Category Archives: pigmentation

Glutathione for skin lightening

Glutathione (GSH) either as oral supplements or IV drips as skin lightening agents are the go-to treatments for glowing and bright skin especially in Asian countries and India, where the quest for fair skin is a never ending journey.

In this post we will see what glutathione is? Does it work as a skin lightening agent ? Are there any studies to back up its use in beauty spas or clinics? Is it safe? And is it worth it?

Introduction to Glutathione

Proposed mechanism of GSH as a skin lightening agent

Current scenario

What is the current evidence ?

Concerns with GSH as a Skin Lightening agent

Final word on glutathione for skin lightening

The evidence for oral or topical glutathione for skin lightening is
still not convincing yet to warrant a unanimous recommendation for skin
lightening or as a treatment for pigmentation

Is there a way to naturally increase GSH stores in our body?

YES you can.

The most economical & sustainable way to prevent glutathione depletion in our body is by preventing the need for GSH in the body in the first place by reducing oxidative stress.

Lifestyle habits that one can make to reduce oxidative stress :

  • Limit alcohol consumption
  • Quit smoking
  • Diet rich in fruits, vegetables and nuts which delivers amino acids required for GSH production or rich in other antioxidants : Tomatoes, oranges, spinach, asparagus, avocado, berries, walnuts, almonds ( best consumed raw or lightly steamed)
  • Whey protein is a good source of cysteine (an amino acid essential for GSH synthesis)

Acids in Skincare

We’ve all heard of acids such as glycolic acids, and if you’re acne prone- salicylic acid and the rest. These acids are used in skincare products as chemical exfoliants i.e they help to chemically detach cells in the upper most layer of the skin from one another, yielding a more youthful, smoother, brighter skin.

What are the various types of acids used in skincare ?

How do they work?

Lower strength acids as found in OTC cosmetics (usually <10%) works at the level of the epidermis specifically at the stratum corneum (upper most layer of skin) and causes exfoliation.

Higher strength acids (>20%) are used as in-office procedures by professionals as chemical peels. Higher strength and lower molecular size acids such as glycolic acid can penetrate deep into the skin (upto the dermis) to boost collagen, GAG’s production thereby increasing the thickness of skin, and reversing signs of photoageing such as wrinkles, deep lines, sun spots etc.

Concept behind exfoliation

As we age our skin cell turn over (cells from the lower layer, divide and mature and are eventually shed off) slows down. As a results more cells from the startum corneum accumulate on the surface which gives aged skin a more dull, and rough appearance. Chemical exfoliation using acids helps speed up the process of shedding the upper layers of the skin. Hence, incorporating acids in our skin care are of benefit a we age and and for addressing certain skin concerns. They are un-necessary for younger age groups as their skin can naturally exfoliate at a good rate.

Rough estimate on the average skin cell turnover with various age groups

Acids beyond exfoliation

Uses of acids in skin care products can be more than just for exfoliation. Different acids have a slightly unique properties that help address specific concerns.

How to choose a chemical exfoliant?

Firstly, not everyone needs a chemical exfoliant in their routine. If you do not have any skin concerns, or if you are happy if your existing routine, continue what works for you regardless of whether you have such acids or not in your routine.

Amongst AHAs : 

  1. Glycolic acid is most commonly used and widely available in skincare products. However being of smaller molecular size, it can penetrate the deeper layers of the skin and cause irritation for some. 
  2. Lactic acid: another common AHA, but has additional properties of being able to retain water thus hydrating the skin. It’s also less irritating as compared to GA 
  3. Mandelic acid : a larger molecular weight AHA that is great for people not tolerating other acids or for people with sensitive skin as it is least irritating. 

PHA and PBHAs, the newer generation acids. Not only do they provide gentle chemical exfoliation, some PBHAs such as lactonionic acid help hydrate and soothe the skin. 

Note: The tolerability of such acids are also dependent on the overall formulations. Some products have a combination of these acids for maximum benefit and least irritation. Most often you only require a single product, and try not to use too many chemical exfoliants in your skin care routine without a professional consultation. 

