Skin Pigmentation Disorders: Aetiology, Assessment and Aesthetic Treatment Options

CLINICAL ▼
Skin pigmentation disorders: aetiology,

assessment and aesthetic treatment options
While topical hydroquinone (HQ) remains the gold

Abstract standard treatment for hyperpigmentation (Kim and
There are various types of skin pigmentation disorders, from less severe forms Cho, 2010), it has significant side effects such as skin
such as freckles, solar lentigines and post-inflammatory hyperpigmentation, irritation and sensitivity, dermatitis and increased hy-
to more severe conditions such as melasma and chloasma. Skin pigmentation perpigmentation. Therefore, it is vital for aesthetic prac-
disorders are more commonly seen in women due to hormonal factors, and titioners to be aware of the vast range of treatment op-
those with darker skin types. Hyperpigmentation is a chronic disorder that tions that are available to them. Laser and light therapies
can be frustrating for patients and health professionals alike because it is and revolutionary advanced cosmeceuticals can also act
very difficult to treat. Like acne vulgaris, pigmentation disorders can cause as effective alternatives to HQ.
significant stress and embarrassment for patients, so understanding the In this article, the author will examine common types
different types of hyperpigmentation and identifying appropriate treatments of hyperpigmentation and explore the evidence support-
is vital for aesthetic practitioners. Integrating new treatments, products and ing current treatment options.
protocols will benefit patients as well as aesthetic practices when effective
results are achieved. This article will discuss the mechanisms known to be Skin pigmentation disorders
involved in pigment formation, explore various treatment modalities currently Common skin pigmentation disorders include melas-
available to treat skin pigmentation disorders, and recommend ways to ma, post-inflammatory hyperpigmentation (PIH), solar
manage patient expectations during the initial consultation. lentigines, ephelides (freckles), genetic dermal hyper-
pigmentation and drug-induced hyperpigmentation. In
Key words general, hyperpigmentation is caused by an increase of
► Hyperpigmentation ► Skin ► Chemical peels ► Laser and light therapies melanin in the skin due to sun damage, inflammation
and skin injuries (including acne scarring) which can
also leads to darkening of the skin.
H
yperpigmentation is a skin condition that is The synthesis of melanin is a complex multistep proc-
frequently seen in medical aesthetic clinics. ess, catalysed by at least one or a number of enzymes,
Those affected by skin pigmentation disorders the most prominent of which is tyrosinase (Slominski
often report feeling self-conscious and/or de- et al, 2005). Melanin, the type of pigment responsible
pressed about their appearance (Kim and Cho, 2010). for colour in the skin, hair and eyes, is produced by
In some Asian cultures, pigmentation can be more of a melanocytes at the lower layer of the epidermis (Slo-
concern to people than wrinkles (Kim and Cho, 2010). minski et al, 2005). Ultraviolet (UV) light stimulates
As non-surgical cosmetic procedures are becoming melanocyte activity and with age the regulation of
more popular in the UK and beyond, the demand for melanocyte distribution is less controlled by the body
treatments for hyperpigmentation is also on the rise. meaning it is more common for age spots, sun damage,
To effectively treat patients with hyperpigmentation, freckles and melasma to appear (Dayan, 2008). Those
aesthetic practitioners will need to recognise the type with darker Asian, Mediterranean or African skin tones
of pigmentation they are being presented with to de- are more prone to hyperpigmentation (Kim and Cho,
termine the most appropriate treatment(s) for the best 2010), especially if they have undergone excess expo-
results. If hyperpigmentation is treated incorrectly, it is sure to sunlight.
possible for it to appear worse than it was when the pa- Pigmentation disorders are broadly divided into
tient first presented to the clinic. hypermelanotic, where there is excess melanin but
a normal level of melanocytes, and hypermelano-
© 2014 MA Healthcare Ltd
cytic, where there is excess melanin and an increased

LAUREN SIBLEY number of melanocytes. These skin conditions can also
Lead Aesthetic Practitioner and Clinic Manager, be hypomelanotic/ameianotic and hypomelancytic/
Juvea Aesthetic, London. amelanocytic in nature, caused by melanin deficiency
e: lsibley@juveaaesthetics.com and a reduction or absence of melanocyte numbers, re-
spectively (Katsambas and Dessinioti, 2014).
