THE BASICS: WHAT IS PIGMENTATION?
Patient: ‘Can I remove my freckles?’
Doctor: ‘Yes, we have a few different lasers for pigmentation here.’
Patient: ‘But I don’t want to remove pigmentation. I want to remove my freckles.’
Newsflash: Freckles ARE pigmentation. So are acne marks, sunspots, melasma, and age spots!
The above is a common scenario we come across on a daily basis when it comes to pigmentation removal. Pigmentation is a big skin concern, especially in Asia where fair flawless skin is deemed as highly desirable. What is pigmentation and what causes it? How can it be treated and can all pigmentation be 100% removed? Here’s all you need to know, and more!
What is pigmentation, and what causes pigmentation?
Pigmentation is caused by the production of melanin in our skin. The darker our skin colour, the more pigment/melanin there is in our skin. Melanin is produced in our skin by cells called melanocytes. These melanocytes contain melanosomes which produces and stores melanin.
Melanocytes are located between the epidermis and dermis layer. (i.e the first and second layer of our skin). Some of these melanosomes are transferred to skin cells called keratinocytes. The transfer of melanosomes, and therefore melanin, to the different layers of the skin will determine the type of pigmentation you have, and also which pigmentation removal treatment will be most effective for you.
Pigmentation is caused by a few factors:
- Sun exposure results in an increase in melanocyte size and pigmentation formation
- Hormones, especially female hormones, play a part in pigmentation formation. (Fact: Women are 3 times more likely to suffer from pigmentation than men. It is more common in women during or after pregnancy, or after menopause.)
- Genetic – A family history of pigmentation also increases the chances of one having these issues. The most common genetic conditions would be freckles or sun spots. There are also birthmarks – i.e. pigmentation present at birth.
- Some medical condition and medication may also cause pigmentation formation, or increased sensitivity to it.
What type of pigmentation do I have?
In general, there are two main categories of pigmentation; epidermal (first layer of the skin) and dermal (second layer) pigmentation. From a layman’s perspective, we can identify most of them by the naked eye upon close-up examination.
Epidermal pigmentations are usually more distinct, darker in colour, and the borders/edges of the spots are defined and can be seen clearly.
I usually further classify epidermal pigmentation to superficial epidermal pigments (on the surface of the skin) and intraepidermal pigments (inside the first layer of the skin). This is because treatments for these two types are different.
Dermal pigmentations (deeper) usually appear as slightly blurry, hazy patches on the skin. This type of colouration is typically lighter, and the borders/edges of the spots are less clear than epidermal pigmentation.
At Mizu, we also utilize a computerized software with the VISIA machine to identify the type of spots and also the depth of the pigmentation situated in the skin. This allows the doctor to further confirm the diagnosis and choose the most appropriate treatment for different conditions, as well as to monitor progress over subsequent visits.
THE BEST WAY TO TREAT PIGMENTATION: COMBINATION TREATMENT(S)
Most pigmentation can be effectively treated with a combination of topical creams and laser treatments, and sometimes oral medication. The most important part is to prevent them from returning, and to prevent any undesired side-effects. Identifying the type of spot you have is the most crucial step in the treatment process, as it determines the type of medication, creams, and lasers that will be effective for you.
STEP 1: Topical creams
The most common topical cream we prescribe at Mizu for pigmentation is a custom-formulated Hydroquinone-based cream.
Hydroquinone is a mainstay in pigmentation treatment and it works by blocking the production of melanin in the skin. Hydroquinone is known by some as a ‘bleaching cream’. It may sound scary, but on the contrary, it does not bleach the skin, and also does not remove pigmentation. Instead, hydroquinone lightens it by reducing the amount of pigments (melanin) being produced by the skin.
For some conditions, especially epidermal pigmentations, it is important to start on a course of hydroquinone for 2-4 weeks before any laser treatments, as this greatly decreases the chances of any spots from reoccurring. Hydroquinone as a stand-alone treatment may not treat pigmentation as effectively as a combination treatment. Hydroquinone is usually used for 3-6 months, and no more than that, as it may cause side effects.
A steroid cream is also sometimes used in conjunction with laser treatments. This is used to prevent Post-inflammatory Hyperpigmentation (PIH) which can happen with some laser treatments when there is scabbing of the skin involved. A steroid cream is usually used for 1 week post-laser treatments.