Products mentioned available at shop my shelf or my amazon store front (for Indian products)

What can go wrong with such products?

Irritation is the most common side effect of using such products. It can present as redness, burning or itching. It can also be seen as bumps resembling acne. Start by using such products just once-twice a week instead of every night and do not forget your sunscreen.

Some people may be allergic to certain acids, always perform a patch test prior to using such products especially if you have sensitive skin.

Over exfoliation can disrupt your skin barrier, making it sensitive, dry and irritated. In this case, stop using such chemical exfoliants and jut stick to the basics: cleanser, moisturiser and sunscreen.

If you already have a routine for your acne or pigmentation, please consult your dermatologist prior to incorporating such products in your routine.

Dark circles: More than meets the eye

Dark circles though very common, can be difficult to address. Many factors are involved in causing dark circles, such as ethnicity, bone structure, anatomy of the skin etc, and most times a cream or serum cannot address all the factors involved, thus resulting in failure of treatment.

Let’s try to understand more about dark circles here.

What causes dark circles ?

There can be intrinsic factors (internal, genetically predetermined factors, inevitable) or extrinsic factors (external, environmental impact, modifiable).

These factors are non modifiable and most topical products such creams/serums cannot completely address these factors
Extrinsic factors can be modified to reduce the risk of developing or worsening of dark circles

Types of dark circles

Understanding the type of dark circles helps guide the treatment options.

Some OTC products that may help

Find products mentioned here
Find products mentioned here

Why are my eye creams not working?

So you have been using eye creams religiously for a long time and you still have not seen results. Why isn’t t it working for you?

  • Lack of sun protection: The under eye area is a commonly missed site during sunscreen application.
  • Not making the necessary lifestyle changes: Ongoing stress, lack of sleep, not cutting down on smoking and alcohol.
  • Underlying cause not addressed: Continuous scratching from eczema irritation.
  • Lack of patience: Depigmenting creams take time to work
  • Incorrect choice of product or treatment: Some form of dark circles benefit more from prescription medications or from a combination of products + in office procedures such as fillers, chemical peels etc
  • Unrealistic expectation: No creams/serum can 100% reduce dark circles. Shadowing effect due to bone structure cannot be corrected by creams. Constitutional pigmentation respond only minimally to OTC products.

Dark spots post acne

Medically termed as “Post Inflammatory Hyperpigmentation” or PIH, these are dark brown to blue to black pigmentation that are left behind as a sequelae of the acne.

PIH can cause more concerns for individuals with acne than the acne itself but the good news is that, PIH are lesser evils of all pigmentation issues that occurs in our skin, they are preventable and completely treatable for many.

So why do PIH occurs ?

Skin type (i.e darker skin type), along with UV radiation and ongoing inflammation from the acne all work together to cause PIH

How can one minimise the risk of development of dark spots or PIH?

Though PIH/dark spots from acne can fade with time, we do see many individuals whose PIH last longer than expected.

Why is my PIH not fading?

Do over the counter products work for PIH post acne?

To some extent, YES, they do!

OTC products that addresses pigmentation along with treatment for acne and sun protection can definitely help fade acne scars as long as they are superficial epidermal PIH. Deep/Dermal PIH or mixed type of PIH would respond better to prescription medications +/- in office procedures such as chemical peels, LASERS etc

Products mentioned

Freckles or Sun spots?

The beauty standards of this world fuelled by unrealistic expectations through social media has made the slightest blemishes on the skin an un-welcomed sight.

The world is more forgiving towards skin blemishes now, luxury brands are embracing models with vitiligo, freckles have made their way into instagram filters and I personally love seeing this change.

I’m hoping this post will help individuals understand why freckles occur and hopefully help one embrace them.

What are freckles?

Ephelides the medical term for freckles are small unform light brown pigmented areas (maucles) usually occurring on sun exposed skin such as the cheeks, bridge of nose or over the hands.