224 Journal of AESTHETIC NURSING ► June 2014 ► Volume 3 Issue 5
Journal of Aesthetic Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on April 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
▼ CLINICAL
Aetiology and diagnosis ►► Create a broader, more effective treatment plan

Although the main risk factor for hyperpigmentation ►► Monitor treatment progress
is exposure to natural or artificial ultraviolet (UV) ra- ►► Accurately assess treatment outcomes
diation, hormonal factors have been implicated in the ►► Fulfil all the attributes of skin health (e.g. smooth,
pathogenesis of more severe forms of hyperpigmenta- firm, hydrated and even-toned).
tion such as melasma (Bandyopadhyay, 2009). This is
because these skin conditions more commonly affect Medications
women and can be associated with hormonal distur- It is essential for aesthetic practitioners to make a note
bances, oral contraceptives and pregnancy (Lufti et al, of any medications their patients may be taking as they
1985; Ortonne et al, 2009). could contribute to their skin pigmentation. For exam-
ple, the contraceptive pill can often be a cause of melas-
Post-inflammatory hyperpigmentation ma on the upper lip in women (Bandyopadhyay, 2009).
PIH presents owing to facial acne vulgaris, which com-
monly occurs in patients with Fitzpatrick skin types Pigmentation history
IV–VI and can have a considerable effect on quality of The next step will be to get a further understanding of
life. PIH can be a source of embarrassment, self-con- the hyperpigmentation by asking patients when they
sciousness and frustration for patients, and often inter- first may have noticed it, what treatments and products
feres with daily living activities (Kim and Cho, 2010). they have already tried, and whether they have noticed
Although topical HQ is the currently the gold standard anything which exacerbates the condition.
treatment for PIH (Kim and Cho, 2010), other conven-
tional treatments for this skin condition include gly- Skin condition
colic acid peels, salicylic acid peels, topical tretinoin, The author then determines the condition of the pa-
topical steroids, topical kojic acid, Q-switched laser and tient's skin by analysing it with the Visia machine (The
combination therapies (Kim and Cho, 2010). Cosmetic Imaging Studio, London). Visia uses mul-
tispectral imaging to reveal signs of pigmentation and
Melasma skin damage, as well as other imperfections and signs
Although the aetiology of melasma remains poorly of ageing. The author uses Visia skin analysis as a tool
understood, it is mostly attributable to sun exposure to create a patient-specific treatment plan. Using this
and genetic predisposition. Melasma presents as ir- technology also has the benefit of monitoring a pa-
regular, light to dark brown, grey, blue or black macules tient's progress, as it allows the patient to see any skin
and plaques, mainly on the face and also on the neck, condition improvements themselves.
and the décolletage (Bandyopadhyay, 2009). Although
melasma is more commonly seen in women, men make Treatment planning
up 10% of reported cases (Katsambas et al, 2003). At the end of the consultation, the author discusses
Three clinical types of melasma exist based on distribu- the best treatment options with the patient based on
tion: centrofacial, malar and mandibular (Deo et al, 2013). the type and severity of hyperpigmentation. Many fac-
Melasma is also classified by the degree of melanin deposi- tors are involved in the elimination of pigmentation
tion in the skin (epidermal, dermal and mixed) (Deo et al, treatments when creating skin health restoration. The
2013). Epidermal melasma is the most common type and is author uses Obagi's (2014) essential and practical skin
characterised by increased melanin in the dermis, whereas classification, which helps in clinical treatment and
mixed melasma refers to a combination of epidermal and selection of the proper procedure and depth. Skin is
dermal melasma (Rivas and Pandya, 2013). classified by thickness (thick, medium, thin); colour
(original, deviated); oiliness (oily, dry); laxity (skin, skin
Consultation + underlying muscle); and fragility (strong, fragile).
When a new patient comes to the author's clinic, she To select the correct topical agent for treatment the
takes a full medical history before starting the consulta- classification is based upon the mechanism of action
tion. The author conducts her consultations based on as well as the therapeutic value of the agent. Topical
Zein Obagi’s skin health restoration principles, where agents can be classified as essential (must always be
'healthy' skin is smooth, firm, even in colour, hydrated, used); supportive (maximise benefits when used along
tolerant and free of clinically apparent disease with essentials); questionable; and no proven benefits
Through having an in-depth consultation with the (Obagi, 2014).