STEP 2: Laser Treatments
In recent years, the quickest and most effective way to treat pigmentation is by laser treatments. The latest technology for removal is with a Pico-second laser, but that doesn’t mean that all other lasers are not good or sufficient either. We have 3 different types of laser machines in Mizu that we use for different types of spots. They are the Discovery Pico laser, the ProYellow laser, and the Q-switched laser.
I started my career doing plenty of lasers and learning their quirks and capabilities – and over time, have chosen these 3 stalwarts to maximize the efficacies of my treatment. As a key opinion leader and trainer in both the Pico laser and the ProYellow laser, I choose my different lasers according to the different pigmentation conditions, the depths the lasers can reach, and I’ll sometimes incorporate all 3 different lasers for a course of treatment, as both epidermal and dermal pigmentations can both be present at the same time.
As mentioned above, the reason for choosing the different laser types is because they provide different wavelengths of laser energy to target the different pigmentation situated in the various skin layers.
At 1064nm wavelength, the Q-switched laser is most suited to target dermal pigmentations. The Q-switched laser has been a mainstay in aesthetic treatments for a few years. At Mizu, although the Q-switched laser is used less frequently now due to faster technology like the Pico laser, it is still a popular laser, as it is able to regenerate heat energy to rejuvenate the skin while removing pigmentation. The Q-switched laser is effective in reducing brown acne marks as it not only does it fade pigments, it also treats and reduces acne and pore size at the same time. Read more about the Q-switched laser here.
As a maintenance treatment, the Q-switched laser is also often used to prevent pigmentation from appearing after treatment.
At 577nm wavelength, the ProYellow laser is particularly useful for epidermal pigmentation such as superficial freckles, some sun spots, age spots, and stubborn conditions such as vascular melasma. Vascular melasma is a multi-layer pigmentation condition that results from an increased in blood vessels under the skin. These blood vessels are reduced with the ProYellow laser and in turn reduces pigmentation.
Like the Q-switched laser, the ProYellow laser is a versatile laser. It is used for a variety of conditions such as melasma, sun/age spots, freckles, facial flushing, acne treatment, post acne redness, skin brightening and rejuvenation, etc. Due to its unique wavelength, the energy from the ProYellow laser is absorbed by both pigmentation and the underlying blood vessels. This results in breakdown of pigmentation and at the same time, reduces the blood supply to the skin cells that produce these pigments. This will prevent these skin cells from producing pigments and ensure longer-lasting results.
Discovery Pico laser:
The latest technology when it comes to pigmentation and tattoo removal, the Discovery Pico comes in 3 different wavelengths – 532nm, 1064nm and 694nm wavelength. Each wavelength is used to target different pigmentations at different layers of the skin, therefore removing pigmentation more effectively and quickly.
The standout technological advancement of the pico laser is the laser’s very short pulse duration. Compared to its predecessor, the Q-switched laser, the pico laser has a pico-second pulse duration compared to a nano-second pulse duration (the q-switched laser).
Pico-second is a measure of time. 1000 pico-seconds = 1 nano-second. This means that the pico laser fires each laser beam much faster than a q-switched laser, and is able to clear most pigmentation faster, and more effectively. The speed of the laser is what generates the photo-acoustic laser energy to shatter and break down pigmentation.’
The Discovery Pico is chosen at Mizu because it has been shown to have the fastest pulse duration and the highest available peak power to most effectively break down pigmentation.
STEP 3: Maintenance, Prevention and oral medication (occasionally)
Sunscreen is a crucial step before and after laser treatments. Although non-ablative lasers do not thin the skin, the skin can be more susceptible to sun damage for 1-2 weeks after a laser treatment It is advised that adequate sun protection is observed before and after a laser treatment.
Sometimes, oral medication such as tranexamic acid can be prescribed for certain conditions. Tranexamic acid helps reduce hypervascularity (blood vessels) and also blocks the production of melanin. A good skincare routine should also be observed.
PIGMENTATION LASERS: HOW IT WORKS
How do lasers actually remove pigmentation?
Lasers utilise either photo-acoustic energy (pico laser) or photo-thermal energy (q-switched, yellow laser, ruby laser etc.) to break the pigmentation in the skin into smaller fragments which are cleared off by the skin immune system.
