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Common Pigmentation Concerns in Asian Skin

Asia is the largest continent on earth. More than half of the world's population is found in this region, which includes China, Singapore, Malaysia, Indonesia, Japan, Korea, and India. It has been observed that Asians tend to have more skin issues related to pigmentation due to their higher production of melanin. Among them are melasma, freckles, post-inflammatory hyperpigmentation (PIH), solar lentigo, Hori's Nevus, and Nevus of Ota[1]. A variety of factors can contribute to pigmentation problems in Asian skin. Fortunately, most are cosmetic in nature and can be safely and effectively treated. 

Why are Asians more prone to pigmentation? 

The Fitzpatrick Scale generally classifies Asian skin as Type III to IV in ethnicities like Chinese, Koreans and Japanese, and Type IV and V in ethnicities such as Malays, Indians and Pakistanis [2].   

The pigment-producing cells, melanocytes, are responsible for skin pigmentation, which results in darker skin. While it has been established that the genetic makeup of all human races consists of the same number of melanocytes, the size of the melanocytes and the amount of pigment produced varies for individuals. 

So why are skin pigmentation issues more prevalent among Asians?   

Singapore's climatic conditions, particularly its abundance of sunshine all year round, are a major contributor. Prolonged exposure to ultraviolet rays (UV) in sunlight triggers melanin production in the skin.     

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Apart from the climatic conditions, several physiological and genetic characteristics of Asian skin led to excessive pigmentation [2]. Firstly, the melanocytes in Asian skin tend to produce more melanin or pigment. Secondly, Asian skin is more sensitive and vulnerable to damage due to its thinner stratum corneum, the protective barrier over the underlying tissues.

Thirdly, Asian skin have more sebaceous glands often resulting in excessive body oil production, which can lead to acne and scarring. As a result of skin irritation or inflammation, Asian skin produces more brown pigment. This is one of the factors that leads to darkening compared to skin types I and II. Finally, certain topical and oral medications can also play a role in hyperpigmentation, as some of these drugs can increase your skin’s sensitivity to the sun. Some of these medications include antibiotics, NSAIDs, antidepressants, oral contraceptives, and antihistamines. 

What are some common skin conditions of Asians?  

Broadly speaking, a combination of genetic characteristics and climatic conditions are responsible for a large number of Asians developing skin pigmentation issues [4].  

1. Melasma 

It is a common skin problem symptomised by brown to grey-brown patches on the face. The condition usually manifests in areas like the nose bridge, cheeks, chin, forehead, and above the upper lip. More prevalent in women than men. Leading causative factors include a genetic predisposition, excessive sun exposure, hormones, pregnancy, the use of medications such as oral contraceptives and tanning beds. 

2. Solar Lentigo (Solar Lentigines) / Age Spot 

Multiple different names for this type of pigmentation, including solar lentigines, aged spots, sunspots and liver spots. These dark spots are common among people in their forties and beyond. They appear as flat and relatively darker spots on the sun-exposed areas of the body, hence the names such as sunspot and solar lentigo. These skin pigmentations also form as melanin production tends to increase in older people. They are a precursor to seborrheic keratosis. 

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3. Freckles

They are similar in appearance to solar lentigo but are much smaller. Freckles appear in clusters and have relatively less definition. The major difference is that freckles are a genetic condition that gets triggered by exposure to sunlight. So, this condition usually appears with the onset of summer and subsides in winter.    

4. Post-inflammatory hyperpigmentation (PIH)

Also known as acquired melanosis, PIH is usually a temporary, but sometimes can be a prolonged form of pigmentation that is caused by trauma such as acne, wounds, infection, and burns. The condition occurs when melanin gets deposited inside the keratinocytes and dermis.  

5. Seborrheic Keratosis

It is a harmless skin growth seen more often in older people. You can recognise them by the slightly elevated lesions that are brown, black or light tan coloured, and have a waxy scaly appearance. They may arise within solar lentigines causing localised thickening and a change in the texture of the lentigo spot. Apart from extended exposure to harsh sunlight, causes include hereditary factors and ageing.  

