The treatments vary from melanin blocking agents combined with topical medications such as Retin A which causes the body to exfoliate the skin to rid the body of the hyperpigmentation while prohibiting new melanin production to laser treatments.  The treatments wholly depend upon your needs and skin type.  Some treatments can actually cause hypo- (lack of) and hyperpigmentation problems in some individuals.  Care must be taken in proper diagnosis for a successful result.

Are You a Candidate for Hyperpigmentation Removal?
This entirely depends upon the cause of hyperpigmentation and the treatment which is suited to your needs and skin type.  Some you very well may be able to handle, some you may not be a candidate for.  The first step is consulting with a qualified surgeon or dermatologist to determine the cause and then go over your options for a solution.  For instance, you may be a candidate for hydroquinone use in hyperpigmentations but not laser resurfacing.  Some may only need medication cessation or substitution.

This is really important as not all skin types and individuals will be a candidate for every technique or treatment.  This largely depends upon your skin type, wound type response and the presence of ethnicity in your family history (keloids and hypo- or hyperpigmentations can form in darker skinned individuals).

Regardless, and especially for surgical applications -- an individual must be in good health, not have any active diseases or pre-existing medical conditions and must have realistic expectations of the outcome of your treatment.  Communication is crucial in reaching one's goals.  You must be able to voice your desires to your physician if he/she is to understand what your desired results are.  Discuss you goals with your physician so that you may reach an understanding with what can realistically be achieved.

You must be mentally and emotionally stable to undergo an cosmetic procedure or treatment. Some of these treatments will require patience and stability in dealing with the healing period.  There is sometimes a lull or depression after surgery or during prolonged treatments and if there is already a pre-existing emotional problem, this low period can develop into a more serious issue. Please consider this before committing to a procedure.  If the above describes you and you have the desire to rid yourself of hyperpigmentations, you may be a good candidate for these treatments. 

Your Options for Hyperpigmentation Removal
Depending upon the cause there are several options.  Some consist only of creams or changes of your skin care routine or sunbathing habits -- some even substituting or changing brands of hormonal supplements or birth control pills.

Hydroquinone (BLEACHING agent):
For standard non-hormone induced hyperpigmentations Hydroquinone usually reduces or removes hyperpigmentations very effectively.  For the person who do not wish to have expensive or invasive procedures or only has slight hyperpigmentations - hydroquinone can be a good option.  However, these products may not be suitable for your needs and they will also take longer than some treatment options.  Hydroquinone is a melanin blocker.  You may have heard it call d skin bleach but in actuality it prohibits new melanin production as your body goes through natural or chemical-assisted exfoliation.  These products can be obtained over the counter in weak strengths or by prescription for your plastic surgeon or dermatologist.  Some formulations are even available on the Internet.

Formulations of 4% used to be thought to be the best as irritation would erupt in higher strengths.  This has been proven although strengths up to 10% are routinely formulated for patients.  However it must be noted that higher strengths of Hydroquinone have caused hydroquinone-induced ochronosis (black speckling in the dermis) in patients with darker skins.  And have even been banned in parts of Europe and all throughout Asia due to the belief that higher concentrations are carcinogenic.

Hydroquinone is used by itself, it can be mixed with others such as...

• arbusome
• azelaic acid
• glycomelanin
• kojic acid
• licorice extract
• melawhite

Lustra Bleach (brand name, BLEACHING agent): (Medicus) 4% Hydroquinone, 4% Glycolic and emollient. It is richer and is less reactive and drying. It is used as standard Hydroquinone.

Kojic Acid is available over the counter in weaker strengths, from your aesthetician or through your physician - it is a natural agent capable of blocking melanin production without the stigma of Hydroquinone use.  They are either made from one or two sources (or a combination of both): ester of kojic acid  from certain Japanese mushrooms or asafetida extract [also known as Asafoetida, Devil's dung, giant fennel and gum asafetida,  (Ferula assa-foetida syn F. foetida)] which is native to Afghanistan. 

Hydroxy Acid "Peels"
The peels one can get at an esthetician/aesthetician/facialist ofice can be considered rather mild to slightly invasive.  Alternatively, you may visit a dermatologist and they have access to strengths that are much more penetrating - we will cover these as well.  These aren't exactly peels per se, but cause a reaction in your skin that makes you peel a few days later on your own.  They increase cell turnover rate and thicken the dermis as well as correct hyperpigmentation or t exture problems.  Of course the amount of improvement depends on the strength or number of treatments you have.  The ones that you can get in a spa by a facialist are usually not that strong.  However, some aestheticians are offering strengths which should only be offered by a Dermatologist or physician.  