patient, practitioners are able to:
►► Perform a comprehensive skin analysis Managing expectations
►► Establish a detailed diagnosis Patients with hyperpigmentation require ongoing treat-
►► Enable treatment of not only the main problem, but ment and reducing the visibility of pigmentation can
also associated problems be a lengthy process. Consequently, managing patient
Volume 3 Issue 5 ► June 2014 ► Journal of AESTHETIC NURSING 225
CLINICAL ▼
expectations during the initial patient consultation is ered to be the rate-limiting enzyme for the biosynthe-
crucial, no matter how severe the condition is. sis of melanin in epidermal melanocytes, its activity is
Like with all aesthetic treatments, patients want a thought to be a major regulatory step in melanogenesis
'quick fix' and rapid results. However, it takes at least (Baumann and Allemann, 2009). There are several prod-
2–6 weeks for treatments to take effect and 5 months ucts on the market containing ingredients that inhibit
of daily use for maximum results. Moreover, between tyrosinase and thus decrease melanin formation. These
treatments, patients can suffer from skin peeling which ingredients include aloesin, arbutin, kojic acid, liquorice
can be irritating, uncomfortable and make them feel extract, emblicanin, paper mulberry or mulberry extract
self-conscious. This is especially if the patient has (Baumann and Allemann, 2009).
undergone a chemical peel or is on a protocol of HQ-
based or retinol-based products. In light of this, it is im- Hydroquinone
portant to give the patient all the facts about what they The most common treatment for melasma remains topi-
can expect during and after treatments. cal HQ at concentrations of 2–4% (Halder and Richards,
To manage patient expectations at the initial consulta- 2004). Clinical improvements usually present after 4–6
tion, the author thoroughly explains how their particular weeks (Rivas and Pandya, 2013); however, long-term
treatment will work. The author also explain the trans- treatment and prevention has been difficult to achieve,
formations their skin is going to go through and what as traditional dermatologic treatments address the skin
they will experience at each stage of their treatment. It is surface and symptoms without addressing cellular func-
made clear that patients are likely to suffer skin peeling, tion or improving the overall skin condition (Obagi,
redness, irritation, itching and burning, and that these 2014). Cosmetic products containing HQ are often la-
are normal signs of the skin repair response. The author belled as 'skin brighteners' (DeCaprio, 1999).
also provides patients with basic tips, such as using fewer HQ occurs naturally in various plant-derived foods
pumps of a product or decreasing frequency of applica- and drinks, such as vegetables, fruits, grains, coffee, tea,
tion if excessive irritation occurs. beer, and wine (DeCaprio, 1999). It exerts its depigment-
As the skin becomes stronger and more tolerant fol- ing effect by inhibiting tyrosinase and by virtue of its
lowing regular treatment, less irritation will occur. The cytotoxicity to melanocytes (Penney et al, 1984), and is
first 6 weeks are always the hardest for patients with known to cause reversible inhibition of cellular metabo-
hyperpigmentation, however It is important to stress lism by affecting both DNA and RNA synthesis (Nord-
that patience is key and that perseverance will lead to lund, 1988). HQ is also an efficient blocker of tyrosinase
optimum results. Results and comfort do not necessar- and has been shown to decrease its activity by 90% (Nor-
ily go hand in hand—the success of treatment comes dlund, 1988). Although HQ is effective as a sole agent,
down to patient compliance. Aesthetic practitioners it can often combined with other ingredients such as
provide the tools and knowledge to improve the con- tretinoin, glycolic acid, kojic acid and azelaic acid (Gue-
dition of the skin, but it is down to patients to follow vara and Pandya, 2001).
their treatment protocol. The author always makes her In the 40 years that HQ has been on the market, no
patients aware that she is contactable at the clinic at human cases of cancer have been attributed to its use
all times for concerns regarding their treatment, even if (Baumann and Allemann, 2009). However, the Food and
they simply require some support and advice. Drug Administration (FDA) has expressed concern about
side effects associated with topical use of HQ, which can
Treatment options lead to a condition called exogenous ochronosis (Picardo
There is a vast range of treatment options for skin pig- et al, 2007). Ochronosis presents as asymptomatic blue–
mentation, with varying degrees of efficacy and success. black macules in the area of HQ application, which put
Treatment modalities include depigmenting agents, simply is a more permanent form of hyperpigmentation.
chemical peels, topical retinoids, laser and light therapies It usually occurs after prolonged use of HQ in concen-
and combination therapies and less studied treatments. trations of 4% (Lawrence et al, 1988). Exogenous ochron-
osis occurs more frequently among patients with darker
Depigmenting agents skin types (Barrientos et al, 2001).