And what about downtime for such lasers?
Another common question I always get from patients is ‘will there be scabbing and can my pigmentation be burnt off?’, thinking that they will have to take days of leave off for a treatment – and the answer is, you don’t need to!
The downtime for non-ablative lasers are practically close to none.
Scabbing usually occurs only when there is damage to the skin. Technically, in order to reduce side-effects, the laser should be administered in a way that there is minimal scabbing and slight darkening of the pigmentation. This darkening will fade over the next 1-2 weeks. Scabbing is not encouraged as it might result in hyper-pigmentation (more pigments), especially for dermal pigmentations on Asian skin.
Only a few conditions are suitable for scabbing; such as superficial freckles, solar lentigos (age/sun spots), and some skin tags.
Can pigmentation be 100% removed?
Not all pigmentation can be removed completely – certain superficial ones can be completely removed, but others, such as melasma or other dermal pigmentation usually gets reduced by 70-90%.
The most important thing to note in regards to treatment is to properly identify the type of pigment(s) and choose an appropriate laser with the right settings. In experienced hands, most pigmentation conditions can be treated very effectively without undesirable side-effects.
How often will I need to return for treatment?
Typically, the interval between each treatment is about 3 weeks. Depending on the type of pigmentation, a longer interval might be required if a strong laser setting is used. It usually takes between 2-8 session of laser treatments to significantly reduce pigmentation, depending on the condition. After pigmentation reduction, a laser treatment once every few months would be beneficial to maintain the results and reduce any surfacing pigmentation.
Could pigmentation come back after removing them with lasers?
Some pigmentation may seem to “come back” after treatment. However, with good sun protection and proper skin care, these can take years to resurface. Adequate sun protection also ensures that new pigments do not form.
New spots can surface due to existing melanocytes which are not destroyed by the laser as they are part of the skin structure. These melanocytes can produce pigmentation when triggered by factors such as damage from the sun, hormonal changes (such as during pregnancy and menopause), or even stress.
After treating your pigmentation, the occasional laser treatment can also help prevent new spots from forming. Maintenance laser treatments can remove it before they resurface and show on the skin.
However, with time, the effects of hormones, aging skin, and accumulated sun damage can still result in some spots forming.
What side-effects are there?
On the contrary to common myths out there, pigmentation removal lasers WILL NOT thin the skin. in fact, these layers help rejuvenate the skin and stimulate collagen production to some extent.
However, pigmentation laser treatments do temporarily render the skin more sensitive to sun damage. Prolonged sun exposure should be avoided 1 week before and at least 1 week after treatment to prevent hyperpigmentation from occurring.
Hyper-pigmentation (darkening of the pigments) can also occur if unsuitable laser settings were used. Therefore, identifying what type of pigmentation you have and treating it with the right laser and settings is crucial in getting good results, as well as preventing unwanted side-effects.
What can I do if I experience hyperpigmentation due to an unsuitable laser procedure?
The good news is that hyperpigmentation usually resolves by itself. However, it can take a very long time. It can take from 2 months to 1 year for hyper-pigmentation to resolve by its own. Fortunately, this can usually be hastened with the help of topical creams such as hydroquinone or arbutin-containing skincare products. A laser treatment with a slightly lower power setting can also help reduce hyperpigmentation over time.
The best way to treat hyper-pigmentation is to actually avoid it. Therefore, it is stressed again that measures to prevent hyperpigmentation such as using topical creams before laser treatments is very important. Not all pigmentation are alike, and not all laser treatments are suitable for just any kind of spots or marks. Avoid hyperpigmentation by also making sure your condition is properly identified by your doctor to ensure the right laser and treatment is used for you.
Dr. Tan Ying Zhou, Medical Director
As a regional trainer and key opinion leader for the Discovery Pico laser as well as the ProYellow Laser, Dr. YZ Tan has met and trained many doctors in the use of these lasers, as well as done over 20,000 laser treatments (and counting) over the span of his career.
Having treated various types of pigmentation issues, he has harnessed the capabilities of the lasers, and is continuously improving and fine-tuning his laser treatments in search of the best way to remove pigmentation. Most of the patients he meets for the first time have the same common misconception about lasers, which is how this post came about!
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