Derm-it Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-it Trotter! Don't Swear About Skincare.
Melasma, Acne Scars, & Sunspots: Stop Treating Them the Same
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Dark spots can be frustrating, especially when they seem to stick around despite your best efforts. Dr. Heather Woolery-Lloyd joins us to break down what causes hyperpigmentation, the differences between melasma, post-inflammatory hyperpigmentation, and sunspots, and how dermatologists approach treatment.
We discuss the role of sunscreen, visible light, hydroquinone alternatives, chemical peels, and evidence-based skincare ingredients that can help fade discoloration. If you're tired of guessing what works, this episode offers a practical roadmap to treating hyperpigmentation more effectively.
What Hyperpigmentation Really Means
SPEAKER_02People with darker skin are much more likely to develop it. And that's because the cells that make pigment called melanocytes are more robust. And if you want to add that on in the morning because it maybe might make your sunscreen more effective, because it helps to kind of prevent those free radicals from the sun. I always say when I'm treating hyperpigmentation and particularly melasma, I want the skin to be fast asleep. I don't want it to be irritated. I don't want it, so I want the person to be on a very stable skincare routine.
SPEAKER_01Welcome to Dermot Trotter, Don't Swear About Skin Care, where host Dr. Shannon C. Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
SPEAKER_00Welcome to the Dermot Trotter Don't Swear About Skin Care podcast. On today's episode, I have Dr. Heather Worley Lloyd, a board-certified dermatologist and also board-certified in lifestyle medicine. She's dedicated to a holistic, evidence-based approach to skin health. And she also serves on as an advisor for leading skincare and wellness brands, and she's sought after majorly across beauty media, both nationally and globally. Welcome to the podcast, Heather. It's great to have you here.
SPEAKER_02Thank you. Thank you.
SPEAKER_00I'm happy to be here. Well, we are excited to talk more with you today about hyperpigmentation. This is an issue a lot of people suffer with, have a lot of complaints with, and really dissatisfied, I think, with you know attempts to treat it. But I wanted you to talk more about just what it is, because I think there's some confusion sometimes on what is it versus maybe skin lesions and what actually causes it as well.
SPEAKER_02So basically, hyperpigmentation is when the area you're concerned about is darker than your surrounding normal skin. And it can be something common causes of hyperpigmentation are things like melasma. Sometimes that's called the mask of pregnancy, where people get patches on their cheeks or the center of their forehead or their upper lip during pregnancy, or with birth control pills, or with hormones. Another common cause of hyperpigmentation is something we called post-inflammatory hyperpigmentation that can occur after acne. So dark marks after acne, after a burn. I always make a joke, that's why I don't cook, because I have so many empty common with hyperpigmentation from burns on their wrists. So it really is just when the area that you're concerned about is darker than your surrounding normal skin, and there are many different types of hyperpigmentation.
SPEAKER_00So do we find, you know, are people more likely to hyperpigment in different coloring, like shades of pink versus brown or tan, or how do you typically see that present with different skin types?
SPEAKER_02So uh definitely people with darker skin are much more likely to develop it, and that's because the cells that make pigment called melanocytes are more robust. So they're very efficient at making melanin, which is the pigment in our skin. And so any injury to the skin or inflammation cause those melanocytes to turn on, make a lot more pigment, and that's why we see the dark spot.
SPEAKER_00Probably one thing I think people
Who Gets Dark Spots And Why
SPEAKER_00get confused with, you know, they see dark spots and like, oh, are these age spots, or is it really just hyperpigmentation? I was gonna have you touch a little bit upon kind of the differences because I do think it's confusing for people, or they're using you know, things to lighten or what they think might help with hyperpigmentation, but it's actually a skin lesion that might need a different intervention.