Topical agents used to treat hyperpigmentation include
tyrosinase inhibitors, melanosome-transfer inhibitors, Topical retinoids
melanocyte cytotoxic agents, topical retinoids, peeling Retinoids are a family of compounds derived from vi-
agents and sunscreens (Baumann and Allemann, 2009). tamin A that includes betacarotene and other caroten-
oids, retinol, tretinoin, tazarotene, and adapalene (Bau-
Tyrosinase inhibitors mann and Saghari, 2009). Several different substances
Tyrosinase is the enzyme that controls the synthesis of comprise the family of retinoids, which are lipophilic
melanin and is a unique product of melanocytes (Bau- vitamin A derivatives that easily penetrate the epider-
mann and Allemann, 2009). As tyrosinase is consid- mis (Ortonne, 2006). The effect of retinoids on pigmen-
▼ CLINICAL
tation involve various mechanisms which have not yet case with HQ, which often is used in combination with
been completely identified. Retinoids exert their depig- retinoids (Kligman and Willis, 1975).
menting effects directly by influencing melanocytes as
well as indirectly by modulating melanogenesis (Nair et Laser and light therapies
al, 1993). Topical retinoids have been shown directly af- Skin pigmentation disorders are often associated with
fect melanogenesis via tyrosinase expression (Orlow et skin ageing and overexposure to the sun. From the age
al, 1990; Nair et al, 1993; Ortonne, 2006). of 30 years, the skin is less able to regenerate from sun
It has been suggested that, by inhibiting the detoxi- exposure and age spots start to appear (Grimes et al,
fication of toxic species, retinoic acid enhances the 2008). Although these age spots pose no health risk
melanocytotoxic effect of depigmenting agents (Kasraee (Grimes et al, 2008), they can be unsightly and create a
et al, 2003). By accelerating the cell turnover of epider- patchy, less youthful appearance.
mal keratinocytes, topical retinoids promote a decrease Freckling and age spots can be successfully lightened
in melanosome transfer to the keratinocytes and induce or removed with an alexandrite 755 nm laser (Patil and
dispersion of keratinocyte pigment granules leading to a Dhami, 2o08) such as the Elite MPX (Cynosure, Berk-
uniform distribution of melanin content in the epider- shire), which the author uses in her clinic. However, the
mis (Kasraee et al, 2003). More rapid epidermal turnover wavelength of this laser is only suitable for Fitzpatrick
also reduces the cohesiveness of corneocytes and thus skin types I and II. In the author's experience, for epi-
induces desquamation that consequently leads to an ac- dermal and dermal pigmented lesions such as melasma,
celerated loss of melanin in the stratum corneum. Part of a Q-switched 1064 nm laser gets incredible results. Q-
the effect is based on the stimulation of the cell turnover switched lasers use photoacoustic energy to break down
of epidermal keratinocytes, which promotes a decrease the pigment into tiny particles which is then slough
in melanosome transfer and accelerates the loss of mela- away (Patil and Dhami, 2o08). In the author's experience,
nin via the epidermopoiesis (Kasraee et al, 2003). for light pigmentation such as age spots or freckles, they
The side effects of retinoids, such as dryness, irritation can be lightened or completely removed in as little as 1–3
and scaling, are signs of a damaged skin barrier. This treatment sessions. The light targets areas of excess pig-
condition allows for other agents to more readily pen- ment by safely breaking down the excess melanin and,
etrate into the skin and enhance their efficacy, as is the while the pigmentation may darken in the first few days
CLINICAL ▼
after treatment, the excess melanin then sheds naturally that are anti-inflammatory, stimulating and pigment-
away (Patil and Dhami, 2o08). For deeper pigmentation, correcting. According to Obagi (2014), the principles
it may take between 1–3 monthly treatments to see maxi- and steps of a skincare regimen are:
mum benefits. ►► Preparing the skin
To further support the benefits of using a Q-switched ►► Epidermal stabilisation to improve the epidermis, re-
laser to treat PIH, a study was carried out in Korea by to pair DNA, provide anti-inflammatory agents, and en-
evaluate its effectiveness for facial acne and PIH (Kim sure constant epidermal renewal and maintenance of
and Cho, 2010). Forty participants aged 19–27 years skin strength
with PIH and mild-to-moderate acne did not use any ►► Melanocytes stabilisation to make melanocytes resist-
other skin-lightening products for the duration of the ant to harmful external and internal stimulation that
study, with a washout period of 5 days for patients us- leads to discolouration
ing topical retinoids or other regimens with secondary ►► Dermal stabilisation to stimulate collagen and elastin
skin-lightening effects. Kim and Cho (2010) concluded production, glycosaminoglycan (GAG) restoration,
that Q-switched laser treatment was effective at treat- and improve skin circulation
ing PIH. They also found that this method produces an ►► Hydrating and anti-inflammatory
additive effect, resulting in a more refreshed appear- ►► Sun protection.
