Whatever the case may be, considering exposure to the sun is responsible for the majority of the damage to the skin, it is a topic that is worthy of revisiting on a regular basis.

Education for you, as an aesthetician, and more importantly for your clients is a primary concern in regards to this topic. According to a study published in the Journal of Dermatologic Surgery, which Jennifer Linder, M.D. references in her article Caring for the Skin Cancer Patient on page106, 94 percent of the participants were concerned about the risks of developing skin cancer and yet 68 percent of them still believed they looked better and healthier with a tan. Based on these findings, there is clearly more work to be done in terms of education.

Skin cancer is the most obvious concern when you see a sunburned or tanned skin. However, there are many other disorders that are either a direct or indirect result of the assaults of exposure to the sun. Therefore, you will find that the articles prior to the feature focus on sun care and prevention. While those that follow the feature are centered on sunburns, skin cancer, and working with skin cancer patients to provide services that compliment the treatments they undergo with their physician.

For the feature however, we opted to explore that which gives our skin, hair, eyes, and nails their color – Melanin. In accordance with last month’s feature format, we once again asked three writers to contribute to our feature on melanin. Howard Murad, M.D.; Peter T. Pugliese, M.D.; and Michelle D’Allaird have each written complimenting portions that will enlighten you as to the in’s and out’s of melanin –its purpose, function, and reason for being; the disorders that exist when it fails to function properly due to genetics or trauma; and finally your role as an aesthetician, what options are available to you and how you can best advise your client.

The numbers found by the study are hardly surprising considering how flippantly we live our lives. We eat all the wrong foods and far too much of them. We exercise far too little and watch television or sit in front of a computer more than we should. Instead of building a “village” through knitting circles and community socials, we spend our time chatting in discussion forums with people far and wide that we will never meet. In short, we think more about the here and now than 10 years from now, never mind 30 to 50 years from now when all of these bad choices will matter. Short term gains for long term sacrifices.

So, how do you educate in the face of that mentality? You talk to your clients about why it is important, not just that it is important. You talk to them about the many disorders that come from careless sun care and you explain the process of melanogenesis and how that tan that they think makes them look healthy is actually their skin’s way of saying you’ve harmed me. You maintain a consistent message. If you can do this in a caring, informative manner you will make a difference in someone’s life.

Understanding Melanin

by Howard Murad, M.D.

Uneven skin tone is a top skin concern for clients and aestheticians alike. This article offers a review and touches on the newest developments in melanin research and treatment.

Most, if not all of your skin care clients, will tell you that skin discoloration is one of their top concerns. Uneven skin tone is usually not a client’s only skin issue as it goes hand in hand with many skin diseases and disorders. Skin discoloration is the result of melanin production (melanogenesis) or the lack of it and it can complicate skin treatments. Knowing this, it is therefore important to understand melanin and its basic function in skin.

What is Melanin?

Melanin is pigment and it gives our skin, eyes, and hair color. Its primary function is to protect the skin from damage, including photo-damage and/or trauma and it does this as a direct reaction to inflammation. With sun exposure, microinflammatory processes in skin stimulate the production of melanin. Melanin absorbs and converts sunlight to heat as it helps skin cells scavenge free radicals and prevent malignancies from occurring. Melanogenesis also helps protect skin that is healing. We can see this process clearly with acne scars or macules.

Darker skin means there is more melanin in the skin cells, but it does not mean the skin has more melanocytes. No matter what skin color we have, we are all born with a similar concentration of melanocytes, which are located in the basal layer of skin. Melanocytes are dendritic cells, cells that have branch-like projections known as dendrites, and make up about three percent of the cells in the epidermis. Each melanocyte produces the melanin for about 36 skin cells.

Melanin is often misunderstood, for example, a decrease in melanin is actually what leads to hyperpigmentation disorders, freckles, age spots, and melasma. In fair-skinned individuals, basal cells contain only a few small melanin granules that are barely visible. Whereas, the basal cells of tanned skin or individuals with darker skin contain a distinct amount of melanin granules. The number of active melanocytes decreases by an estimated 10 to 20 percent per decade of adult life. The melanocytes that remain attempt to compensate for the missing ones, so you have an overproduction of pigment in one area and a decline or complete absence of melanin in another. This is why age spots form and skin becomes splotched with darker and lighter shades of color. Melanin becomes disproportionately concentrated in moles, freckles, etc. During a skin evaluation, the presence of uneven skin tone or freckles indicates that there is a lower amount of melanin in the skin, thus a reduced capacity for DNA repair. In sum, the client is at increased risk for photocarcinogenesis and great care must be taken to prevent further skin damage with sun protection.

The relationship between melanocytes and keratinocytes (skin cells) is referred to as the epidermal-melanin unit. The melanin produced in the melanocyte is transported by melanosomes through the dendrites, which transfer the melanosomes to the kertinocytes. Melanocytes produce two types of melanin: eumelanin and pheomelanin. Eumelanin is brown to black, while pheomelanin is yellow to red.