SPEAKER_02Yes, so you're right. There are things, and even sometimes like we have things we call solar lenticos or sunspots, and sometimes when people have those on the face, they can kind of look a little bit like melasma. But in general, when you have a skin lesion like a freckle, a sunspot, which we call solar lentigos, or um, you know, something that's more permanent, those types of things generally don't get better with skincare. In general, that's a general statement. Um, where and they're more, I always want to say in those things, it's like the melanocyte setup house. It's like set up its house and it wants to be there. So it's harder to get rid of it. Doesn't mean you can't get make them better with skincare or with procedures, but it's much harder because the melanocytes have set up house. Whereas post-inflammatory hyperpigmentation, for example, results as a as a result of some sort of inflammation in the skin. So a pimple is the perfect example. And so that's more theoretically a temporary thing that will go away with time. Although for many people, dark spots from pimples can last, you know, several months or even years, you know, a year or more in some studies.
SPEAKER_00Yeah, and I think too, we all make it a little worse with the chronic picking. If you're a picker out there, you definitely will see that pigmentation kind of hang around for a while. And you mentioned the skincare approach, because I think, you know, that's something I want to focus on with you today, you know, where a lot of people are wondering, you know, how do I even approach it if I have hyperpigmentation in whatever fashion? You know, what are sort of the general treatment strategies or approaches to treating it?
SPEAKER_02So I always start with skincare. That's um one of the, I think one of the most effective ways to treat it. And because hyperpigmentation can be a challenge, it's not like the most straightforward, easy thing. It definitely is one of the more challenging things we treat in Durham. Uh, I usually use a multifaceted approach. So I'll use topical products that have ingredients that help address hyperpigmentation. You also have to use sunscreen, really be religious with sunscreen. I always tell my patients if you're treating hyperpigmentation and you're not using sunscreen, it's like pushing a rock uphill. So you definitely have to wear sunscreen. And then the third thing for more resistant cases, sometimes there's oral antioxidants like polypodium leucatomas, which can also help with hyperpigmentation. So we really take a comprehensive approach, and it starts with skincare and sunscreen. Those are the two main things.
SPEAKER_00Well, I like that you mentioned the
The Core Treatment Strategy
SPEAKER_00polypodium because I do think that's an underrated, you know, utilization for it. A lot of people think about, oh, it's gonna help me if I'm gonna be out in the sun, maybe make my sunscreen work a little better, maybe I'll burn less, you know, the antioxidant properties. But I think then people don't really think about it for disorders that might create hyperpigmentation if they have melasma or if they're just prone to pigment change in general. So love that we highlighted that. But let's go back to the ingredients because I think that's what people are wondering. They're like, okay, so you're recommending ingredients. What type of ingredients? So whether it's azoleic acid or something else that's your favorite or your go-to or combination thereof.
SPEAKER_02Well, that's such a good question because this is a huge part of what I do. And looking for things to manage hyperpigmentation can be a challenge, but the good news is that recently a lot of new things have come to the market. So just to kind of set the scene, originally we used a lot of hydroquinone. Hydroquinone is considered the gold standard, it's definitely the most effective treatment available, but it has some issues. The main issue is that some people are allergic to it. We can't use it long term because this affects plateau over time. And then rarely it can cause this unexpected hyperpigmentation. So it can cause dark spots or ochrinos. The name of that condition is ochrinosis. So even though hydroquinone was great and I used it for many years, I use it a lot less now because we have all of these new alternatives to hydroquinone. So the main um new alternatives that have come to the market that are new treatments for hyperpigmentation are thamidol and another ingredient called melasil. And I'll tell you how they work. So, hydroquinone, the one I mentioned earlier, and what most of the treatments we used in the past did is that they inhibited an enzyme called tyrosinase. And this was the main enzyme that was the driver of pigmentation. So when you inhibited that enzyme, it basically reduced pigment in the skin. And even though that's a really effective treatment, these new alternatives actually work via different mechanisms. So thiamidol works by inhibiting tyrosinase, but it's been specifically tested in human tyrosinase. So all of the things that we used in the past were only tested on mushroom tyrosinase because mushrooms have tyrosinase and that's why they turn brown, actually. Mushrooms have their own melanin. Yeah. Um, and they're and their own type of melanin. And um, so all of the agents that we use in the past have been tested on mushroom tyrosinase. This is the first agent that's actually been tested on human tyrosinase, and it was found to be a big inhibitor of human tyrosinase. So it's very effective. And I use that ingredient all the time. It's called thiamidol. And then another new one that came to the market in the last couple years is melasil, and that works via a different mechanism by basically binding all of the precursors in that pathway of creating melanin. So both of these are something I use in my practice all the time. And then some of the older things that I've been using for years and are continue to be workhorse, workhorse is azoleic acid. That's a very popular ingredient and something that I personally use. Azoleic acid is available over the counter at like 10%, I think is the highest percentage you can get over
Hydroquinone And Newer Alternatives
SPEAKER_02the counter. And then by prescription at 15 and 20%. So I use that a lot in my patients to help maintain melasma, for example, is that is a common one. And then I use it a lot for acne too, because it's also FDA approved to treat acne. So we people who have acne and dark marks, sometimes I'll do a prescription for azalic acid.
