Dark spots and pigmentary issues in Asian patients  (Part I: Prevention)

Dark spots and pigmentary issues in Asian patients  (Part I: Prevention) by Dr.Kang

Did you know that a typical Caucasian has an intrinsic SPF of 1 to 2 while an Asian may have an SPF of about 3 to 5,  which is equivalent to about twice the level of natural sun protection from UV radiation. Other ethnic groups with darker skin may have a natural SPF up to in the range of 9 to 13.5, providing even greater sun protection. This natural protection is made possible through greater melanin production that leads to less burning and lower rates of skin cancer in Asian and other ethnic skins types.

However this natural “sun protection factor” aka melanin produced by the melanocytes can create pigmentary issues for many patients as they enter into their mid to late 30’s. Yes, I am talking about the dreaded dark spots that begin to appear on your beautiful creamy beige (Fitzpatrick 3) or olive to brown (Fitzpatrick 4) or even dark brown (Fitzpatrick 5) skins. For some, pigmentary issues can occur even earlier during pregnancy from increased estrogen levels, triggering the melanocyte-stimulating hormone to produce more melanin. Some have also experienced pigmentary issues after oral contraceptives.

Chances are if you have a pasty white (Fitzpatrick 1) or fair to light creamy (Fitzpatrick 2) skin type, you have been paying attention to your Parents warnings and religiously protecting your skin from sun burn with sunscreen. But for many of you out there with Fitzpatrick 3 to 5 skin types who enjoy looking like the bronze goddess thanks to your ability to tan…..what you didn’t realize is that the repeated exposure to the harmful UV rays without sun protection, has been sensitizing your melanocytes to produce more melanin, ultimately leading to excess melanin clumping up and manifesting as those dreaded dark “sun” spots.

For some, this process can lead to more diffused and blotchy appearing pigmentary issues known as melasma and can occupy an entire anatomical zone on the cheeks, lower face, forehead, chin, or root of the nose. Melasma is also known as chloasma (mask of pregnancy) because it usually starts during pregnancy due to the sudden surge of hormones. The dark patches typically last until the pregnancy ends. However for some,  it can persist and continue to worsen depending on how hyper-sensitized your melanocytes have become from the hormonal surges and concomitantly, how much unprotected sunlight you might have been exposed to during this period.

So why do Asian and other ethnic skin types have more pigmentation issues?

Your melanocytes are located at the junction of epidermis and dermis and produce organelle called melanosome which are then pushed into your regular skin cells, the keratinocytes. It’s interesting to note that all humans in general have the same amount of melanocytes. However your ethnicity and your genetical make up determine how much melanosomes are distributed into your   keratinocytes and how much melanins are produced by these melanosomes, placing you into the various Fitzpatrick skin type along with tendency to burn (Fitzpatrick 1 to 3) or tan (Fitzpatrick 3 to 5). Many Asians in Fitzpatrick 3 originally hail from the northern part of the Far East with relatively light complexion compared to Asians from the South. Their initial response to UV rays is to burn. However as they chronically receive unprotected UV rays, they will tan more than they burn.  Clinically the sensitized melanocytes of these patients can behave unpredictably against their relatively light background complexion during the initial phase of the treatment, making Fitzpatrick 3 skins one of the trickiest and most difficult to treat for their pigmental issues.

So for patients with Fitzpatrick skin types 3 to 5, during your younger days, when the skin is exposed to the sun, melanin production increases, providing you with a glowing tan, essentially serving as your body’s natural defense mechanism against sunburn. As you enter into the Winter months, the tan goes away returning you back to your baseline skin color. However with repeated exposure to UV rays over many decades, melanocytes become progressively more sensitized to the repeated sun exposure and melanin production remains high, leaving you a shade darker compared to when you were younger. It is such a gradual process that most patients are usually not bothered by this unless it’s pointed out to them.  So far so good.  However as you age, the ability of your body to spread out the melanin evenly slows down and, and all it takes is a nice trip down to the Bahamas or sudden hormonal surges from the various triggers to crank up the extra production of melanin from an already sensitized melanocytes. For many Asians and others with ethnic skin, this process inevitably results in an eventual clumping of the melanin into dark spots or pigmentary issues, prompting many to seek treatment with a laser specialist.  Unfortunately any undue irritation or heating of the skin from sub-optimal choice of lasers can potentially create even more pigmentary issues, making it one of the most challenging patient population to treat using laser. I will be discussing more in-depth about the various laser treatments in “section II” of this topic in an upcoming blog, but suffice it to note that the lasers using “Nano” and “Pico” technology have really set the standards for treating Asians and other ethnic skins with pigmentary issues with usually a sound and predictably positive outcome.