In tanned skin, eumelanin is the pigment that has been stimulated. Interestingly, women have more pheomelanin than men, so women’s skin is generally redder than men’s. Those with red hair have high levels of pheomelanin, which imparts a pink to red hue. Pheomelanin is particularly concentrated in the lips and nipples.

How Melanin is Produced

Melanin production and its resultant hyperpigmentation or tanning actually begins in the brain. The pituitary gland is attached to the base of the brain and secretes hormones that govern many body functions. In the case of melanin, the gland is responsible for creating and releasing a class of peptide hormones called intermedins or melanocyte-stimulating hormones (MSH). When skin is exposed to sun or experiences trauma, inflammation occurs, putting inflammatory mediators into motion, telling the brain’s pituitary to send assistance with MSH. Once in the bloodstream, MSH stimulates the adrenal gland, which triggers tyrosine, an amino acid found in the body. Tyrosinase breaks down by tyrosine. Tyrosinase is broken down further to dopamine, and through a process of many more interactions, and broken-down elements, the melanocytes pump out melanin to protect skin cells from damage. This explanation is overly simplified as the actual process of melanogenesis involves many factors and several hormones and interactions that are not completely understood. In general, however, scientists believe that melanogenesis occurs because of a combination of factors including DNA damage, and these factors may vary from client to client. Having said that, you can see why treating hyperpigmentation can be difficult – as much as we know, we still don’t know everything.

Prevention and Treatment

Because the release of melanin begins in the basal layer, the deepest layer of the epidermis, and the layer where new cells are “born” each day, it can be difficult to treat existing hyperpigmentation with aesthetic treatments. Additionally, treatments will take at least a month to work as basal cells move up through the layers of skin to the outermost stratum corneum and become sloughed off with exfoliation.

The best treatment for sun-induced hyperpigmentation is sunscreen, which will help prevent further photo-induced inflammatory processes from occurring. This allows skin to normalize more quickly.

The most common treatment for too much pigment or uneven distribution of melanin is hydroquinone. It’s not exactly bleach, though some people refer to products that contain hydroquinone as skin-bleaching creams. Hydroquinone lightens the skin by inhibiting the chemical reactions that create melanin. It attacks melanocytes as it occupies their receptor sites, blocking tyrosinase. It can be combined with AHAs, which increase cell turnover, hastening skin normalization. Over-the-counter skin lighteners that contain a two percent concentration of hydroquinone or less are adequate for most people. Higher concentrations are available by prescription only. There are also drug formulas that combine hydroquinone with Retin-A and other ingredients. Care must be taken with these prescription products because they can be too irritating and may actually contribute to pigment problems. I often suggest that people alternate hydroquinone-containing products with those that contain other types of brightening agents, or use one type of lightener in the morning, the other at night. Pregnant or nursing women should not use hydroquinone because the appropriate safety studies have never been done.

There are many ways to treat already-existing hyperpigmentation with other hydroquinone-free products and treatments such as chemical peels; tyrosinase inhibitors, such as arbutin, which acts like hydroquinone on the melanocyte receptor sites, bearberry, licorice, kojic acid; in addition to peptides; soothing ingredients; LED; microdermabrasion; retinoids; alpha hydroxy acids; vitamin C; and topical corticosteroids. Vitamin C infusions and in-spa facials will help lighten pigmentation. And with any treatment, sun protection is necessary as a final step to protect the skin.

Inhibit Inflammation with Food

Because an inflammatory process stimulates melanogenesis, certain inflammation-abating foods may also be helpful in preventing skin discoloration, including foods stocked with antioxidants or brightly colored fruits and vegetables, and healthful, EFA-rich protein. During inflammation, intracellular water loss is encouraged, and this can further damage melanocytes and cause them to function erratically or not at all. Therefore, a diet or regimen that encourages the retention of cell water inside the cell and in the cell membrane will fortify melanocyte integrity, ultimately, making skin less prone to discoloration.

While not a complete list, some nutrients to consider adding to the diet include alpha-linoleic acid (ALA), which is found in vegetables, beans, fruits, flaxseed oil; gamma linolenic acid, which can be found in seed oils such as borage, evening primrose, black currant, and hemp; durian and sulfur-containing foods like garlic, onions, meat, and cruciferous vegetables; zinc, which assists with inflammation from acne; grape seed extract; vitamin C; coenzyme Q 10; and pomegranate, which boosts skin’s natural SPF.

We are fortunate to live during an age where we have learned so much about the skin and how it connects to all systems in the body. As scientists research melanogenesis and the body’s microprocesses, we may, someday, have a near-cure to a problem that complicates our treatments and so many of our client’s lives.

Melanin Disorders

Albinism-The lack of melanin in skin. Genetically inherited.