SPEAKER_00Do you find like when you're looking at these ingredients using just one, do you tend to do like a combination approach, or does it vary based on maybe the degree of hyperpigmentation or how much is there, or more of a tolerability issue?
SPEAKER_02It really depends. Um, the good news is some of these newer agents, like melasil and thamadol, really do work well on their own. And sometimes I'll start with those, and then if someone is more resistant, I'll start to add on other products. So tranexamic acid is something that we haven't spoken about. That is available topically, so it's in lots of topical formulations, but it also can be used with microneedling. So there are procedures where people bringodedle and then apply the tranhexamic acid afterwards. There's even procedures where you can inject tranxamic acid into melasma patches. And then finally, there's a pill that's by prescription only with tranexamic acid. So that's a very popular one that I'll sometimes add on. Um, sometimes I'll combine both the thiamodol and the melasol products together. Um, and I'm always focused on sunscreen. That's you know another big thing when it comes to a multifaceted approach.
SPEAKER_00What are your thoughts about some of the more traditional things that we use in skincare, you know, to promote, you know, I always say, or be more like anti-aging, like vitamin A type creams or topical retinoids or even vitamin C, they they get touted sometimes for lightening or brightening properties. And I feel like just clinically, from my own experience, for lightning, I don't always see substantial improvement with those, even though I know we kind of talk about them in that way. I feel like sometimes the brightening impact might just be increased skin cell turnover and skin looks less dull, but does it really look like there's less pigments? So I know you've you've used these with patients in combination with lightning. Do you feel like there's a role or by themselves, or is a little bit more hype associated with those?
SPEAKER_02I think that there can always be a role, but they're not my main workout courses. So my um vitamin C is a very popular ingredient. Um always ask, what about vitamin C? And if you want to add that on in the morning because it maybe might make your sunscreen more effective, because it helps to kind of prevent those free radicals from the sun, um, that's helpful, but I don't ever use it as a primary treatment for hyperpigmentation. Almost never do I use it. It might just be an adjunct, maybe to use in the morning with sunscreen. And as far as retinoids, retinoids play a role, but again, not as a sole treatment. So if someone is being treated for acne, for example, I'll say, I'm giving you these serums that will help with the pigment. And I'll say the ret the retinoid also helps. So it also helps kind of move things along more quickly, but they're not my primary go-tos if someone complains of hyperpigmentation.
SPEAKER_00Yeah, I feel like that's kind of what I've seen clinically. Nice add in, but really by themselves not as helpful. And it just seems to be a lot of information. Like people come in, like, this vitamin C definitely should have, you know, helped me look lighter. I'm like, uh, we don't typically see that as useful by itself, maybe in concert with some other things that we could do for you. But you mentioned like time frame. I think that's everyone's like golden, you know, like question they want to know. Like, hey, I want this hyperpigmentation gone yesterday. So when you're starting someone on a regimen, assuming they're really good, but there's some protection, what type of expectations do you set potentially for improvement or where they should actually see some lightning?
SPEAKER_02So the good news is with well, with hydroquinone, it's quick. In two to three weeks, people see improvement. But you know, I use less hydroquinone now because I have these alternatives. With the newer ingredients like malecillo thamidol, I do still see some improvement within the first month, I would say, but maximum improvement, all of the studies are four months long. So it takes around four months to see really significant improvement. The studies range between three to four months, I would say. Um so that's something that you have to keep in mind when it comes to treating hyperpigmentation. It's a marathon, not a erase. There's um one ingredient I didn't mention, which is another popular ingredient, cysteamine. That's an ingredient that's more like a mask, it's a rinse-off. So you apply it and then rinse it off 10 to 15 minutes
Retinoids Vitamin C And Timelines
SPEAKER_02later. And all of their studies are four-month studies. So that to, and that just shows you that when people who have great products to treat hyperpigmentation are designing studies, they do make them longer studies because they want to see the best results. So people really need to be patient when it comes to treating hyperpigmentation because it does take quite a bit of time to see those significant results. You'll see some improvement in a month, but significant improvement takes months.
