When a topical treatment is not sufficient to remove the spots

The pigment spots are the result of a change in the normal colour of the skin. They are due to a disruption in the pigmentation process (melanogenesis). They result either from the excessive accumulation of melanin on the skin's surface, in which case we speak of hyperpigmentation, or from a lack of melanin, then we refer to hypopigmentation. Generally, pigment spots appear around the age of forty. There are three types of pigment spots:

• The melasma or pregnancy mask:

  It appears as a result of hormonal fluctuations, manifesting as brown spots most commonly distributed across the forehead, cheeks, or lips. These typically form during pregnancy, or when undergoing a medicinal treatment that impacts the hormonal system.

• Lentigo :

  Also known as age spots or sun spots, these brown spots appear on the areas most exposed to the sun's UV rays, namely the back of the hands, the face, the décolletage and the back. They are the result of the photo-ageing of the skin.

• Post-inflammatory hyperpigmentation:

  These spots occur following inflammation. Generally, they are red or even pinkish in colour, but they can also be brown.

Pigment spots can generally be treated with topical treatments designed with depigmenting agents. When these topical treatments for pigment spots are not sufficient to eliminate them, the dermatologist may propose the following alternative solutions:

• Oral Treatment

  Oral treatments are another method for addressing hyperpigmentation, and tranexamic acid is one such treatment. Indeed, it is believed to reduce the activity of tyrosinase by inhibiting the UV-induced plasmin activity, which in turn leads to a reduction in arachidonic acid and prostaglandins, affecting tyrosinase.

  An oral intake of glutathione has demonstrated skin-lightening activity through various mechanisms such as the inhibition of the tyrosinase enzyme and the ability to alter the production of eumelanin to pheomelanin, although its mechanism is not known.

• The chemical peel

  This technique works by inducing the exfoliation of the upper part of the stratum corneum to remove dead cells.

  It promotes the growth of new skin cells to make way for new skin. TCA peeling and AHA peeling are the two most commonly used methods when it comes to dermatological peeling.

• Pigmentary laser treatment

  This type of dermatological treatment allows for precise targeting of pigmented spots. The heat generated by the laser manages to eliminate these spots within five or six days following the session. A commonly used laser is the xenon chloride lamp, which emits broad-spectrum light and is frequently used against melasma. Pulsed dye lasers may also help reduce pigmented spots by reducing the stimulation of melanocytes, although their mode of action is not entirely clear.

• Microneedling

  This refers to the name of a technique during which an instrument dotted with microneedles is rolled over the skin to penetrate the epidermis and reach the upper dermis in order to induce a healing response. This technique is primarily used to enhance the transdermal delivery of various agents for the treatment of hyperpigmentation disorders. A clinical study showed that the treatment with micro-injections of tranexamic acid combined with microneedling resulted in a greater improvement in hyperpigmentation in patients with melasma than the control group.

NAUTIYAL A. & al. Management of hyperpigmentation: Current treatments and emerging therapies. The official journal of INTERNATIONAL FEDERATION OF PIGMENT CELL SOCIETIES · SOCIETY FOR MELANOMA RESEARCH (2021).