The Anti-Aging Series: How to Address Pigmentation Issues

Photo by Tiago Muraro on Unsplash

Anti-aging is a loaded term. One, I hate the negative connotation. We all will age; it is inevitable. It would be odd if we were 65 and still looked 16. There is beauty in “maturing” and I like to think about it like this: how do we slow the process down so we feel good when we look in the mirror?

Two, it’s a really broad term. There are many factors that contribute to a face looking older, including pigmentation from chronic sun damage, volume loss, and wrinkles from laughing too much.  When a product is labeled “anti-aging,” what does it ACTUALLY do?

• Does it lighten your dark spots?

• Does it give you a volume boost?

I think of it mostly as a cat-fishing marketing term, designed to make you feel insecure about whether or not you are looking old. 

Over the next few posts, I’ll illuminate and break down:

• What does anti-aging really mean? So you can have ownership and agency over what exactly is bothering you and what will make you feel your best

• Available treatments to target these issues

Example of a solar lentigo, although they can come in various shapes and sizes (image from dermnetnz.org).

Let’s start with pigmentation issues.

When patients come in complaining of looking old, it’s my job to pinpoint what about looking old is bothering them the most. For most people, it’s the sun spots or “liver spots” that they notice the most. So what are they and why are they there? 

The technical term for sun spots is solar lentigines, which, you guessed it, are due to chronic sun damage.  These are flat, light brown and tan spots that show up on areas that are exposed to sun, like your face and arms. Check out your butt - unless you are a thong bikini wearer (and if so, more power to you!), there will unlikely be any solar lentigines there. 

This is what a solar lentigo looks like microscopically. Note the darkly pigmented tips (rete) of the epidermis.

Your skin cells, or keratinocytes, don’t like ultraviolet (UV) exposure.  UV damages the cellular DNA of the keratinocytes, leading to mutations that increase your risk of skin cancer. For a deep dive on the molecular mechanisms of UV damage in the skin, check out this great review article.

In order to protect themselves from the harmful effects of UV light, keratinocytes will produce melanin, the pigment in our skin. 

Melanin acts as a “natural sunscreen,” blocking harmful UV rays, as well as acting as an antioxidant. This production of melanin in response to UV exposure is the mechanism behind the tanning response, as well as the reason why solar lentigines form.

Okay, so you don’t need to go to the extremes of wearing a facekini, but you get my drift.

The best treatment is prevention!

How do you prevent them? Minimize sun exposure (which is the key to reducing all of these signs of aging). So, if you are younger than 30, wear your SPF 30 sunblock, wide brimmed hats, and try to avoid midday activities.  Believe me, your future 60 year old self will thank you!  

If it’s too late for prevention, there are options. 

Before I dive into what treatments are available, I have to say a word about maintenance.

If you are thinking about treating your sun damage, you should also be committed to a vampire-like lifestyle once treatments are over in order to prevent these spots from coming back. There is no magic, permanent cure. Many patients get treated and often come back upset that their spots have returned. If you’re not going to do the work to protect the time and money you spent to solve this issue, it’s probably smart to not dive in until you are ready.

1. The quickest and most efficient way to get rid of those dark spots is laser.

   Not all lasers are created equal. The most effective ones are those that have a wavelength that specifically targets melanin. One comparative study showed that a frequency-doubled Q-switched Nd:YAG laser is the most effective, compared with liquid nitrogen treatment (a.k.a freezing). Because it targets melanin specifically, it minimizes the damage to surrounding tissues. 
   

2. Another light-based device used often is the intense pulsed light (IPL) device.

   It only works on fair skin, as it does not specifically target melanin and has a high risk of causing burns on those with darker skin. IPL also works well for other skin issues from chronic sun damage, such as redness or blotchiness. 

Investing in laser treatments is a pricy endeavor, so are there any topical treatments?

Why, yes, there are!

1. Topical hydroquinone is a compound that interferes with the synthesis of melanin by melanocytes (the cells that produce pigment in the skin). When combined with a retinoid and topical steroid, it lightens up solar lentigines like magic. Higher concentrations, available by prescription and used under the guidance of a dermatologist, are your best bet, but trying an over the counter product first won't hurt.

2. Chemical peels, used in higher concentrations and applied in office, can also lighten up these spots, specifically glycolic acid, Jessner's, or trichloracetic acid. In my opinion, over the counter “actives” such as vitamin C, kojic acid, and niacinamide work better for prevention, rather than a primary treatment of solar lentigines.

Of all of these options, I have found the highest patient satisfaction with the IPL treatments.

I hope this review of pigmentation issues was helpful in understanding one aspect of what makes us look “older.” Stay tuned for a rundown on wrinkles and volume loss!

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