Unfortunately sun is not the only cause of pigmentary issues. Inflammation of skin from blemish after acne, trauma, burn injury, or even poor choice of laser therapy as alluded to earlier, can all induce post-inflammatory hyperpigmentation (PIH) always worsened by exposure to unprotected sun. This  PIH usually improves with time, but may not completely resolve, once again prompting patients to seek care from their laser specialists.

Finally, the last culprit that’s often ignored is the drug-induced  photosensitivity, known to play a role in 10 to 20% of all cases of acquired hyperpigmentation. Once again it is not the drugs themselves but the drugs heightening your skin’s photosensitivity to the unprotected or poorly protected sun exposure. Some of the more common drugs include:

1. Antibiotics: doxycycline, tetracycline,  ciprofloxacin, levofloxacin, trimethoprim

2. Antifungal: griseofulvin

3. Antihistamine: promethazine, diphenhydramine

4. NSAID: ibuprofens, naproxen, ketoprofen, celecoxib

5. Choletrosl drugs: atorvastatin, lovastatin, simvastatin

6. Antidepressant: doxepin, other tricyclics

Start taking care of your skin early!  So, that you can minimize and perhaps even prevent dark spots from ever occurring.  But how? Well if there is one take home message, it is understanding that the best and the simplest way to prevent sunspots is knowing “how to” use your sunscreen effectively.  It is probably the most economical way as well. In order for you to start using sunscreen effectively, we need to debunk some of the myth about sunscreen use, and trust me using sunscreen “properly” is not as easy as you might have thought…..in fact, in a recent study, only 25% of people knew how to properly protect their skin with sunblock.

1. “As long as I put my sunscreen on in the morning, I am fully protected for the day”

Unfortunately, no….. especially if you happen to be doing outdoors activities. To remain optimally protected, you need to reapply sunscreen every two hours, or immediately after swimming or sweating a lot. At the least, always remember to reapply before you head to the park for a jog or a round of golf. Please don’t rely on that sunblock you put on much earlier in the morning. Your skin will thank you 5 to 10 years down the road.

2. “As long as I stay indoors or on a cloudy day I don’t need sunscreen”

Unfortunately, no. While “skin burning” UVB rays (represents only 5% of all UV rays but accounts for most of skin cancers) can’t penetrate through the home window and are partially filtered through clouds, “skin aging and pigment causing” UVA will penetrate through in both instances as well as through your car window.

The SPF (Sun Protection Factor) is based on the protection from the sun’s UVB rays. However the reality is 95% of all UV rays is UVA. These rays actually penetrates deeper into where melanocytes are, to cause pigmental issues as well as deeper into the dermis to cause gradual weakening of the collagen layer.  As the skin type of the US is quickly changing to encompass more Asian and ethnic skin types, we must all understand that it is the chronic unprotected exposure from UVA which will lead to “pigmental issues” in Asian and other ethnic skin types and “photo-aging and skin wrinkling” in all of the skin types. Therefore, please make sure you are applying sunblocks labeled “Broad Spectrum” with excellent coverage of both UVB as well as UVA rays.

In general for patients with pigmental issues or malesma, “Physical” or “Mineral” sunscreens (as opposed to “Chemical” sunscreens) containing minerals such as Zinc Oxide and Titanium Dioxide are the best because they have excellent blocking properties of both UVA and UVB rays. There are many well vetted brands of sunscreens containing up to ranges of 15% to 20% of mineral content which should provide you with excellent protection of both UVA (pigment and aging) and UVB (sunburn)rays.

3. “A higher SPF allows for longer coverage”

Unfortunately yes and no. There is a popular misconception that SPF is directly related to “time” or length of sun exposure. Another words, If a sunscreen has a SPF of 30, you would be able to stay in the sun 30 times longer than you could without protection, which is “falsely” reassuring for two reasons.

First, SPF actually relates to the “amount” of sun protection which relates to both “intensity” as well as “length” of sun exposure. Intensity in turn depends on the “time” of the day and your geographical location; and, the best gauge for intensity is the “UV Index”. The next time you scroll down your smart phone to look up the local weather forecast, you will enjoy the most up to date UV index. On the same day, New York may have UV index of 4 (low),  North Carolina of 6 (moderate), Miami of 8 (high), Punta Cana of 11 (very high). If you have fair skin that burns easily (Fitzpatrick 1 and 2), you can stay out in the sun unprotected for 20 minutes in NY while you will start burning within 10 minuted in Miami or 6 minutes in Punta Cana. For Asian and other ethnic skin types, you can factor in two to four times longer time before you experience burning.  Another words, SPF will protect you from the sun for different duration of time depending on the  intensity or the UV index of your sun exposure.