They are commonly seen in fair skinned individuals with red hair and blue eyes. Freckles can also occur in Asian and Indian skin type though with lesser prevalence.

In an Indian study of pigmentation disorders in Indian skin type, melasma was the commonest cause and freckles only contributed to ~7% of the study population.

Freckles usually start appearing in childhood & adolescence period.

What causes freckles?

Genetics plays a huge role, mutation of a gene encoding for melanocortin receptors have been found especially in red haired individuals. A positive family history of freckles is usually present.

UV radiation stimulates the melanocytes to produce more melanin (the pigment of our skin) and it also increases the transfer of the melanin to the keratinocytes (cells of the upper layers of our skin) and is responsible for the pigmenation.

Image source: http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%201/FG04_06.jpg

The number of melanocytes (specialised cells in the skin that makes the pigment melanin) are not increased but there is an increase activity of these melanocytes.

For an individual who is genetically predisposed, UVR (sun exposure) can cause the development of freckles

How to differentiate freckles from sun spots?

  • Freckles/ Ephelids
Image source

Freckles appear at early childhood (2-3 years) over the cheeks, nose or the hands.

They are light brown, 1-5 mm in size, round to oval, regular & well defined patches. Freckles are mostly uniform in size, colour and distribution.

They become darker on sun exposure and fade with strict sun protection. Hence they tend to be more prominent in summer and lighter in winter.

They may even fade with age.

  • Solar lentigens / Sun spots
Image credit : DermNetNZ

Starts appearing in adulthood 20-30 years.

Light -dark brown patches on the sun exposed areas such as face, upper neck, hands. They are larger & more irregular than freckles.

Can occur both in light and dark coloured skin.

Caused by prolonged sun exposure over time.

They become darker with more sun exposure and do not fade in winter. They are persistent throughout life and no not fade with time. They may even increase in number with age.

When to worry about freckles?

A child with multiple freckles and a severe intolerance to sunlight

If the child develops severe sun burns even with minimal sun exposure, a detailed medical examination may be required to rule out genetic disorders such as xeroderma pigmentosa where the cells fail to repair the DNA damaged by UV radiation.

Are freckles harmful?

Freckles are completely harmless unless if its associated with the above mentioned condition.

How to fade freckles?

Freckles respond well to strict sun protection either in the form of sunscreens or physical protection.

I’ve mentioned in my previous blog posts on how to achieve a good level of sun protection.

Other form of treatments are topical creams such as hydroquinone or retinoids. However these tend to give an uneven result.

Chemical peels have shown good results, such as spot TCA or Phenol peels. In these procedures, a high strength alpha hydroxy acid (glycolic acid, mandelic acid etc) or caustic acid (TCA)are applied by a dermatologist using a toothpick or cotton buds to the freckles. These areas then forms a scab with falls off in 7-10 days and heals with a normal pigmented skin.

LASERS have been widely used successfully for fading the freckles as well.

All the above procedures do come with certain side effects such as irritation, redness, pigmentation (especially in dark skinned individuals). Therefore always find a dermatologist experienced in this field to perform such procedures.

Recurrence of the freckles or sun spots can occur hence strict sun protection must be maintained even when the freckles have faded.

My advised is, start loving your sunscreen, use it judiciously for best results.

Try the other treatment options if you are very concerned about the freckles but in my opinion, every blemish, or scar or mole adds character to your face, learn to embrace it.

Azaelic acid for your skin care

Azaelic acid is one of the most underrated active skin care ingredient which is found naturally in our skin, and is helpful in the treatment acne,rosacea and as part for your skin care routine for a blemish free skin.

Azaelic acid (AA) is a dicarboxylic acid that is naturally found in wheat, rye and barley. Azaelic acid is also produced by a yeast that lives in our skin called Malassezia furfur. This explains why over colonisation by this yeast results in pale patches in the skin which is medically termed as Pityriasis versicolor. Owing to this acid’s potential to cause reduce pigmentation, azaelic acid has been widely used to treat hyperpigmentation.

How does it work?

