Last updated December 2021
- Excessive skin pigmentation can be due to a number of causes including UV exposure, hormones and skin trauma. It could also be congenital (existing from birth).
- Pigmentation can be treated with lasers and lightening creams.
- The mode of treatment used will be dependent on the type of pigmentation, patient preference, and patient risk tolerance.
- Pigmentation can be classified into epidermal (superficial), dermal (deep) and mixed.
- Different lasers are used for different types of skin pigmentation and skin types.
- UV protection/sunscreen is paramount in the treatment of pigmentation.
- Laser treatment on olive or darker skins needs to be approached with caution.
What is skin pigmentation?
Excessive skin pigmentation is a result of abnormal production and deposition of melanin by the melanocytes. Melanocytes are pigment-producing cells. The number of melanocytes present in our skin will determine our skin colour. Production of melanin is dependent on UV or sun exposure, and is a natural protective mechanism of the skin.
Hyperpigmentation (areas that are darker than the rest of the skin) results from excess melanin production and deposition. Hypopigmentation is the loss of skin pigmentation. This will not be discussed here.
This page will discuss skin pigmentation and its treatment. This discussion will only encompass pigmentation that is in the skin, and will not involve discussion of raised pigmented lesions, moles, or skin cancers.
What causes excessive skin pigmentation?
Excess skin pigmentation or hyperpigmentation is usually caused by an overwhelming increase in melanin. This leads to the excess production and clumping of melanin, and the appearance of brown or darker spots of pigmentation in the skin.
Reasons for skin pigmentation problems are;
- UV radiation – in most cases, especially in areas of high UV radiation levels like Australia, skin pigmentation problems can be caused by excessive UV or sun exposure (most common).
- Hormonal – as seen in melasma or chloasma that is a type of pigmentation usually caused by pregnancy or the pill (common).
- Trauma to the skin – this can be a result of physical trauma to the skin, chemical peels, laser treatments, or acne. This is known as post-inflammatory hyperpigmentation (common).
- Birthmarks and acquired pigmentation – skin pigmentation can be present at birth (birthmarks), appear in childhood, or adulthood. Examples of these include; congenital melanocytic nevus, cafe au lait spots, spilus nevus, hori’s macules, and nevus of ota.
How is pigmentation treated?
The main difference between the two is that lasers can produce a faster and more effective result in most cases. Topical lightening agents usually only fade pigmentation rather than remove it completely.
However, there are more risks associated with the use of lasers as opposed to lightening agents. These risks include worsening of the pigmentation, loss of normal skin pigmentation (hypopigmentation) or scarring of the skin (rare).
Also, with laser treatment there is usually a period of recovery post-treatment. The mode of treatment used will depend on patient preference, patient risk tolerance, and the type of pigmentation treated. Pigmentation can be treated on any part of the face or body, including the neck, décolletage, back, and back of the hands.
How to remove pigmentation with laser
Some lasers can be used for the treatment of skin pigmentation and have minimal or no impact on normal skin. This is possible due to the process of selective photothermolysis. This is a term that describes how a particular laser wavelength is attracted to pigmented lesions, and only minimally to the normal skin to allow selective removal of a lesion. This allows the laser to selectively disrupt the pigment with minimal or no damage to surrounding skin. Generally, the wavelengths that are attracted to the melanin in pigmented lesions range from 532 nanometers(nm) to 1064nm.
One type of laser for treating pigmentation are millisecond pulse width lasers. These lasers emit pulses of light that are attracted to the melanin in the pigment, and this selectively disrupts the pigment by thermally heating it. The length of each pulse in this case is in the millisecond range (1 millisecond = 1/1000th of a second), and although this sounds short, it is actually a long time in this instance. An example of this laser is the Gemini Laser.
Another type of laser for treating pigmentation is a q-switched laser. These lasers emit nanosecond pulses (1 nanosecond = 1 billionth of a second) of light that are attracted to the melanin in the pigmented skin. They also selectively heat the pigment to disrupt it, but as the pulses are much shorter, they also have a photomechanical effect ie. they shatter/shock the pigment causing it to break down. It is this effect that also allows these lasers to remove tattoo pigment as well. Generally the advantage of these lasers is that they require fewer treatments to treat pigmentation than the millisecond lasers. It is a more aggressive and effective treatment, and therefore also has more side effects such as a longer recovery time as well as an increased chance of post-inflammatory hyperpigmentation (see below). An example of this laser is the Sinon Ruby laser.
How to remove pigmentation with skincare
The first method of treating skin pigmentation is to prevent it from appearing or worsening by applying sunscreen daily. UV exposure from sunlight or sun beds will invariably worsen any existing pigmentation and promote further pigmentation to arise. The risk of skin cancers also rises with increasing exposure to UV.