6. Hori’s Nevus

A common skin concern among Asian women, usually between thirty and fifty years old. Hori's Nevus appears as blue-brown macules on facial areas such as the forehead, cheeks, and nose. Unlike normal skin where the melanocytes occur in the upper layers or epidermis, in Hori’s Nevus, the melanocytes are found in the papillary and middle portions of the dermis. Causes include genetic predisposition with triggers such as hormonal changes, age and prolonged sun exposure. 

7. Nevus of Ota

High amounts of melanin and melanocytes are found in and around the eyes of people with Nevus of Ota is a condition commonly seen in Asians, particularly women, and it is present at birth in most cases, while others develop it as adolescents. The condition can be recognised by its characteristic grey-blue hyperpigmentation in one of the eyes, and its surrounding areas. 

What are some recommended treatment options for Asian skin? 

Several types of skin treatments are available for pigmentation problems faced by Asians. This includes invasive therapies such as ablative lasers as well as non-invasive modalities like non-ablative lasers, RF Microneedling, Intense Pulsed Light (IPL), chemical peels and topical medications. However, since Asian skin easily develops hyperpigmentation, it is advisable to avoid ablative lasers like CO2 lasers and also deep chemical peels. 

 Non-invasive treatment modes such as chemical peels, lasers, IPL, and RF Microneedling, are gaining in popularity because they are safe, effective and non-invasive outpatient procedures with minimal to no downtime.   

1. Laser Treatments 

Many Asians seeking safe and effective solutions for skin concerns like melasma, freckles, Hori’s Nevus, and solar lentigo, are opting for laser treatments. As with all skin conditions like acne, not every treatment is suitable for pigmentation. Hence, while searching for popular lasers like Q-switched lasers or pico lasers, always consult with a medical aesthetic practitioner for a detailed assessment to recommend the appropriate treatment for you. 

Besides the popular lasers mentioned above, there is a wide range of other pigmentation lasers available, including Long-Pulsed ND: YAG Lasers, Er YAG Lasers, Alexandrite Lasers, and Yellow Lasers, each with a different wavelength and pulse duration that can target the different depths of the skin and selectively destroy the excess pigment without affecting the surrounding tissue. Some of these lasers can be used singly or in combination for optimum results.   

While it is possible to treat the majority of skin pigmentation problems with the help of lasers and other therapies, melasma is the most challenging. Melasma is a chronic skin disease that cannot be cure, therefore it may still recur after responding positively to treatment. Since the condition cannot be cured permanently, skin care practitioners recommend a regimen comprising periodic laser and energy-based treatments to lighten the pigmentation, and the use of prescription topicals, and sometimes in some patients, oral medications to help control the melanin generation process.     

2. Radiofrequency (RF) Microneedling 

This energy-based device treatment strengthens the basal membranes and prevents melanin from travelling from the epidermis to deep inside the dermis. The minimally invasive procedure creates microchannels and delivers radiofrequency energy to the skin with the help of microneedles. The microneedle electrodes produce an electromagnetic field of energy that safely penetrates and induces a therapeutic effect in the dermal – epidermal junction and the dermal layer.

This methodology makes it easy for RF energy to access the papillary dermis which houses ageing fibroblasts and collagen deposits. The repeated pulsed (RP) technology used in the treatments exclusively targets abnormal tissue membranes and blood vessels that contribute to pigmentation. The generated energy strengthens the papillary dermis or basal membrane, effectively preventing the movement of melanin to the deeper skin layers. Rejuvenation of collagen production also helps improve the skin’s elasticity and reduce pigmentation.    

3. Intense Pulsed Light (IPL) 

This non-surgical therapy treats some form of hyperpigmentation by using a broad wavelength output of non-coherent light, usually in the 500 to 1200nm range. IPL devices use a high-intensity light source that does not use a laser to generate thermal energy by focusing intense pulsed light on pigmentation. Thereafter, the targeted pigments absorb the energy from the IPL and break down into small particles to be flushed out gradually over a period of time by the body’s natural processes. Other benefits of the treatment include increased collagen production, reduction in pore size, and a smoother skin tone. IPL is most appropriate for treating mild or superficial levels of pigmentation. However, when used in combination with other modalities, IPL can deliver relatively better treatment outcomes for pigmentation issues. 

