Age spots, or hyperpigmentation, are the brown, gray, or black spots that can appear on the skin. According to a study published in the Journal of the American Academy of Dermatology, hyperpigmentation can make people look up to 20 years older than their true age.1 Age spots are often accompanied by an overall skin dullness. In another study, researchers found that this lack of luminance and contrast within skin tone also increased the likelihood of being perceived as older.2

PIGMENT PATHWAYS
Age spots can be caused by a number of factors, including sun damage, specific types of medicine, hormone changes, and post-acne scarring. In humans, melanogenesis is the darkening of the skin or an increased production of melanin. This darkening occurs when an excess of melanin forms deposits in the skin. The process is stimulated by DNA damage to the skin induced by UVB radiation. Stimulated by DNA damage when induced by UVB rays from the sun, keratinocytes signal melanocytes to initiate the production of melanin. Once the melanocyte receptors are attacked, it triggers tyrosinase, endothelium (ET-1), and alpha melanin-stimulating hormone (a MSH) to produce melanin. Melanosomes carry melanocytes to the keratinocyte, where they gather to deposit melanin.

There are two forms of melanin: eumelanin, which is black/brown pigment and pheomelanin, which is a yellow/red pigment. There are two types of hyperpigmentation: melanocyte hyperactivity, which brings about freckles and melanocyte hyperproliferation, which causes
age spots.

Ultraviolet exposure can also contribute to uneven skin tone, hyperproduction of more yellow and gray pigments in the skin, and loss of opacity to the skin, leading to dullness. While ultraviolet light is the primary culprit when it comes to causing age spots, other factors can contribute to hyperpigmentation and loss of luminance to the skin. For example, smoking generates free radicals and nitrosamines, decreases the amount of blood flow to the skin, increases wrinkling around the eye and mouth areas, contributes to a sallow complexion, and weakens the blood vessels and immune system. Genetic and hormonal aging brings changes in estrogen and progesterone levels, which can trigger melasma. Post-traumatic hyperpigmentation is caused by stress hormones, which are also common causes for changes in skin color.
Sallow, dull skin, which often accompanies age spots, can be addressed at the same time and in the same way. Dull skin is often the result of reduced cell turnover and accumulation of dead skin cells on the skin's surface. For this reason, skin exfoliation is often used to help reduce the appearance of age spots and improve the appearance of dull skin.

The skin naturally sheds every 28 days. While skin exfoliation is a naturally occurring process, most skin types can use some help. For example, the desquamation process slows with age, causing dull, tired-looking skin. Oily skin tends to saturate dead skin cells, making them difficult to naturally fall off. Dry skin tends to let dead skin cells accumulate too quickly, which can make skin look dry and dull. Most clients' skin will fall somewhere between these two skin types; some type of exfoliation will be very helpful for improving the skin's appearance.

ADDRESSING THE APPEARANCE OF AGE SPOTS
Before determining the best method for diminishing the appearance of age spots, it is key for clients to discuss their hyperpigmentation with a dermatologist to determine that the spots are not any other kind of pathology. Their doctor is likely to ask them a number of questions, such as: When did you first notice the spots on your skin? Did the spots appear gradually or quickly? Have you noticed any other changes in the appearance of your skin? Is the condition itchy, tender, or otherwise bothersome? Have you experienced frequent or severe sunburns? How often are you exposed to sun or ultraviolet radiation? Do you regularly protect your skin from ultraviolet exposure? What kind of sun protection do you use?

Chemical Peels
One of the most prevalent forms of addressing the appearance of hyperpigmentation is with chemical peels. A chemical peel treatment solution involves applying an acid to the age spots. As the skin peels, new surface skin becomes visible. Peels range from mild and at-home to professional and in-spa based. The most important factor when considering various forms of chemical exfoliation is to consider the health of the skin's natural protective barrier. Chemical peels are intrusive to the skin's protective barrier in varying degrees. Over-aggressive exfoliation, or improperly performed chemical peels, can cause more harm than good to the skin, and this damage can be permanent. In all cases, proper consideration of the skin barrier must be part of the protocol.

The regular, proper use of exfoliants helps dissolve dead, flaky skin cells and reduce the appearance of hyperpigmentation. Skin exfoliation will generally cause some mild irritation. Skin care professionals must be careful not to exfoliate excessively as it can cause more damage to the client's skin. Not all clients are candidates for advanced chemical peels; some clients are better served by a medium chemical peel or another skin resurfacing option, such as microdermabrasion.