• Alpha Hydroxy Acids (AHA): Water soluble, these products such as 8% Glycolic acid cream can help remove hyperpigmentations and help with photo damage, thickening of the dermal collagen and increase cellular turnover.  It shows the same type of improvements in other treatments but offer no neoangiogenesis (blood vessel formation) so that telangiectasias are not increased or inflamed.  Includes Lactic Acids.  Higher concentrations work better, of course.  Low PH causes irritation, irritation represents stimulus BUT one needs to change strengths.  You must determine if your physician knows the difference about high concentration, high free acid concentration and low ph - irritation is symptomatic of it working.  Although extreme irritation should be avoided.
• BetaHydroxy Acids (BHA): (Salicylic Acids are most common); lipid soluble. It is an exfoliant, an anti-inflammatory (acetylsalicylic acid - aspirin family), a comedolytic (de-clogging agent for pores). It is in many products. There are BHAs in Oil of Olay's Age Defying Series,  Pond's Prevent/Correct Neutrogena has products with BHA's and are recommend by Dermatologists.  They are not particularly known for removing hyperpigmentations but does increase the rate of exfoliation which increases the chance of removal as long as a melanin blocking agent is used in persons who are prone to re-pigmentation of the treatment area.
• Topical Vitamin A: (Retinyl Palmitate) Such as Retinol Products but specifically Vitamin A in OTC (over the counter) creams/lotions such as the popular "night creams" may contain.

Physician-supplied Formulations & Products
These are more expensive but more effective.  Some can be found on the Internet, others you simply must get from your surgeon or dermatologist.

• Kinerase (N6-Furfuryladenine 0.1%) (KEYEN-er-ace or KINN-er-ace): "Scientifically Proven Results: In clinical studies conducted by a dermatology department at the University of California, Irvine, Kinerase™ was shown to help improve the signs of photoaging. After 24 weeks of treatment, physicians saw improvement in 100% of Kinerase™ patients. Improvement was seen in roughness, blotchiness, and fine wrinkles.
  
  Kinerase™ is not an Acid and Won’t Burn Like One: Unlike many other skin care products, Kinerase™ is non-acidic and won't burn or irritate your skin. In fact, patients using Kinerase™ in clinical studies experienced virtually no side effects."

Click Here to visit the Kinerase Site - ICN Pharmaceuticals, Inc.
Above information was taken from The ICN Pharmaceuticals, Inc. site and all restrictions of the use of this information, in any form, applies.  This product can remove freckles and other hyperpigmentations but only very slowly.

• Retinol: (aka baby Retin A) Medicus: Affirm is one brand, in 3 strengths, 1X 2X and 3X. This are less irritating but still stronger than OTC Retinol formulas. These products cause exfoliation (peeling)
• Retin A: also known as Tretinoin. It is the only FDA approved photo damage treatment lotion/cream. Retin A is a very strong brand, Retin A Micro time released, whereas the Renova is the emollient based and can be too heavy for some and cause break outs. 
• Renova: Vitamin A Aldehyde. This product is Tretinoin 0.05% in an emollient based cream and not as harsh as the Retin A. Hence, less effective than Retin A, more effective than Retinol. The product gets converted into a small amount of Retin A.
• Retin A Micro: 0.1% Tretinoin in microsphere form. It is a strong drug BUT in time release formula so less irritation is seen than in the standard Retin A. Many patients use Tretinoin with the Obagi NuDerm system.
• Avita: (brand) Tretinoin in a less irritating formula.
• Refinity Peel:  15% lactic acid (AHA) product with cosmederm- 7 and a  70% glycolic peel with .06 pH and cosmederm-7. This product increases the cellular turnover rate, helps with hyperpigmentation and corrects skin mottling. Irritation can be moderate - individualistic. (by Collagen Corp)
• Beta-Lift by Medicus: B-Lift X (salicylic acid peel). May cause exfoliation , peeling skin, slight pinkness for a few days. Medicus markets a peel per pack kit, that includes enough product for 1 peel with complete instructions for both patient and physician.

Intense Pulsed Light: For increased effectiveness, these products are frequently used before and after Laser surgery or dermabrasion or Intense Pulsed Light (IPL) treatments.  Especially in ethnic patients or persons with darker skin tones (significant melanin presence).   Usually, standard hyperpigmentations (even freckles) and sun damage can be removed with Intense Pulsed Light without the use of hydroquinone or peels.  You may have heard of PhotoDerm or FotoFacial/PhotoFacial; these machines produce intense of flashes of light capable or removing pigmented areas effectively.  Please see our Intense Pulse Light Section for more information.

Laser resurfacing: Sometimes actual removal is needed via laser peels.  These treatments evaporate the first few layers (or even deeper) of damaged or pigmented skin to reveal fresh, even toned skin.  Many patients are required to use hydroquinone or Kojic acid before these treatments to prohibit excessive hyperpigmentations post-treatment.  Please see our Laser Resurfacing & Treatment Section for more information.

Physician Strength Chemical Peels
Hyperpigmentations can be removed with in-office chemical peels, or with a series of peels.  Please see our Chemical Peel Section for more information.

Microdermabrasion
Microdermabrasion is a mini procedure that involves the skin being sandblasted by aluminum oxide crystals, vitamin C crystals and other types of mild abrasives to remove the horny (top) layer of the skin; dead skin cells.  This process promotes the production of new cells in the basal (deepest) layer of the dermis.  A series of microdermabrasion treatments can lessen the look hyperpigmentations in some patients.  Please see our Microdermabrasion Section for more information.

