Experts advise multifaceted strategy for hyperpigmentation

Las Vegas - Treating excess pigmentation without hydroquinone requires a multipronged attack, including thoroughly researched agents wherever possible, according to experts at Cosmetic Surgery Forum, held here.

“What’s hot in the skin brightening market is the ‘hydroquinone holiday,’” says Manjula Jegasothy, M.D., associate clinical professor of dermatology, University of Miami Miller School of Medicine. With physicians and the Food and Drug Administration expressing concerns about hydroquinone side effects including hyperpigmentation, she adds, “There’s been an explosion in hydroquinone-free brighteners.”

In this product category, she says, Elure Skin Brightening Complex (lignin peroxidase, Syneron) stands among the most thoroughly researched options. Its active ingredient has been widely researched and is derived from a common tree fungus, she says.

“While hydroquinone prevents the development of progressive pigmentation, lignin peroxidase has been shown to break down melanin in the keratinocyte, thereby reducing pigment already present,” Dr. Jegasothy says. “It could be postulated that if your hyperpigmentation is more superficial, then this product may be more effective than even hydroquinone, because it addresses the keratinocyte.”

According to Carl R. Thornfeldt, M.D., “Lignin peroxidase is an interesting approach, because it breaks down the eumelanin, and produces faster results than hydroquinone. But remember, pheomelanin is involved as well,” and he is unaware of any effects the product has on this type of melanin.

Furthermore, he says, the pigmentation process includes 14 major steps and three auxiliary steps. “Hydroquinone works on only one of those steps. A couple products, like licorice, address three of those steps. But because it’s a continual, dynamic change, and melanocytes are responding to various insults in the area, those cells will be at different stages of development. So for me as a skin biologist, it doesn’t make sense” that inhibiting just one step will produce optimum effects.

Rather, he says, “You must stop the whole process - the activation, synthesis and distribution of melanin.” Dr. Thornfeldt is a private practitioner in Fruitland, Idaho and is CEO and founder of Episciences.

Jeannette Graf, M.D., agrees that because pigmentation is such a complex problem, “I like to throw everything at it.” Rather than relying solely on Elure, she says, “I use multiple tyrosinase inhibitors, as well as serine protease inhibitors, which inhibit the melanosome from dumping melanin into the surrounding epidermal keratinocyte.”

Total Soy Complex (Aveeno/Johnson & Johnson) contains both types of inhibitors, she says. Dr. Graf is assistant clinical professor of dermatology, Mount Sinai School of Medicine, New York.

Vivian Bucay, M.D., notes that treating pigmentation also requires addressing vascularity. In this regard, a study has shown upregulation of vascular endothelial growth factor (VEGF), as well as the presence of more and larger vessels, in perilesional skin of melasma (Kim EH, Kim YC, Lee ES, Kang HY. J Dermatol Sci. 2007;46(2):111-116. Epub 2007 Mar 23). Accordingly, she says that henceforth, “We will see more of a trend toward addressing vascularity, as well as pigmentation.” Dr. Bucay is in private practice and is a clinical assistant professor of dermatology, University of Texas Health Science Center, San Antonio.

Disclosures: Dr. Thornfeldt is a shareholder in Episciences. Dr. Jegasothy reports no relevant financial interests. Dr. Graf is a consultant for Allergan, Merz, RXi Pharma, Neutrogena and Johnson & Johnson, but reports no financial interests relevant to any of the topics discussed. Dr. Bucay is a consultant for Allergan, Merz, Biopelle, Aveeno and Ferndale Labs.