  • Azaelic acid has been shown to have a bacteriostatic (inhibits the growth of microbacteria) and bactericidal (kills the microbacteria) action against micro organisms in our skin particularly Priopionibacterium sp (bacteria responsible for acne).
  • Azaelic acid also displays anti keratinising effect i.e it inhibits the proliferation of keratinocytes (cells of our skin) which would otherwise build up and clog our pores thus leading to formation of comedone (white or black head)- precursors for acne. If you recall from my previous posts, retinoids (vitamin A derivative) also has this action. AA does not however reduce sebum production (oil secretion) in your skin unlike oral isotretinoin (vitamin A derivative used in the treatment of acne).
  • Azaelic acid demonstrated cytotoxic effect (toxic to cell) towards active melanocytes (pigment producing cells of our skin), which means it does not affect the inactive melanocytes in the normal skin, thus it particularly targets just the abnormally pigmented area. It also inhibits the action of the enzyme tyrosinase, which is required for melanin (skin pigment) synthesis. Therefore it is effective as a skin lightening agents and is used to treat pigmentation disorders.
  • Azaelic acid (AA) has been found to act as a scavenger of reactive oxygen species (ROS) therefore reduces inflammation and redness of the skin.
  • Source :https://www.ncbi.nlm.nih.gov/pubmed/1712709

Dermatological conditions in which Azaelic acid is proven to be beneficial

Acne:

Azaelic acid in the strength of 20% have been shown to be effective in the treatment of mild to moderate acne. Studies have shown that twice daily application of 20% AA cream is effective than a vehicle (cream without any active ingredient) in the management of acne. Significant results were only well appreciated after 12 weeks i.e 3 months of continuous use. A study has also shown that 20% AA is as effective as 0.05% tretinoin (retinoid) in the treatment of comedonal acne.

Another study comparing the effectiveness of 15% AA with 5% benzoyl peroxide and 1% clindamycin gel (other active ingredients for the treatment of acne) showed equal efficacy of AA at the end of 4 months.

All these studies as well as reports from dermatologists have noted that the average time of achieving improvement with AA for acne was ~73 days equivalent to over 2 months of continuous use.

Azaelic acid is a great option for acne prone skin especially if someone is not tolerating other active ingredients used for acne such as adapalene, tretinoin or benzoyl peroxide.

Rosacea:

AA is FDA approved in the US for the management of rosacea (particularly papupopustular rosacea). Rosacea is a condition which can present like acne with multiple red bumps with red inflamed cheeks. Patients with rosacea have extremely sensitive skin and the redness can be triggered by various stimuli such as hot drinks, smoking etc.

15-20% AA used topically twice a day was shown to be effective for reducing the number of papules and pustules and to a little extent the redness in patients with rosacea. These improvement were achieved over a 15 week course of treatment.

Pigmentation:

Azaelic acid either alone or in combination with various other active ingredients is used to fight pigmentation. A study on the effectiveness of topical 20% AA in patients with FST IV -VI i.e brown or Indian skin type to black African type, concluded that twice daily application of AA lighten the pigmentation after 24 weeks (6 months) and also improved the smoothness and texture of the skin (which is great if you’re trying to even out your skin tone and skin texture)

Combination of 20% AA and 0.05% tretinoin is also available for the treatment of melasma. The study to support this combination compared AA as monotheray vs the combination therapy. Patient showed faster improvement in the form of decrease pigmentation and decrease in the size of the pigmented area in the combination group than AA monotherapy. However at the end of the study, i.e 6 months both treatment form achieved similar overall results.

How to use azaelic acid ?

Studies on azaelic acid either use 15% or 20% AA applied to the entire face twice a day. The side effects are mild stinging sensation or itching for the initial few days which subsides with subsequent continuous use.

  • First cleanse your face using a gentle cleanser
  • Let your face dry for like 30 mins and then apply a small amount of AA to your entire face.
  • If you are new to active ingredients for your skin care, I suggest starting with a low strength such as 10% AA twice a day to a clean face which can then be increased to 15% or even to a maximum of 20% AA.
  • This can then be layer with a moisturiser on top.
  • Do not forget your sunscreen in the morning after the above routine.
  • AA can be used as spot treatment for the inflamed acne or rosacea as well in addition to the twice daily application.