What to Expect at Your Consultation
After checking a few surgeons' backgrounds and credentials, you will make an appointment for a consultation. You will meet with these surgeons/dermatologists/aestheticians (depending) and discuss your goals and you will disclose all information regarding your health; if you smoke, what medications or vitamins you presently take, etc. -- this is very important.  You really should consider smoking cessation as this can significantly decrease healing for more invasive procedures. Visit the Medication & Supplements List for more information. 

You will discuss your complaints and concerns and discuss the various techniques, the amount that can be corrected, etc.  He or she should discuss the risks associated with hyperpigmentation removal procedures with you, as well. 

If you would like more information on Consultations or a list of questions to ask your surgeon please visit the Consultation Help Page.  If you should choose to book or reserve a surgery date for a more invasive treatment you will usually give a deposit to hold your surgery date.  Most times if you cancel a few days beforehand, this amount is non-refundable.  After paying your deposit and scheduling a surgery date, you will also schedule a pre-operative appointment...

Your Preoperative Appointment
This appointment addresses more questions you may not have thought to ask at the initial consultation, such as more surgical details, concerns and even ascertaining that your surgeon is aware of what you desire from your procedure.  Just as your surgeon will make certain that you know what it realistically possible from this procedure.

You will also discuss your pre-treatment instructions and speak about the recovery period instructions and what to expect in the months ahead.  For less invasive means you may be briefed at your initial consultation.   For surgical procedures, you may be given prescriptions for antibiotics, pain relievers, perhaps blood pressure medicines, prescription anti-inflammatory drugs and perhaps a box or directions for gaining a box of Arnica montana.  Would like to know more on the benefits of Arnica montana?  Perhaps you will be instructed to obtain Bromelain or other types of remedies, although many surgeons would rather have you not take ANYTHING other than your prescription medications, please do not go against your surgeon's wishes.  Remember, always ask your doctor before taking any of these products. 

Please do not hesitate to address any concerns that you may have during this time and even after your pre-operative appointment. If you remember something when you get home or the next day or even the day of surgery - don't be afraid to ask. 

Preparing for Your Treatment
You should be given a pre-operative information packet that explains everything you should do and know before your treatment date.  If you are having Laser please see our section on Laser Resurfacing & Treatment Preparation.  If you are having Intense Pulsed Light treatments, please see that section for preparation information.  For Chemical Peels, please see its respective section.  For Microdermabrasion, likewise.

How Hyperpigmentation Removal Is Performed
Depending upon the procedure the pigmentation irregularity may be removed either all at once or gradually by either, manual or chemical-induced exfoliation, laser or Intense pulsed Light treatment or other means.  Please discuss this with your physician and see the appropriate pages in this website for procedure-specific details.

The Road to Recovery & Perseverance
The recovery period varies significantly and is highly dependent upon the treatment chosen.  Please see the appropriate procedure section for detailed information regarding its recovery period as well as discuss this with your physician.

Some patients experience a lull or down period where they become depressed or feel unattractive. This is very normal.  Please print out our Emotional Preparation Sheet so that you will be able to remind yourself that you will get through your low period.

Risks & Complications of Hyperpigmentation Removal
The risks, complications & contraindications vary significantly and is highly dependent upon the treatment chosen.  

For Chemical Peels:
If you have oral herpes.  You MUST gain the approval of your primary physician and seek a prescription for oral acyclovir -- one brand name is Zovirax®.  This is very important!  Zovirax® can significantly decrease your chances of a break out.  If you have a break out during your healing period, it can spread to your entire face and result in severe and permanent scarring.

Be careful of crusting or excessive weeping.  In AHA peels you may think this is normal but there is a borderline appearances that you must watch out for.  Ask your skin care specialist for specifics regarding what to look for.  If for a typical AHA peel, you should feel and look normal within 3 to 4 days.  For deeper peels your downtime may take weeks and then months for complete recovery.

For Microdermabrasion:
There are not many risks associated with microdermabrasion if you are a healthy adult, but enough to mention for those of you with skin or medical conditions.  If the medical grade machines are used at high power it carries potential risks of hyperpigmentation, perforation, bleeding, and infection. Infection can also be a risk if the machines are not sterile.  Many components of these machines are meant to be sterilized, autoclaved or changed out with a new disposable piece.  Any and all pieces that come into contact with your skin should be able to be sterilized or changed out.  Furthermore, it was brought up by a doctor in an article on Medscape, that there could be possible harm from the inhalation of the aluminum in the Al2O3 crystals, also known as Corundum.

For Melanin Blocking-type Formulations:
Risks can be irritation, permanent hypopigmentation, increased hyperpigmentations if you do not use sun block during this time.   Ochronosis (black speckles or discolorations) if high strengths are used for long periods of time - especially in patients with ethnic backgrounds, or naturally darker skin.  

Related Links 
Tri-Luma For Melasma 
Obagi For Better Skin 
Retin A Micro 
Intense Pulsed Light Therapy (PhotoDerm, PhotoFacial, FotoFacial, EpiLight) 
Chemical Peel Information (Phenol, Jessner, Blue Peel, Retin A) 
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