Dermatologist Debriefs

The Five Faces of Facial Pigmentation: Everything You Need to Know

• Stefanie Williams

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Get ready to deep dive into the complex world of facial pigmentation! In this enlightening episode, we uncover the five primary types of irregular pigmentation, making sense of conditions like melasma, chronic sun damage, freckles, seborrheic keratosis, and post-inflammatory pigmentation. Dr. Stefanie Williams shares her expertise, demystifying these skin issues and explaining their underlying causes.

Learn why accurate diagnosis is essential for effective treatment, particularly how certain interventions, like laser therapy, can have varied outcomes depending on the specific pigmentation type. 

Speaker 1:

Dermatologist debriefs.

Speaker 2:

Join no-nonsense dermatologist Dr Stephanie Williams as she debunks myths and shares her professional insights, separating facts from fiction, in just a few minutes would like to speak about the five main types of facial pigmentation, because there's so much confusion about it and people really mix them up very frequently. But in order to treat irregular pigmentation, it is absolutely vital to establish a correct diagnosis first. And I'm going to just speak briefly about each individual type because I just want to really speak more about the differences between the five types and to go more in detail on each individual one. That will be a topic for a different day. And before we get started on those five skin conditions, I just wanted to clarify that I'm talking about irregular pigmentation here. I'm not talking about lightening your natural skin color. So why is evening out irregular pigmentation important, and that's actually important for all skin types? It's because research has confirmed that, no matter what skin color you are, you will be considered not only more attractive but also more healthy if your skin color is even rather than patchy. Okay, so let's get started.

Speaker 2:

Skin condition number one is melasma. So melasma are larger patches. They're very sharply demarcated, usually symmetric, and they're kind of bizarrely configured. They often have a confetti sign and you may see them, example, above the upper lip or along the cheekbones. So who gets melasma? It can be quite related to hormonal changes, so they're more common in women, also more common in pregnancy. That's why some people refer to this condition as a mask of pregnancy, although you can get it outside of pregnancy, of course, and also if you are on other hormonal treatments, like the contraceptive pill, your risk of developing melasma increases too. And I want to mention one word of caution about treatment. So I'm not talking about treatments in detail today that will be in a different session but I just want to mention that I advise against laser treatment for melasma specifically, and the reason for this is that you may get the impression of a good result initially, but then it very often happens that you have a worsening or a rebound a few weeks or months after your laser treatment, which is of course not what you want to end up worse than you started. So for melasma specifically, I would suggest other treatment options rather than laser.

Speaker 2:

Skin condition number two is chronic sun damage. So in chronic sun damage there are loads of smaller, less defined pigment spots called solar lentiginous or sunspots. You might get them on the hands as well, and sometimes they're called liver spots on the hands, but in chronic sun damage your entire face may be covered with solar lentiginous, including so-called sun terraces such as the top of the ears, and you may also see this kind of generalized freckling in other sun-damaged skin areas like the shoulders or the forearms. Chronic sun damage is more common in fairer skin types and, of course, in those with a strong UV exposure history. For example, if you have grown up in a hot climate, you're working outdoors or you've got outdoor hobbies, then you are at higher risk to develop these solar lentiginous. So this looks like a general kind of mottled appearance with loads and loads of irregular pigment spots all over the face. This condition, in contrast to melasma, does in my experience respond quite nicely to pigment lasers. So lasers here can be a good option.

Speaker 2:

Skin condition number three are freckles. The medical term is ephilides and I apologize if I didn't pronounce that correctly because English is my second language. But these are true freckles, so they are smaller than solar lentiginous. They are light brown, quite symmetric round spots that characteristically darken with sun exposure. They're more common in fair-skinned individuals and individuals with red or blonde hair and blue or green eyes, so typical kind of Irish skin type, and they have a very characteristic behavior of fading in the winter and darkening in the summer months, fading in the winter and darkening in the summer months.