Sunscreen should be applied everyday, even if it is cloudy, or overcast, as UV light is still present. It is also important to avoid direct sunlight, especially during the middle hours of the day, seek shade when possible, and wear a hat and protective clothing. For more information on sunscreens, click here.
Topical lightening agents can be used in conjunction with sunscreen to help reduce skin pigmentation. Topical lightening agents like serums help to reduce pigmentation by inhibiting enzymes that produce melanin (skin pigment) and by increasing the turnover of the skin to minimise existing pigmentation. Common lightening agents include; hydroquinone, kojic acid, paper mulberry bark extract, retinoids, and glycolic acid. For more information on pigmentation serums click here.
Types of pigmentation
Skin pigmentation can be categorised into three categories;
- Epidermal (superficial) pigmentation – these pigmentation types are usually close to the surface of the skin and are induced by sun exposure and include solar lentigos, freckles, and cafe-au-lait macules.
- Dermal (deep) pigmentation – these pigmentation types are usually found in the dermal layers, and include hori’s macules, and nevus of ota.
- Mixed dermal/epidermal pigmentation – these pigmentation types traverse through both the superficial and deeper layers of the skin. Melasma is an example of this.
Which laser is best for hyperpigmentation?
Different types of lasers can be used to treat different kinds of pigmentation, depending on the level of pigment in the skin and the cause of the pigmentation.
Solar lentigos or sun spots (epidermal)
The most common forms of pigmentation are due to sun exposure. Solar lentigos, colloquially known as ‘sun spots’ are an example of this. Solar lentigos are not cancerous, and appear as flat brown ‘muddy’ patches on the areas of skin that are more exposed to the sun. They commonly occur on the cheeks, temples, and forehead.
For those wanting to treat this type of pigmentation, the Sinon Ruby laser is usually the most effective. These lasers are highly attracted to melanin (pigment), and as solar lentigos have more melanin than the surrounding skin, they tend to pick up the laser energy more than the surrounding normal skin. This is akin to a black car heating up more than a white car when parked in the sun. The lasers cause mechanical and thermal destruction of the pigment and results in clearing of the pigment.
Case study: This female presented to Victorian Cosmetic Institute with a large solar lentigo on her face with surrounding smaller ones on her cheek. She underwent treatment with the Ruby laser and achieved the result seen in the after photo after one treatment. The total downtime/recovery period was approximately one week, where the pigmented spots became darker and then fell off.
Seborrhoeic keratosis are brown, wart-like growths on the skin. They can appear like stuck-on sultanas on the skin. They are benign growths, but need to be distinguished from malignant lesions such as melanoma prior to laser treatment. Seborrhoeic keratosis can be removed with lasers such as the Gemini laser, or radiofrequency devices such as the Pelleve. These devices heat up the seborrhoeic keratosis and basically allow them to be separated from the skin and wiped off.
Post-inflammatory hyperpigmentation (mixed dermal/epidermal)
Post-inflammatory hyperpigmentation is due to trauma to the skin, resulting in inflammation and pigmentation. Causes include; acne, laser, laser hair removal, IPL, chemical peels, and physical trauma. In the case of post-inflammatory hyperpigmentation, it is important to note that treatment of this type of pigmentation can be worsened if the treatment further irritates the skin. In particular, laser treatments aggravate and irritate post-inflammatory hyperpigmentation and commonly make it worse. At the Victorian Cosmetic Institute, our doctors recommend the use of topical agents for post-inflammatory hyperpigmentation rather than lasers. The doctors at Victorian Cosmetic Institute often prescribe a combination of hydroquinone, tretinoin, hydrocortisone, and kojic acid (Kligman’s formula) for post-inflammatory hyperpigmentation.
Case study: This patient presents to Victorian Cosmetic Institute with a history of facial acne. The before picture depicts some active acne as well as post-inflammatory hyperpigmentation as a result of previous acne lesions. The after photo was taken after 6 months of treatment for active acne as well as the use of Kligman’s formula for the treatment of post-inflammatory hyperpigmentation.
Melasma/Chloasma (mixed dermal/epidermal)
Melasma or chloasma is a form of pigmentation that is stimulated by oestrogen (either from pregnancy, the pill, or normal circulating oestrogens) and is a difficult form of pigmentation to treat. It appears as brown-gray patches on the face, usually on the cheeks, between the brows and on the upper lip. The following pictures show some examples of treatment results at Victorian Cosmetic Institute.
Freckles are small brown spots on the skin that tend to be more prominent in summer and fade slightly in the winter. Freckles are usually genetic and are brown because of the pigment melanin. Freckles are very small patches of brown skin, usually less than 3mm in diameter.