ance, even skin tone, smoother texture, skin tightening
and reduced pore size (Kim and Cho, 2010). Conclusion
Patients who present with skin pigmentation disorders
Chemical peels and topical agents often report feeling self-conscious and can find it dif-
In her clinic, the author uses the 3 Step Stimulation Peel ficult to adhere to skincare regimens. It is important for
(ZO Skin Health, London) to treat hyperpigmentation, aesthetic practitioners to educate and support patients
sun damage and melasma. Before the peel takes place, about their skin condition both at the initial consulta-
skin conditioning using topical agents such as a retinol- tion and during difficult times in their treatment plan
based product is essential to ensure optimum results. (e.g. when the skin is peeling or irritated).
Stabilising the skin before a peel will make the skin There are several highly effective treatment options
stronger and able to repair its self with out any damage; for all types of hyperpigmentation, whether mild (so-
allow it to heal better and faster; enable it to function lar lentigines and freckles) or more severe (melasma).
as well as possible; and encourage it to remain younger- While topical HQ continues to be the gold standard
looking and more radiant (Obagi, 2014). for treating skin pigmentation disorders, with several
The author usually starts her patients on a 6–12 week advances in cosmeceutical skin products, studies have
product protocol, supported by ZO Skin Health agents also shown that Q-switched lasers and topical retinoids
such as Glycogent (exfoliation accelerator, 10% glycolic can be efficient therapy modalities.
concentration, pH); Brightenex (non-HQ 1% retinol
skin brightener and correcting cream); Retamax (1%
retinal stimulating collagen formation and skin barrier References
function); Melamin/Malamix (4% HQ skin bleaching Bandyopadhyay D (2009) Topical treatment of melasma. Indian J
Dermatol 54(4): 303–9. doi: 10.4103/0019-5154.57602
and correcting crème). She also introduces tretinoin
Barrientos N, Oritz-Frutos J, Gómez E, et al (2001) Allergic contact
and encourages the use of sun protection (SPF 50).
dermatitis from a bleaching cream. Am J Contact Dermat 12(1):
The 3 Step Simulation Peel includes the application 33–4
of the peel solution (17% salicylic acid, 10% trichlorace- Baumann L, Allemann IB (2009) Depigmenting agents. In:
tic acid and 5% lactic acid) to remove outermost layers Baumann L Cosmetic Dermatology. 2nd edn. McGraw-Hill
of the skin, the stimulating retinol cream (6%), and a Medical, China
calming cream to minimise any inflammation and ir- Baumann L, Saghari S (2009) Retinoids. In: Baumann L Cosmetic
Dermatology. 2nd edn. McGraw-Hill Medical, China
ritation. Some patients will notice that their skin has
Dayan N, ed. (2008) Skin Aging Handbook. An Integrated Approach
a yellow tone after the peel, but this will disappear on
to Biochemistry and Product Development. William Andrew Inc,
washing the face the following day. Some light peeling New York
can also be expected for a few days. The author usually DeCaprio AP (1999) The toxicology of hydroquinone—relevance to
recommends three treatments at 4–6 week intervals to occupational and environmental exposure. Crit Rev Toxicol 29(3):
see optimum results. 283–330
Deo KS, Dash KN, Sharma1 YK, Virmani1 NC, Oberai C (2013)
After care and follow-up Kojic acid vis-a-vis its combinations with hydroquinone and
betamethasone valerate in melasma: A randomized, single blind,
After any medical aesthetic treatment, it is vital that pa- comparative study of efficacy and safety. Indian J Dermatol 58(4):
tients use effective skin care to prevent further damage 281–5. doi: 10.4103/0019-5154.113940
and maintain skin health. For patients with skin pig- Grimes PE, Hexsel DM, Rutowitsch M (2008) The aging face
