sometimes pairs it with tretinoin. “They can work well together to really reduce the melasma and pigmentation, as found in the Nu-Derm System by Obagi, alongside Obagi Professional C Serum to help brighten the skin.” For patients who are allergic to hydroquinone or would prefer not to risk any downtime, Dr Bawa recommends iS Clinical Brightening Serum, Brightening Complex and Active Serum to reduce the melasma in a gentler manner. “I always tell my patients that we can calm the melasma and then manage it, however, usually, it cannot be fully cleared. We have got great results where the melasma becomes barely noticeable — especially with tinted sunscreen — but it is very challenging to fully get rid of it,” says Dr Bawa.