What to expect with Azaelic acid?

AA is a good option to treat mild to moderate acne and rosacea and its safe during pregnancy and can be used safely in nursing mothers as well.

For those of you who are planning pregnancy, or are pregnant, AA is a great option to use especially for someone who was using a retinoid (which is contraindicated in pregnancy) and needs some other active ingredient for their skin care.

Azaelic acid will definitely test your patience. Acne and rosacea usually show improvement in 2-6 months while it can take upto 6 months to achieve significant results with AA for pigmentation disorders such as Melasma.

Azaelic acid available in the market

AA is available as 10%,15% and 20% cream and gel particularly used for the treatment of acne and rosacea.

Finacea 15% is available as a foam and is particularly useful for rosacea who cannot tolerate other ingredients present in the cream base.

AA is also available as a combination of 20% AA + 0.05% tretinoin cream and as a combination with trenexamic acid in a serum form.

All about sunscreens

Sunscreens are the number one skin care product every dermatologist swears by. In the Western countries, where the incidence of sunburns and skin cancers are high among Caucasians, sunscreen is life saving. In a country like India, where the individual’s skin type (FST IV and V) predisposes them to pigmentation disorders (melasma, post inflammatory hyperpigmentation -PIH), sunscreens are the first armour to fight against pigmentation.

Lets recap a little on solar radiation, so as to understand what exactly a sunscreen does.

UVA– 98-99% of the solar radiation reaching the earth’s surface. UVA is the spectrum of UV radiation that can penetrate the dermis and is responsible for immediate tanning, photoaging, pigmentary disorders, photodermatoses such as polymorphous light eruption etc

UVB– 1-2% of UVR reaching the earth’s surface. UVB is highly energetic but does not penetrate beyond the epidermis (superficial layer of skin) and is responsible for sunburns, skin cancers and delayed tanning. UVB is also required for Vitamin D synthesis in our body.

UVC– filtered out by the ozone layer and does not reach the earth’s surface.

How sunscreens work?

There are two types of sunscreen :

Physical or inorganic sunscreens

They contain titanium dioxide, zinc oxide, iron oxide, or calamine, and functions by forming a coat on the skin that reflects, scatter or absorb the UVR. Physical sunscreens are ideal for patients with sensitive skin as the ingredients do not interact with the proteins and lipids in the skin, and they can protect against both UVA and UVB radiation but they bear the disadvantage of leaving a white cast on the skin. The newer physical sunscreens are relatively more expensive as well.

Micronised & ultrafine particles of zinc or titanuim oxide are generally considered more acceptable cosmetically. Multiple positive reviews on elta MD and LRP physical sunscreen, consumers remarked that these sunscreens do not leave white cast and blends easily.

Neutrogena and kiehl’s have mixed reviews. They seems to be well suited for fair skin individuals and not very aesthetically pleasing to individuals with darker skin tone.

Chemical or organic sunscreen

Most sunscreens available in the market are chemical sunscreens. They contain ingredients that can absorb UVR and converts it to heat energy which then dissipates into the environment. They do not leave a white cast on the skin and hence considered more cosmetically acceptable.

Chemical sunscreens are most commonly found in the market. Bioderma photoderm max has a combination of both physical and chemical sunscreen and no white cast on application.

Active ingredients in chemical sunscreens

It is not uncommon to find a mixture of both physical and chemical sunscreen as well. The disadvantage of a chemical sunscreen is that the active ingredients can react with components in the skin such as proteins and lipids which then may result in wanted production of reactive oxygen species causing irritation to the skin. Susceptible individuals may be sensitized to these components in the sunscreen which will manifest as contact allergic dermatitis (red, itchy skin). For this reason physical sunscreens are preferred for patients with sensitive skin.