mentation disorders, the author recommends products in darker racial ethnic groups. In: Grimes PE. Aesthetics and
▼ CLINICAL
Cosmetic Surgery for Darker Skin Types. Lippincott Williams &

Wilkins, Philadelphia
Key points
Guevara IL, Pandya AG (2001) Melasma treated with hydroquinone,
tretinoin and a fluorinated steroid. Int J Dermatol 40(3): 212–5
►► Hyperpigmentation may present as solar lentigines
(less severe) or melasma (more severe), for example
Halder RM, Richards GM (2004) Topical agents used in the
management of hyperpigmentation. Skin Therapy Lett 9(6): 1–3 ►► An in-depth individual initial consultation including
Kasraee B, Handjani F, Aslani FS (2003) Enhancement of the a Visia skin analysis is required to examine the
depigmenting effect of hydroquinone and 4-hydroxyanisole patient's medical history and aid the creation of an
by all-trans-retinoic acid (tretinoin): the impairment of appropriate treatment plan
glutathionedependent cytoprotection? Dermatology 206(4):
►► Advanced skincare treatments can work effectively
289–91
to reduce mild-to-moderate hyperpigmentation,
Katsambas AD, Stratigos AJ, Lotti TM (2003) Melasma. In:
Katsambas AD, Lotti TM, eds. European Handbook of with little downtime needed
Dermatological Treatment. 2nd edn. Springer, Berlin ►► The new generation of Q-switched Nd:YAG lasers
Katsambas A, Dessinioti C (2014) Melasma: the most common can be used to achieve highly effective results for
pigmentary disorder. http://tinyurl.com/nbe8sug (Accessed 20 even the most severe cases of melasma
May 2014)
Kim S, Cho KH (2010) Treatment of facial postinflammatory
hyperpigmentation with facial acne in Asian patients using
of induced melanogenesis in Cloudman melanoma cells by four
a Q-switched neodymium-doped yttrium aluminum garnet
phenotypic modifiers. Exp Cell Res 191(2): 209–18
laser. Dermatol Surg 36(9): 1374–80. doi: 10.1111/j.1524-
4725.2010.01643.x Ortonne JP (2006) Retinoid therapy of pigmentary disorders.
Dermatol Ther 19(5): 280–8
Kligman AM, Willis I (1975) A new formula for depigmenting
human skin. Arch Dermatol 111(1): 40–8 Ortonne JP, Arellano I, Bernebury M et al (2009) A global survey of
the role of ultraviolet radiation and hormonal influences in the
Lawrence N, Bligard CA, Reed R, Perret WJ (1988) Exogenous
development of melasma. J Eur Acad Dermatol Venereol 23(11):
ochronosis in the United States. J Am Acad Dermatol 18(5 Pt 2): 1254–62. doi: 10.1111/j.1468-3083.2009.03295.x
1207–11
Patil UA, Dhami LD (2008) Overview of lasers. Indian J Plast Surg
Lufti RJ, Fridmanis M, Misiunas AL et al (1985) Association of 41(Suppl): S101–S113
melasma with thyroid autoimmunity and other thyroidal
Penney KB, Smith CJ, Allen JC (1984) Depigmenting action of
abnormalities and their relationship in the origin of melasma. J
hydroquinone depends on disruption of fundamental cell
Clin Endocrinol Matab 61(1): 28–31
processes. J Invest Dermatol 82(4): 308–10
Nair X, Parah P, Suhr L, Tramposch KM (1993) Combination of
Picardo M,Carrera M (2007) New and experimental treatments of
4-hydroxyanisole and all trans retinoic acid produces synergis-
cloasma and other hypermelanoses. Dermatol Clin 25(3): 353–62
tic skin depigmentation in swine. J Invest Dermatol 101(2): 145–9
Rivas S, Pandya A (2013) Treatment of melasma with topical agents,
Nordlund JJ (1988) Postinflammatory hyperpigmentation. Dermatol peels and lasers: an evidence-based review. Am J Clin Dermatol
Clin 6(2): 185–92 14(5): 359-76. doi: 10.1007/s40257-013-0038-4
Obagi ZE (2014) ZO Skin health Restoration treatment & Slominski A, Wortsman J, Plonka PM, Schallreuter KU, Paus R,
rejuvenation manual. Obagi, London Tobin DJ (2005) Hair follicle pigmentation. J Invest Dermatol
Orlow SJ, Chakraborty AK, Boissy RE, Pawelek JM (1990) Inhibition 124(1): 13–21
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CLINICAL ▼