SPEAKER_00Yeah, it definitely is more of a marathon, which I know can be frustrating for patients, especially if I haven't convinced them to be great about their sun protection, like you mentioned. Like it's the two steps forward, one step back, if they're still out there. Or I have moms that are at these baseball games in the evening and they're still getting a fair amount of sun and not protecting. And we always joke in Ohio the best time for patients to see a difference is fall and winter because the sun does literally hide here for a while. So it benefits us for some of the lightning that we will get for our patients. Now, I know like doing procedural type things, kind of laser and stuff, a whole nother topic. What about chemical peels? Do you feel like there's a role for those, or how do you bring those on board? And what do you look for in a peel that's useful, especially somebody maybe with darker skin versus lighter skin?
SPEAKER_02So I definitely do chemical peels, particularly for two groups for my patients with melasma, because melasma can be one of the more challenging types of hyperpigmentation, the dark patches on the cheeks from you know pregnancy and birth control and hormones. But a lot of people get melasma out of the blue. A lot of my patients will move from in the north, so a climate like yours move to Miami and they'll say, I never had this before I moved to Miami. And that's because the UV index here is so high. So, and it's and hyperpigmentation in general is heavily driven by sun. But if you have this predisposition to melasma, but you were in kind of a climate where you weren't getting a lot of sun, you might not have developed it. But once you move to Miami, if you have that predisposition, it's gonna come because we get so much incidental sun exposure going to the grocery store, walking outside to get your mail two seconds, and the sun is like in your face. So you can't you can't escape it here. So, um, so yes, I do do chemical peels for my patients with melasma and also for my patients with acne that's not responding to traditional treatment. So if you have a little bit of acne and the acne is doing okay, but I want to get a little bit better and you have dark spots, chemical peels are a great option. For people with darker skin, I typically use lighter chemical peels. So I use salicylic acid or glycolic acid, 20 to 30 percent. And I use a series of peels. Again, this is where patients is key. So after the first peel, people often say, Oh, can't you just peel this all off in one peel? But really, in darker skin types, that's not safe. And the risk of post-inflammatory hyperpigmentation getting worse, you know, making the problem you have worse is where it's high if you do a very deep peel. So superficial peels are the safest, and usually you do a series of three to five peels, maybe every month. So once a month for three to five months to get the best results.
SPEAKER_00And do you feel like mandelic acid, does it have a role? Does it help much? I mean, I I know obviously talked about as being maybe gentler, maybe a good formulation, but do you feel like it get delivers results?
SPEAKER_02I don't use it so much in my practice. I really do stick to the cells looking glycolic. But that being said, it is a great peeling agent for people with more sensitive skin because the molecule is much larger, so it's much less irritating. And I have colleagues who love mandelic acid peels because they are a gentler option. So I don't personally use them, but I definitely think that they can play a role.
SPEAKER_00Before peeling someone, this is just what we were taught back in training. We had several attendees they'd like to pre-treat with one of those topical ingredients. Have you do you do that too? Do you feel like there's benefit of maybe traditional hydroquinone or one of the newer ingredients? You know, maybe if somebody needed to get that extra boost from a peel, is that something you find beneficial as well?
SPEAKER_02Yes. So I always start with skincare. So it's not ever, every, I would say never, does someone come into my office for the first time and get a peel the first day? I'm always gonna start with skincare. And that's important for a few reasons. First of all, if you do skincare and it works, you might not need a peel.
