We have to be careful when treating pigmentation marks because the oriental skin is easily damaged. None of us wants to treat someone and then find that the mark is larger and darker than before. I believe that it is better to use safer ingredients to try and lighten pigmented marks.

How do we achieve that?

The first line of treatment is defence against sunlight. If the client does not protect the skin, then it is not worthwhile trying to treat these pigmentation marks. These marks are particularly resistant in Japanese.

If you look at old-fashioned farm-working women, they will notice almost none of them have any "shimi" marks. That is because these ladies wear thick scarves around their faces when they are out working in the fields and they get virtually no sun exposure at all. Light coloured skin is prized as a feminine point of beauty, so these workers are very careful to avoid the sun on their faces and hands. I ask clients with "shimi" to try and do the same thing by wearing thick wide-brimmed hats or use a black umbrella so that they reduce the amount of sun coming into contact with the pigmentation mark. If they do not do that, then, I warn them, it will be much more difficult to get a satisfactory result.

The next important point is to protect the skin with a sunscreen that is especially strong in the UV-A range. Here you have to be informed about ingredients. Look at the list of ingredients and try and identify the sunscreen agents. 

Most "broad-spectrum" products have benzophenone (or oxybenzone) as their UV-A screen. In fact the protection is inadequate because it allows a lot of "soft" UV-A rays into the skin. Parsol 1789 (butyl methoxydibenzoylmethane) or titanium dioxide and zinc oxide provide much better, though still inadequate protection from UV-A. Japanese and Chinese clients with pigmentation problems should be sure to use skin care products with the best protection from UV-A and need not use a UV-B protection rate greater than SPF 16-20.

Once you have established that the sun protection is as good as we can make it, then you can concentrate on reducing the melasma. Of course I do not mean that you have to hold back treatment.

The safest and most physiological active agents to use for lightening pigmentation are vitamin A and C, and lactic acid. Antioxidants should be used in conjunction and I recommend oral antioxidants as well as topical products because one needs to persuade the melanocyte to make as little melanin as possible. Oral vitamin C may be useful in lightening pigmentation provided that adequate sun protection is being used. I recommend about 1000 mg of oral vitamin C (best taken as the ester) and I also use the strongest vitamin C that I know of as a topical agent.

I use a product with ascorbyl tetra-isopalmitate which is much more effective than 15% ascorbic acid or magnesium ascorbyl phosphate. This form of vitamin C is absorbed into the cell in high concentrations and creates an antioxidant atmosphere that counteracts the oxidising atmosphere that is necessary for the chain of reactions that produce melanin. In addition it is a tyrosinase inhibitor.

Vitamin C in the tissues also reduces the damage caused by UV rays. An advantage of ascorbyl tetra-isopalmitate is that it does not irritate or exfoliate skin. I have used ascorbic acid but I worry that the exfoliant activity might reduce the protection afforded by the horny layer. The horny layer is our greatest natural protection against sunlight – even better than a tan! I have had a great deal of success with magnesium ascorbyl phosphate, which suits the Oriental skin superbly.

Vitamin A works on the DNA and controls of the production of melanin and works wonderfully well with vitamin C. However, I have found that rather high levels of vitamin A are necessary to do this. In my experience the best form of vitamin A for treating pigmentation is either retinol or retinyl acetate but bear in mind that these agents in high dose may cause a retinoid reaction. I have seen favourable results with retinyl palmitate but it takes a longer time and seems more suitable for maintenance therapy. I believe that high doses of vitamin E are also necessary for Orientals to give a wider spectrum of antioxidant support.

Lactic acid is another important physiological agent that lightens pigmentation blemishes. It can be used as either ammonium or sodium lactate and is most effective at concentrations greater than 5%. I recommend that it should be used as a toner for the skin as it usually comes in liquid form.

With persistent use of these important agents one can get a favourable result even though it may take time. The great advantage is that there will not be a rebound hyperpigmentation as one often gets with hydroquinone. These are physiological agents and they can all be used for treatments with iontophoresis and sonophoresis to get an even faster result.

Peeling for pentration of actives

Iontophoresis and sonophoresis are not available to everyone so here is where I believe we should use careful, light peeling to improve the penetration of the active ingredients. I believe that we should see that peeling is merely a way of getting better penetration by removing the obstruction of the intact horny layer. We need only to make the horny layer more penetrable, not to destroy it. That is where ultra light peeling becomes extremely useful.

I use a preparation of lactic acid (in preference to glycolic acid) at a pH of about 3 to 3.5 in a low concentration of 10%. This means that the exfoliation will be minimal, even invisible. I prepare it in a thick gel which can then be painted onto the skin and then allowed to dry in five minutes. In Oriental patients I only use this in one layer. There is no chemical burning, and the important thing is that the bonds between the cells of the horny layer become less obstructive to the penetration of products placed on the skin.

I also use ascorbic acid at 15% and above as a peeling agent. The advantage is that the very chemical that you need to get into the skin is also the peeling agent. The treatment will facilitate the penetration of the vitamin C. Of course the vitamin C has to be ultra fresh and has to be mixed at the time of treatment. Once we have made the horny layer more permeable, we can then apply products containing vitamin A and C or any other active that lightens pigmentation. Of course this sort of treatment can only be done about once a week and the client has to make sure that they are well protected from the sun.

There are a number of other special ingredients such as licorice or vanilla extracts and many people like to use arbutin, but I have not had experience with this. I have refrained because some research suggests that the arbutin is changed into hydroquinone in the cells. Maybe I have been over-cautious.

I have used azelaic acid but in general one has to use a 20% concentration which is only available as a medical product. In lower concentrations it does work to a degree, but the disappointment is that the improvement is not maintained. For difficult cases, rather ask the client to get a prescription for azelaic acid from her doctor or dermatologist and use this in conjunction with a good mixture of vitamin A and C.

Another useful agent is kojic acid but here again the concentration has to be rather higher than one can get in a simple cosmetic product. Kojic acid is part of the manufacture of sake and the hands of the workers in the sake factory that I visited, impressed me. Their hands were pale and did not have the usual blemishes that one sees in mature Japanese men. The skin looked healthy and I can only surmise that kojic acid is not irritant to skin.

Licorice extract (glyzerrhetinic acid) is very expensive and is usually supplied in very low doses in cosmetic products. I also tried other products like vanilla extract with some success – but not enough. When I am desperate I have used these agents but I often find that the initial rapid lightening is not maintained.

The problem with treating pigmentation is that we are not interested in 60% lightening and the Orientals especially are not interested in a partial result. Only the complete disappearance of the marks will satisfy. Whatever success we may have had at night in reducing the pigmented marks, the fact is that everyday the sun undoes most of our work and stimulates the melanocyte to make more pigment. That is the battle that we have with Oriental skin. However, take my advice and never be tempted to destroy the melanocyte in Orientals.