Freckles are responsive to the Sinon Ruby laser. The Gemini laser is an effective laser for Asian freckle treatment. Patients who tend to freckle may freckle with sun exposure. Most patients show an improvement > 50% after treatment in their freckling as long as daily sunscreen is used. For more information on freckles and some case studies, click here.
Brown birthmarks (epidermal)
Brown birthmarks, otherwise known as cafe-au-lait spots, are not uncommon and can appear anywhere on the body. These spots can be different sizes and shapes and often range from light to dark brown.
Epidermal or superficial brown birthmarks such as cafe au lait spots and congenital melanocytic naevi can also be treated with the Sinon Ruby laser.
Pigmentation on Asian, olive, or dark skin
Pigmentation problems commonly occur on people with Asian, olive or dark skin. These can be more difficult to treat than pigmentation on fair skins, and require a different approach.
Laser treatments can sometimes cause post-inflammatory hyperpigmentation (see above), and this can make the original pigmentation problem seem worse initially post laser. It is important therefore to ensure proper:
- Preparation of the skin – often lightening serums/creams are used prior to help prepare the skin and reduce the chance of post-inflammatory hyperpigmentation
- Laser settings – choosing a laser that is appropriate to these skin types, the use of skin cooling during laser, lower settings, smaller laser spot sizes to minimise effects of the laser on the normal collateral skin
- Post-laser treatment – ensuring that the proper creams, including sunscreens and sometimes steroids, are used post-laser.
This patient presented with a number of pigmentation issues, including solar lentigos, seborrhoeic keratosis, and hori’s macules (deep dermal pigmentation). Her skin was prepared with Kligman’s formula (a lightening serum) prior to treatment with laser, and a combination of lasers were used to treat the various pigmentation problems she had. There was a short period of time when the patient experienced hyperpigmentation post-laser, but the final result shows a significant clearance of pigmentation after 6 months.
Dermal pigmented lesions are deep skin pigmentation that is best treated with the 1064nm wavelength of the Piqo4 laser or the 694 nanometer wavelength of the Ruby laser. The 694 and 1064 nanometer wavelengths are deeper penetrating, and are able to shatter deeper pigments. Types of dermal pigmentation include; melasma, Nevus of Ota, Nevus of Ito, Becker’s nevus, and acquired bilateral nevus of Ota-like macules (Hori’s macules/naevus).
Can pigmentation be removed?
Existing pigmentation can be removed using different laser treatments, depending on the type of pigmentation. The Fraxel laser can be used to remove or minimise some types of sun damage, while the Piqo4 laser can be used for post-inflammatory hyperpigmentation or Melasma.
Pigmentation can also be minimised by using high SPF sun protection every day and regularly exfoliating your skin. You can also take extra precautions to protect your skin such as using pigment inhibiting serum and taking Vitamin B3 or applying Vitamin B3 (Niacinamide) topically.
What is the best treatment for pigmentation?
The best treatment for you will depend on the kind of pigmentation you have as well as your specific skin type. You will have an initial consultation with one of our team members to determine what the most effective treatment will be to address your individual goals and concerns.
How long will it take for me to see results after pigmentation treatments?
You should begin to see results after your first treatment, but this will also depend on your specific treatment plan as well as your skin’s level of resistance to the procedure.
You will not see full results until after you’ve had all of the treatments in your plan.
Is pigmentation removal treatment suitable for pregnant or breastfeeding women?
This treatment is not suitable for pregnant or breastfeeding women.
How do I prepare for pigmentation removal?
For two weeks prior to your pigmentation treatment, you should avoid getting a spray tan, being in a tanning booth, getting excessive sunlight or receiving any other skin procedures such as a chemical peel. You should also avoid waxing your face.
Immediately before your treatment, you should thoroughly cleanse your face. Our doctors will discuss any other necessary preparations with you in your initial consultation.
Is there any downtime required?
There is minimal downtime associated with this procedure. You should be able to return to normal activities very soon after treatment, but this will depend on which treatment you receive. Your skin may appear red and tender for a few days afterwards.
You should avoid direct sun exposure, strenuous exercise or direct heat for 7 days after treatment.
Why should I choose the Victorian Cosmetic Institute to treat my pigmentation?
At the Victorian Cosmetic Institute, our doctors will carefully assess your pigmentation problem and formulate a treatment plan for you. We have a wide range of treatment options available, including a large number of topical agents and lasers. We will ensure that you will get the treatment most suited to your pigmentation.
Our doctors are also highly experienced in laser treatments and will be able to give you the best advice for your treatment. We will make sure you understand exactly what will happen and what to expect.
Making your initial inquiry can be daunting, so you may prefer to fill out our “make an enquiry” form. You can call us on 1300 863 824 to make an appointment or you can book a consultation appointment online.