Speaker 2:

And I want to just speak a little bit more about the difference between chronic sun damage with solar lentiginous and real freckles, because both of these skin conditions look freckly, so to say. Freckly, so to say. And in adults, if you see that the entire face is covered in what you think may be freckles, in the vast majority of cases this is actually chronic sun damage. So in children that might be freckles, but adults, who are covered in freckly dispigmentation, usually this is a sign of chronic sun damage and our skin unfortunately doesn't forget any sun exposure from the past. So this may go back to your childhood and your skin just adds up all of those hours of sun and then at some point it will develop this mottled skin appearance of chronic sun damage. So just to speak, summarize the difference between those two, because they are very often mixed up. So solar lentiginous of chronic sun damage, this mottled skin appearance, appears in later life because you've got the accumulation of the sun damage over the years, while real freckles appear in childhood, often by the age of two already. That's not to say that you may not start with freckles and then later on develop chronic sun damage because both of these conditions occur at a higher prevalence in fair-skinned individuals occur at a higher prevalence in fair-skinned individuals.

Speaker 2:

Another difference is that freckles are generally smaller, with about one or two millimeter diameter, compared to solar lentiginous, which may be around five millimeter or even bigger, and freckles are more kind of symmetrically round, whereas solar lentiginous might have a more kind of irregular border Seasonal change. I mentioned already freckles. Real freckles may fade in the winter, while solar lentiginous remain more constant throughout the year and the seasons. Throughout the year and the seasons. Both types of pigmentations are influenced by sun exposure and are more common in fair skin types. But freckling is much more tied to a genetic predisposition, whereas solar lentiginous are primarily a result of cumulative sun damage over time, primarily a result of cumulative sun damage over time. Under the microscope they are also different. So freckles have a normal number of melanocytes these are the pigment building cells while solar lentiginous have an increased number of melanocytes under the microscope.

Speaker 2:

Another type of pigment spots that is sometimes confused with both solar lentiginous and also freckles are so-called siboroid keratosis, so they can appear on the face and on the body, and on the body they tend to be more kind of raised and warty and are very easy to distinguish. But on the face they can be quite flat and that's why sometimes they are confused with sunspots. But if you look very closely with a magnifying glass and if you touch them you will usually find that they are slightly raised compared to solar lentiginous and freckles. Also, generally there are fewer of them, so it might be a single lesion or a few isolated lesions. So that's another factor how you can distinguish them Under the dermatoscope. This is a special type of lighting a dermatologist uses. They are very easy to distinguish because they've got kind of key features that we can see when we look at them with our dermatoscope.

Speaker 2:

There is also a subtype of seborrheic keratosis called dermatosis papulosa negra, or DPN, where there are loads of smaller brown bumps, in particular in darker skin types. So DPN has a very strong association with family history and around a third of black Americans do show some DPN and one of the more well-known people you may have noticed this in is the actor Morgan Freeman. So in this condition DPN, there are many more and they can be confused with freckles. But they are slightly raised and they are a very different type of pigmented lesion and notably seroric keratosis typically don't respond to laser treatment or don't respond as well as solar lentiginous do, but they can be frozen or they can be removed with electrocautery or surgical curettage. So there are definitely options to remove them, but it is a little bit less straightforward. Maybe straightforward maybe. Now.

Speaker 2:

We are coming to condition number five, the last one on my list of the most common forms of irregular pigmentation on the face, which is post-inflammatory pigmentation or PIH. These PIH lesions are brown patches in areas of previous inflammation, for example after acne spots. They're more common in darker skin types and very important. This type of dispigmentation needs a two-pronged approach of not only treating the pigmentation itself but also addressing the inflammation only treating the pigmentation itself, but also addressing the inflammation that drives the pigmentation. So these five conditions are common forms of irregular pigmentation on the face.

Speaker 2:

Number one melasma. Number two chronic sun damage, with the mottled pigmentation of solar lentiginous. Number three real freckles. Number four subaracharotosis, which includes DPN. And number five post-inflammatory pigmentation or PIH. There is, of course, a possibility that you may suffer with more than one of these. For example, I have quite a few patients who present with both melasma and chronic sun damage. But these are the main five types that you should know about. I will speak in more detail about the treatment of these different types of irregular pigmentation in another post, but everything has to start with a correct diagnosis, in particular, as treatment for one type may be contraindicated for another, and this is what today was all about. So I hope this makes sense and I will speak to you again very soon.