Deep peels can only be performed by a medical professional in a medical setting. The most prevalent and caustic deep facial peel is phenol. Phenol (carbolic acid) is a classic deep chemical peel that was discovered in 1900 to treat the appearance of acne scarring. Because phenol has a bleaching effect, it is recommended for those who have severe visible signs of photoaging, but it is not recommended for darker skin types or clients who be given oral sedatives and pain relievers, either through a shot or intravenously; general anesthesia may also be used. Because phenol is toxic when absorbed in large doses, the patient may be put on a heart monitor and receive intravenous fluids. After the skin has been thoroughly cleaned, the chemical will be applied and allowed to penetrate. After one area of the face is treated, there will be a 15-minute break before the next area is treated to avoid allowing too much phenol in the patient's system. Depending on how large an area is being treated, the entire procedure may take 60 to 90 minutes. After a phenol peel, the patient's face will be bandaged, swollen, and uncomfortable. Full recovery after a phenol peel can take up to one month and the skin must be soaked four to six times daily, followed by ointment application for the first 14 days. Antiviral medication should also be taken for 10 to 14 days. Patients will be advised to avoid all sun exposure for three to six months. Several follow-up appointments will be necessary to monitor progress.

TCA chemical peels are mid-level peels that involve applying trichloroacetic acid to the skin. These peels are best for addressing the appearance of sun-damaged facial skin, fine lines, dark spots or hyperpigmentation, acne scars, and superficial facial scars. They are done on an outpatient basis, but may require light sedation depending on the concentration of the acid used. Although TCA peels are applied in the same way as milder peels, the acid used in TCA peels is much more potent, causing a more significant burn. TCA peels are performed on an outpatient basis, usually in the setting of a doctor's office. Depending on the concentration of TCA used and the patient's preferences, light sedation might be used, though local anesthesia may not be needed.

Medium chemical peels are applied in the same way as light chemical peels: the skin is prepped and cleansed, then the chemical solution is applied and left on the skin for a short duration, depending on the needs of the client. The solution is then washed away and followed with an application of soothing ointment. Depending on the size of the area being treated, a medium chemical peel may take from 15 to 60 minutes to complete, though most treatments can be completed within 30 minutes.

After TCA peels, a superficial crust or "frost" forms over the treated area; this crust is a result of the TCA coagulating with the protein in the skin and peels off within three to seven days. Healing time takes approximately two weeks and treated skin will initially be red and swollen with swelling worsening during the first 48 hours. In some cases, the client's eyelids may swell shut and blisters may form. The client's skin will crust and peel off in seven to 14 days and must be soaked daily, followed by prescription ointment to aid in healing. Antiviral medication will be prescribed for 10 to 14 days.

Jessner's peel solution, formerly known as the Coombe's formula, was originally formulated by Dr. Max Jessner and has been in use for over 100 years. He formulated this solution out of several different chemicals, including resorcinol, salicylic acid, and lactic acid dissolved in ethanol to reduce the toxic effects of each individual component.

This treatment is considered a superficial peel that is used to treat the appearance of photoaging, age spots, acne, post-inflammatory hyperpigmentation, melasma, and freckles. During the application, clients may experience a warm, tingling, or burning sting. After the treatment, the skin may appear white and frosted. During the following days, it will appear red and progressively deepen to a tan/brown color. Skin conditions during the peeling process may range from mild stinging and swelling to mild redness, crusting, and peeling. The skin can become very dry, tight, and somewhat uncomfortable.

This type of facial peel is also performed in the office of a plastic surgeon or dermatologist in a medical spa setting. This peel is deeper than the beta hydroxy acid peel and is used to help remove the appearance of scars and wrinkles and help improve the appearance of pigmentation. It is usually performed in conjunction with a Jessner's peel. The client leaves with the chemical peel solution on their face. Once again, irritation and subsequent recuperation time is required, as well as diligent sunscreen use.

Alpha hydroxy acids are a group of organic carboxylic compounds typically derived from food products, including glycolic acid from sugar cane, lactic acid from sour milk, malic acid from apples, citric acid from citrus fruits, and tartaric acid from grapes. Glycolic acid penetrates the surface layers of the skin and loosens the dry, thick skin that makes the complexion look aged and dull. Glycolic acid, in concentrations of five to 10 percent, was found to help promote skin exfoliation, creating a smoother texture. Ten and 50 percent solutions help with additional skin smoothing. High concentrations of this acid, which are only used under medical supervision, create a strong glycolic peel to help reduce the appearance of sun damage and hyperpigmentation. For a glycolic peel performed by a licensed aesthetician, a formula of 30 percent glycolic acid with a pH of 3.5 should be used to help minimize irritation that may result from the peel. Professionals can use a fan if clients experience tingling or feelings of irritation. Some side effects can include redness, irritation, blistering, burning, and swelling.