4. Topical Medicated Creams 

Topical medicated creams are useful for treating mild cases of skin pigmentation problems. Generally, hydroquinone and tretinoin are prescribed for reducing light and superficial pigmentation. Hydroquinone helps reduce pigmentation levels by inhibiting the production of melanin in the skin. However, prolonged use of the medication can result in the formation of blue-black pigmentation – a condition called exogenous ochronosis. Therefore, it is advisable to use hydroquinone under a doctor’s advice and supervision.   

Tretinoin is a topical retinoid derived from Vitamin A. It is commonly used to treat skin concerns such as hyperpigmentation, in addition to acne. Basically, tretinoin stimulates skin cell growth by accelerating the epidermal turnover rate. The overall benefits of this process include reduced pigmentation, wrinkles, and a smoother skin texture.   

Generally, topical medical formulations are safe to use, but it is best to purchase them with a prescription from your physician. This will help avoid unexpected side effects. 

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5. Chemical Peels 

Medical-grade chemical peels are basically made of exfoliating acids that speed up the skin-shedding cycle and increase the speed at which fresh skin is regenerated [5]. Along with the skin’s upper layer, unwanted melanin deposits also get removed in the process. This results in the reduction of various superficial epidermal hyperpigmentation only.  

Compared to superficial peels, medium and deep peels act at much deeper levels of the skin. For Asian skin, too deep a peel may cause hypopigmentation or PIH and may not be a suitable option. Apart from standalone treatments, chemical peels are sometimes used in combination with other non-invasive modalities to maximise treatment outcomes. 

What are some procedures to be avoided for Asian skin? 

While chemical peels and ablative laser treatments may produce effective results, they can also lead to unwanted aesthetic side effects. Asian skin types are relatively more sensitive and delicate to pigmentation and therefore particularly vulnerable to such skin complications. 

Asians generally have darker skin photo-types which are at a greater risk of developing an inflammatory response to physical or chemical irritation. Therefore, they are more prone to complications after undergoing some dermatological procedures such as ablative lasers and deep peels. The undesirable reactions include hyperchromia, hypochromia, and hypertrophic scars [5]. 

Ablative Lasers 

Laser treatments such as CO2 are classified as an ablative modality because they inflict heat injury to the skin layers in order to initiate the healing process. In contrast, non-ablative laser treatments leave the outer skin unharmed and bypass it to treat the inner layers. Some of the undesirable side-effects of ablative laser treatments include the risk of PIH, infection, redness and peeling of the skin, scarring and deterioration of skin tone. Some of these treatments are more suitable for Caucasian skin and generally not appropriate for Asians as their skin reaction can lead to PIH.   

Deep Chemical Peels 

Phenol or trichloroacetic acid peels have a deep-acting action capable of removing damaged skin cells from the middle layer of the skin. Due to the deep peel, it may damage your skin causing your skin to react by producing melanin resulting in PIH marks. These peels can also lighten the treated skin area and deprive it of its tanning ability [6]. As a result, the treated skin becomes very sensitive to sunlight and needs to be properly shaded from sunlight to prevent sun damage and pigmentation. 

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Key Takeaway

Partly due to prolonged exposure to harsh sunlight and partly due to genetic factors and physiological factors, many Asians suffer from skin hyperpigmentation issues such as melasma, PIH, solar lentigo, Hori’s Nevus and Ota’s Nevi. Fortunately, most of these skin problems are cosmetic in nature and easily treatable. Given the sensitive nature and delicate structure of Asian skin, it is advisable to use safe and effective therapies like topical creams, chemical peels, lasers, IPL, and RF Microneedling that you can discuss with your medical aesthetic doctor. 

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