Second, if you are using chemical sunscreen (everything other than Zinc Oxide and Titanium Dioxide), the sun will break down as much as 90% of their effectiveness within the first few hours, thus recommendation that you reapply sunscreens every two hours while outdoors in the sun.

So in summary, the numerical value of your sunblocks’s SPF should not be equated with how much longer you can stay out under the sun, but rather, how much UVB rays are being blocked out if properly applied (which is “ideally” every 2 hours while you are outdoors)

Presently the biggest issue with SPF system is that it has no bearing or guidance on your exposure to UVA which actually represents 95% of all UV rays and accounts for most of the the pigmentary and aging changes. As a result the rest of the world has implemented “UVA protection” systems using “PA” in Asia and “PPD” in Europe.

In summary what’s most paramount for Asian and really all the skin types is that you are using a “Broad Spectrum” sunblock containing high mineral content to effectively block out both UVA and UVB rays and that you ideally reapply the sunblock every 2 hours, especially if you are spending time in the outdoors for extended period.

4. “I tan easily or I have dark skin so I don’t need sunscreen”

Unfortunately no. While Asians have a natural SPF of 3 to 4 and darker ethnic skin may have SPF of up to 13.5, it is still less than a sunscreen with SPF of 15 which only blocks out 93% of “sunburn and cancer” causing UVB rays. Another words, Asians and darker skin still can get sunburned as well as develop skin cancers from UV damage.

Despite everyone wishing a glow from the sun exposure, the reality is that there is no such thing as a “healthy” tan. Tan is a result of your skin trying to increase melanin production in an attempt to protect further damage at a cellular level from the UV rays. Chances are if you have the skin type which rarely burns, you will still tan even with the sunblock. However using sunblock, you will be able to maximally protect yourself from the insidious photoaging damage and pigmentary issues and still receive a bit of “healthy” tan.

5. “The SPF of 15%  in my makeup and moisturizer is all I need”

Unfortunately no…. while SPF of 15% in most make ups and moisturizers provide some additional protection, they are not “Broad Spectrum” sunblocks and and will be a poor substitute as your only source of sun protection.

6. “Sunblocks are oily and make me break out”

Patients who are prone to breaking out essentially have sensitive skin and as such, are careful about lathering up their face with any chemical containing lotion. Thankfully, there are enough highly regarded sunblocks that are labeled “non-comedogenic”  and “preservative free” out in the market. In fact some are specifically formulated for “acne-prone” skin. You can go to any reputable cosmetic counter or your specialist office and easily access a sunblock made specifically for your acne prone or sensitive skin.  Finally, you should avoid sunscreens containing  “Oxybenzone” due to allergy reaction and “Parabens” due to their association with carcinogenic and aging effect.

In summary, for most of you out there in your 40’s and up who hadn’t sun protected your skins while in your 20’s and 30’s, your melanocytes would have become sensitized enough that by now, you are having to deal with these pesky pigmental issues. Fortunately for now, you can easily conceal them with foundation.  However keep in mind that although Asian skins develop wrinkles about a decade later than Caucasians, for many, skin wrinkles tend to appear more coarse and thicker due to inherent thickness of the Asian skin. When this occurs, the foundation that use to cover the pigments flawlessly, will begin to cake and settle into the inevitable lines and wrinkles. For many this becomes a dilemma as they enter 60’s and older because covering their pigments with the foundation had become a daily ritual for the past few decades; but as they age, they find it increasingly more difficult to conceal their pigments without looking all caked up. Hopefully by using Broad Spectrum sunblocks beginning early in life, you will be able to “prevent” the woes and frustration of having to camouflage these pigmental issues later on in your life.

Conversely, for those of you in your early 20’s of Asian or other ethnic descent, you really needn’t look further than seeing your parents and grandparents to see how much photoaging and pigmental issues you may be encountering within a few decades.

I promise you “prevention” is the best type of treatment when it comes to pigmental issues, and will also help with less wrinkles, coarseness, and drying of your skin as well.  Please share this Blog with your friends and children so they begin to wear Broad Spectrum Sunblock early to minimize photoaging and pigmental issues later on in their life.

In “part II” of pigmental issues in Asian and other ethnic skin types, I will discuss different options of treating your pigmental issues including topical therapy as well as what is considered the golden standard of laser therapy for pigmental issue in 2020.