Chemical Peels Without Making It Worse
SPEAKER_02So that's one of the main reasons why, because we have some really good, effective agents now that people have great results with. But second of all, you do want to pre-treat the skin, have the skin be a little bit calmer. I always say when I'm treating hyperpigmentation and particularly melasma, I want the skin to be fast asleep. I don't want it to be irritated. I don't want it, so I want the person to be on a very stable skincare routine with no irritation, no redness. And once I've established that, then I'll start the peels. The one key thing, if you do do peels and you're using a retinoid, like a prescription tretinoin or tazerotine or a dappylene or triferritine or an over-the-counter retinol or retinol, we have all of these retinoids now. Um, we do try to stop those seven days before the peel. So if you're using a product with any of those ingredients, you want to stop them seven days before the peel. Because if you're using a retinoid, the peel can be deeper than expected and you can have that unwanted side effect of hyperpigmentation. So that's one key thing when it comes to skincare. I always stop the retinoid seven days before or any exfoliating thing. If someone is using a really strong exfoliating glycolic acid, for example, at home, they might want to stop that before peel. That's a common, some people have noticed that when they get their eyebrows waxed. If they're using a retinoid, they'll, you know, it'll rip off their skin with their eyebrows. And so it's the same concept with the peel. If you're using a retinoid, your skin is in a different state and the peel will be much deeper than we expect.
SPEAKER_00That's a really good point. Because I think people forget, you know, that they're even on it, or sometimes they don't even divulge it. Hopefully, if we're doing the skincare, we have an idea of what they're doing. Because with the skincare, I mean, with these ingredients to lighten, combination there of maybe with the peels, the one thing that I know we want to put in spotlight is definitely sunscreen. And especially talking about some benefits of tinted sunscreens, you know, for patients that are at risk for hyperpigmentation or if they have a pigment disorder. I wanted to kind of just touch upon that more because I think people think of just tinted sunscreens. I think when I talk to my patients, like, oh, they think they're tinted just to give them a little coverage, like a foundation, and not really appreciating that there's some value in why they're tinted, especially if they might be prone to hyperpigmentation.
SPEAKER_02So this is one of my favorite topics to talk about because tinted sunscreens are extremely
Tinted Sunscreen And Visible Light
SPEAKER_02important for hyperpigmentation, and I'll explain why. So our traditional sunscreens block UVA and UVB, and those are the wavelengths of light that can contribute to skin cancer, can contribute to aging, and dark spots, because UVA does contribute to dark spots. But now the most recent research is showing us that visible light, which is the light from the sun that we can see. So how I always describe it to patients is remember in third grade where they would shine a light through a prism and then it would turn into all of the different colors of the rainbow? That's what visible light is. And so the blue wavelength of visible light is a driver of pigment production by our melanocytes. So it's the thing that turns on that factory so the melanocytes start creating more pigment. So our traditional sunscreens that are say broad spectrum UVA, UVB protection, actually don't protect us against visible light. And the only ingredients that really protect us against visible light are iron oxides. And iron oxides are the pigments that make a tinted sunscreen. So they're a combination of red, yellow, and black pigments. And again, from middle school or elementary school, if you mix those paints together, you get brown. So all of our makeup has iron oxides. Anything that has like a brown color or any color is usually these iron oxides. So iron oxides are the ingredients in sunscreens that helps to block visible light, which I mentioned is the big driver, blue light specifically, of pigment. It's the thing that turns on the factory and makes our melanocytes create extra pigment. So if you're worried about hyperpigmentation, ideally you should be using a sunscreen that's both UVA, UVB, and visible light. And the way you can get the visible light is looking for a tinted sunscreen. And I just want to mention one more thing. There are some sunscreens that are not tinted that have been shown to protect against visible light because they add these really effective antioxidants into them. So there are there are some formulas because some people don't like tints because you know it can get on your clothes, it can give you a little bit messy. Um, so there are a few formulas that have been shown to help protect against visible light, even though they don't have iron oxides. But in general, you need iron oxides to protect against visible light.
SPEAKER_00Yeah, I agree with you on the whole messy and discolored. My husband, he gets melasma and he gets so frustrated, but he doesn't, he feels like the tints are too feminine for him. He feels like it's more of a makeup. So he actually appreciates those that do not have the tints. So I totally get what you're saying there. Because I do think as we're improving with sunscreens, our focus has been, you know, kind of on the filters, right? And US, I think, you know, you and I know this that we we haven't always had the best filters, kind of jealous of some other countries with sunscreen development and filters that they have. But I know we've got some newer filters coming to the market. So I think that's an exciting development that I know you're also ready and geared up for, too.