What does SPF and PA factor mean?

SPF stands for sunburn protection factor which is a measure of protection against UVB induced sunburn. Sunscreen which only mentions SPF means they only provide protection against UVB and not UVA ( the spectrum which is responsible for pigmentation, photoaging). The grading of SPF is as follows:

  • Low: SPF 2 – 15
  • Medium: SPF 15 – 30
  • High: SPF 30 – 50
  • Highest: SPF >50

An SPF of 15 blocks 93% and an SPF of 30 blocks 95% of the UVB radiation. Note that double the SPF does not mean double the protection. Sunscreens with higher SPF contains more active ingredients which may make the product less pleasing to use to some individuals.

PA factor measures the protection against UVA. It measures the Persistent pigment darkening (PPD) or tanning after UVA exposure.

  • PA + : some protection from UVA
  • PA ++: moderate protection
  • PA +++: best protection
  • PA ++++: highest protection : rare to find this in products

How to use a sunscreen?

A given sunburn protection factor in a sunscreen can be obtained only when the right amount of sunscreen is used. Studies use 2mg/cm2 when testing for SPF in a sunscreen, however in reality we tend to use a lesser amount which will then result in a lower SPF than what is labelled in the sunscreen. Therefore dermatologist recommend a higher SPF (SPF>30) to help compensate for the inadequate application.

Dermatologist use the “teaspoon rule” to determine the correct amount of sunscreen needed.

  • 3 mL (slightly more than half a teaspoon)- 3 mL for each arm and 3 mL for the face and neck
  • 6 mL (slightly more than a teaspoon)- 6 mL for each leg, 6 mL of the chest and 6 mL for the back

Apply a sunscreen at least 20 mins prior to outdoor exposure so as the ingredients can form a uniform layer on the skin. It is also ideal to wait 20 mins before putting on clothes otherwise a significant amount of sunscreen will be wiped away during the contact with clothing. The best way to do this is to apply a sunscreen right after a shower or washing your face in the morning and not wait until its time you get dressed for work.

When to re-apply a sunscreen?

We are all familiar with the golden rule of “re-application of sunscreens” which states that a sunscreen must be re-applied every 2 hours as physical activities like touching your face, sweating, friction from contact with sand at the beach can remove some amount of sunscreen from your skin. Reapplication is also recommended after activities in water.

So does this rule apply to modern water-resistant sunscreens which can bind effectively to the skin and retains its said SPF even after 40-80 mins immersion in water?? Recent studies have shown that reapplication helps compensate for the under application of sunscreens. Reapplication after 20 mins also provides better protection against sunburn than delayed reapplication i.e after 2 hours. Therefore early reapplication of a sunscreen is preferred, ideally within the first hour of the first application.

Gentle application is better for sunscreens with gel, or creams consistency. Rubbing it immediately on the skin is recommended for spray sunscreens.

Always search for a broad spectrum sunscreen (UVA & UVB protection) and a water resistant sunscreen.

White cast of physical sunscreens.

The white cast blends with the skin in 30-40 secs of gentle rubbing.

Aesthetics of chemical sunscreens

No white cast, no excuse. Wear sunscreen.

Scientific evidence of the effectiveness of sunscreens for melasma in Indian patients.

A recently published study in the Indian journal of dermatology which studied the efficacy of two different sunscreens on skin pigmentation. A total of 230 patients were recruited in the study. One group was given a sunscreen with an SPF of 50 with PA +++ and the other group a sunscreen of SPF 19 and PA +++. At the end of 12 weeks of twice daily usage, a significant improvement in the form of decrease density of pigmentation and better radiance was noted in both groups. The conclusion is that:

Regular use of a sunscreen with high UVA protection (PA+++) highly effective in improving the skin radiance and in decreasing the skin pigmentation.

So my advised is always look for a sunscreen with PA+++ if you have pigmentation issues, and if you are also prone to sunburns, then get one with an SPF of at least 30.

Hope this was helpful. And stay tune to my next posts on “Controversies regarding sunscreens”.