Acne, eczema, psoriasis, are all skin conditions that can cause discomfort and embarrassment. But for many patients, the worst part of these and a number of other skin ailments may be the residual pigmentation left behind even when the conditions are successfully treated.
"Hyperpigmentation is so inextricably linked to many forms of skin disease, yet it just doesn't get a lot of respect, and for a lot of patients, particularly women, it's the most irritating part," says Ranella Hirsch, M.D., president of the American Society of Cosmetic Dermatology and Aesthetic Surgery.
According to Dr. Hirsch, who practices in Cambridge, Mass., "Hyperpigmentation is often a cosmetic issue, but can also be a medical one. In either case, it is one that has been underrated for years, because it actually affects people in a very profound way."
In Montclair, N.J., Jeanine B. Downie, M.D., sees the problem frequently.
Hyperpigmentation can result from a variety of causes, both common and rare. More infrequent origins include conditions such as acanthosis nigricans, which can cause a velvety black textural color change under the arms and in the skin folds around the neck; insulin resistance; and certain internal cancers.
But for the most part, the doctors say the hyperpigmentation is benign in the sense that it is not a condition that will kill the patient, but it is a condition that can have long-term effects.
Dr. Hirsch cited acne and the subsequent postinflammatory hyperpigmentation as a prime example.
Dr. Downie, assistant attending physician at Mountainside and Overlook hospitals, adds some other conditions that are commonly associated with hyperpigmentation.
"Often, when I think of hyperpigmentation, I associate it with the melasma dark spots after an acne breakout and postinflammatory hyperpigmentation occurring secondary to a drug," she says.
"One thing that breaks my heart is when I see marks left in women who have tweezed hair from their chins. Also, too often many people with skin of color - Asian-American, African-American and Latino-American - do not feel that the sunblock rule applies to them.
"When I see hyperpigmentation, I don't think, 'disease state.' I think, 'This person wasn't wearing sunscreen.' The first thing is for patients to start wearing an SPF 30 broad-spectrum protection.
"So, I take the quote 'Use sun protection everyday, rain or shine, January through December,' and then I add 'regardless of ethnicity.'
"That's really the key. People with skin of color tend to think the melanin in their skin will protect them," Dr. Downie says.
"Melasma is a specific presentation of hyperpigmentation on the face," Dr. Hirsch says.
"The condition is related to a specific hyperpigmentation of the skin that is predestined in certain skin types and is greatly exacerbated by several factors, such as hormonal effects stemming from pregnancy, going on and off hormone replacement therapy, and the birth-control pill.
"In all cases, sun exposure worsens the problem and broad-spectrum sunscreen is an imperative part of therapy," she says.
When melasma occurs, Dr. Hirsch advocates starting treatment as expediently as possible.
Although treatments are available, they aren't easy, quick or inexpensive.
"It's very difficult to treat melasma. Epidermal melasma, the more superficial disease, is much more successfully managed via a series of therapies: chemical peeling and certain prescription bleaches and creams," she says.
"When the pigment is a little deeper, some recent case reports using the new fractional resurfacing modalities have reported success, with some of the cases showing newer fractional techniques that may prove promising for the treatment of hyperpigmentation," Dr. Hirsch says.
Dr. Downie says the fractional laser may be especially useful in treating skin of color.
"The fractional laser has made treating melasma much more delightful. I can offer it to my melasma patients who don't feel like doing a series of superficial epidermal peels or hydroquinone therapy, which produce results much more slowly. I can offer five or six fractional treatments and probably remove about 80 percent of the melasma, and people often prefer that versus 25 peels, even though the proportional cost goes up significantly," Dr. Downie says.