SPEAKER_02Yes, I'm really excited because this is a huge part of what I do. So getting more tools into my toolbox is fantastic. And so the new ingredient that's coming is called Tenosorb S. So just again to lay the groundwork, um, we haven't had a new sunscreen in the US in over 20 years. Over 20 years, okay. And in the rest of the world, so in Asia and in you know Europe, they have new sunscreens, but we don't have any new sunscreens. So um one of the areas that we're not good at covering is long wave UVA. So we have one ingredient, Avobenzone, that's good at protecting us against long wave UVA. And by the way, that's the that's the sunscreen that that's the I'm sorry, the wavelength of light that is also a driver of pigmentation. So we talked about visible light, but also long wave
New UV Filters Plus Big Myths
SPEAKER_02UVA is too. So Avobenzone is the ingredient we have in the US, but we didn't have like a lot of other tools. So there's a new ingredient that has been available in the rest of the world for over 20 years, but finally we think it's going to get approved in the US this summer, and it's called Tinosorb S. And it is a new ingredient that helps to block UVA. So it has broad spectrum coverage, actually, but the important part is that it also blocks UVA. And the interesting thing about it is that it also will be in the category called generally recognized as safe. So the only other two sunscreen ingredients that are in that category are zinc and titanium. So we'll have another um ingredient in that generally recognized the safe category that you know means it can be used in kids. And so it's a really exciting time. Um I can't wait for it to get approved.
SPEAKER_00We're thinking this is gonna be this year sometime. Is that what we're looking for? Sometime in the summer. We don't know when, but sometime. That's exciting. That's exciting. Well, you know, I I think too, you know, you know, with you know filters, you know, developing, it's gonna serve us well, not only obviously for hyperpigmentation, but skin cancer and other things too. You know, with hyperpigmentation, are there other, you know, you know, treatments and we've talked about any other myths, misunderstandings that you feel like surround this that you feel like people just really need to know this isn't true or this is really what's going on?
SPEAKER_02I would say one myth that drives me crazy online is people will put lemon juice on their skin and they think that lemon, they think citrus, or I don't know why, maybe they think vitamin C. I guess for people making their hair blonde back in the day. So they think that lemons can help with this, but actually lemons are not good and actually can cause hyperpigmentation. So if you put lemon juice on your skin, you can get something called phytophotodermatitis, which is a reaction where the sun basically can cause blisters anywhere where the lemon is on your skin and you can develop hyperpigmentation. So that one drives me crazy. So some of the at-home remedies I think are the ones that um I am not so excited about because I find that not only are they not helpful, because like I keep mentioning, pigmentation is hard to treat. So if you're mixing something up in your kitchen, it's not likely to work. But second of all, they can actually make it worse. So those are the ones that's a big, big myth. And another myth, or or just something that people really need to understand from an education standpoint is the importance of sunscreen. And if you really are worried about pigment and it's something that really bothers you, you really have to protect yourself from the sun.
SPEAKER_00Perfect. Perfect. I think we've got, I think today people are gonna understand hyperpigmentation much better, understand these ingredients, exciting things that we now have. And also, I think, you know, just optimism. So a lot of people think there's not much I can do, or maybe they've tried some things without success. And sometimes it's the sun exposure, it's just the time frame, and probably to maybe things they were attempting to use that just really aren't as effective as the things you've talked about with us today. Yes, yes. Well, I want to thank you so much for coming on the podcast, Heather. This has been fantastic.
SPEAKER_02Thank you. Thank you for having me.
SPEAKER_00Of course, and we'd love to have you again. And I'm sure there's a lot more we could talk about as well. But we'll leave the lemon juice down in Miami for all the limes for the margaritas. And stay tuned for the next episode of Dermot Trotter Don't Swear About Skin Care.
SPEAKER_01Thanks for listening to Dermotrotter. For more about skincare, visit dermittrotter.com. Don't forget to subscribe, leave a review, and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