Beta hydroxyl acid peels typically use salicylic acid for a less irritating peel. They are often used in conjunction with other peeling ingredients, such as in the Jessner's peel. These peels are beneficial for helping reduce the appearance of sun damage and age spots.

Medication
Prescription bleaching creams, such as hydroquinone, can be used alone or with retinoids and a mild steroid to gradually fade the appearance of age spots over several months.

Laser and IPL
Laser and IPL therapies help to destroy melanocytes. These treatments should only be performed by a medical doctor or licensed professional and typically require several sessions.

Cryotherapy
This procedure involves applying liquid nitrogen or another freezing agent to the pigmented spot to destroy the extra pigment. As the area heals, the skin appears lighter. Cryotherapy for hyperpigmentation treatment is typically used on a single age spot or a small grouping of age spots.

Dermabrasion
This procedure consists of sanding down, or planing, the surface layer of the skin with a rapidly rotating brush. It removes the surface of the skin and a new layer of surface skin becomes visible. Temporary redness and scab formation can result from this treatment.

INGREDIENTS IN SKIN CARE TREATMENTS AND PRODUCTS
In the past, ingredients such as hydroquinone and mercury chloride have been used to treat visible signs of hyperpigmentation. Today, there are ingredients derived from nature that can help to lessen the appearance of hyperpigmentation from numerous causes without taking the risk of causing the client any future health complications.

Arbutin – This natural ingredient is derived from the leaves of bearberry, cranberry, mulberry, or blueberry shrubs and also is present in most types of pears.

Kojic Acid – Kojic acid is a by-product in the fermentation process of malting rice for use in the manufacturing of sake, the Japanese rice wine.

Azelaic Acid – Azelaic acid is a component of grains, such as wheat, rye, and barley.

Vitamin C – Vitamin C and its various forms of ascorbic acid have been shown to be an effective skin exfoliant.

Glutathione – Found naturally in the body, this ingredient can be combined with many other agents, like vitamin C, to help treat hyperpigmentation.

Matrixyl 3000® – A combination of peptides, Matrixyl 3000 helps reduce the appearance of age spots and fine lines.

Hexapeptide-2 – This ingredient is a fast-acting peptide that helps to brighten the appearance of the skin.

Willow Bark Extract – Extracted from the white willow tree (Salix alba), this extract helps with mild exfoliation of dead skin cells to reveal a more youthful complexion.

Licorice Extract – This extract is known for helping to brighten the appearance of the skin.

Bellis Daisy – Bellis daisy helps to decrease the appearance of age spots and is derived from the daisy flower.

Deep Sea Thermophilus – This ingredient, which is found near deep sea thermal vents, contains proteins and enzymes that help to improve the appearance of the skin.

Laminaria Digitata – Laminaria digitata is brown seaweed that is rich in polysaccharides and vitamins.

Spirulina – Spirulina is known as a unique source of omega 3 fatty acids and gamma linolenic acid.

References
1 Matts P.J., Fink, B., Grammer, K., & Burquest, M. (2007, December). "Color homogeneity and visual perception of age, health, and attractiveness of female facial skin." Journal of the American Academy of Dermatology, 57(6), 977-84.
2 Porcheron, A., Mauger, E., & Russell, R. (2013, March 6). "Aspects of Facial Contrast Decrease with Age and Are Cues for Age Perception." Public Library of Science.

Lydia Sarfati is the founder and CEO of Repêchage, the first company to bring seaweed-based skin care treatments and cosmetics to the United States market. Sarfati is an international industry leader and the developer of the world-renowned Repêchage® Four Layer Facial®, what Cosmopolitan UK has called "the best facial of the century." Today, together with her husband David Sarfati, co-founder and COO, Sarfati oversees a 50,000-square foot manufacturing, research, development, and training facility in Secaucus, New Jersey. She appears nationally and internationally at aesthetic trade shows, and attends and conducts overseas conferences in Asia, Europe, the Middle East, Central America, and South Africa.