Vitiligo-Characterized by a loss of melanocyte cells. Can be caused by diabetes, physical trauma or Addison’s disease.

Hypopigmentation-White areas that usually occur post skin trauma, burns, blisters, cuts.

Post-inflammatory hyperpigmentation-Darkened areas that usually occur post skin trauma.

Melasma-Also known as the mask of pregnancy or chloasma. Hormonally related. Located in down the center of the face—upper lip cheeks and forehead. Symmetric patches on the face that worsen with sun exposure. Can be result of pregnancy or the use of birth control pills.

Menopausal lateral pigmentation-Pigmentation associated with menopause. Usually occurs on the lateral areas of the face—from the ears toward the middle of the face. Results because of a lack of estrogen.

Macules-Pink or purple spots that remain after acne lesions heal.

Age spots-Also known as liver spots or solar lentigines or lentigos. Appear as flat, gray, brown or black spots. Occurs from chronic sun damage.

Freckles-Also called ephelides. Genetically inherited, they darken with sun exposure and are found on fair-skinned individuals. Indicate a lower level of melanin and sun protection. Occur from acute sun damage.

References

Murad H, Jankicevic J. “Dietary Supplementation as a Nutrition Intervention Strategy to Increase Intracellular Water and Phase Angle.” Orlando, FL. American College of Nutrition 48th Annual Meeting and Conference, 2007.

Murad H. Wrinkle-Free Forever. New York: St. Martin’s Griffin, 2003.

Murad, H. Sealed for Your Protection. Dermascope. Sept 2008; 33: 79-86.

Murad H. Antioxidants: Nutritive Effects on the Skin. Paper presented at: Noah Worcester Meeting; January 2004, Maui, HI.

Moy LS, Moy RL, Murad. Glycolic acid peels for the treatment of wrinkles and photoaging. J Dermatol Surg Oncol. 1993; 19:243-246.

Fuller B, Smith D, Howerton A, Kern D. Anti-inflammatory effects of CoQ10 and colorless carotenoids. J Cosmet Dermatol. 2006;5(1):30-8.

Yoskimura M, Watanabe Y, Kasai K, Yamhoshi J, Koga T. Inhibitory effect of an Ellagic Acid-Rich Pomegranate Extract on Tyrosinase Acitivity and Ultraviolet-Induced Pigmentation. Biosci Biotechnol Biochem. 2005; 69 (12):2368-2373.

 Murad H, Shellow W. Pomegranate Extract Both Orally Ingested and Topically Applied to Augment the SPF of Sunscreens, Cosmetic Dermatology, October 2001.

H Murad. Thoughts on the Process of Aging. Cosmet Dermatol. 2009; 22 (2).

Kligman LH. Photoaging: manifestations, prevention and treatment. Clin Geriatr Med. 1989; 5: 235-51.

Murad H. Skin Immunity, The Next Generation of Skin. Les Nouvelles Esthetiques & Spa. 2008; 7: 130-136.

Murad H, Tabibian M. The effect of an oral supplement containing glucosamine, aminoacids, mineral, and antioxidants on cutaneous aging. J Dermatol Treat. 2001; 12:47-51.

Murad H, Shamban AT, Premo PS. The use of glycolic acid as a peeling agent. Cosmet Dermatol. 1995; 13 (2): 285-307.

Howard Murad, M.D. has devoted his life to making beautiful, healthy skin attainable for everyone with his internal and external approach. A board-certified dermatologist with a thriving practice, a trained pharmacist, and Associate Clinical Professor of Dermatology at UCLA, Dr. Murad has built a patient base of 50,000 people including Hollywood stars. Over the years, treating such a wide variety of individuals presenting every conceivable skin condition gave him direct insight into what his patients wanted and needed to care for their skin at home. Putting theory into practice, he developed targeted formulas to alleviate even the most frustrating skin concerns with his line of skincare products.

Disorders of Pigmentation

by Peter T. Pugliese, MD

We can divide disorders of pigmentation into two broad types: Hypopigmentation and Hyperpigmentation. Melanin is either totally lacking or in low production in hypopigmentation. Hyperpigmentation is characterized by excessive production of pigmentation. In both of these disorders, the melanocyte is the target cell of whatever etiological factor produces the disorder.

Disorders of Hypopigmentation

Albinism – Albinism is a genetic disease and is therefore an inherited disorder in which there is a lack of melanin in the skin, hair, or eyes. (All albinos have pink eyes). Albinism occurs in all races and thus is worldwide; it even occurs in animals. Since there is no cure for albinism, individuals who have this disorder must protect themselves from UV damage. Sunglasses are important as many albinos have visual problems and frequently are afflicted with abnormal eye movements called nystagmus.

Vitiligo – Vitiligo is a pigmentation disorder characterized by loss of melanin (depigmentation), thought to be due to attacks by the body’s immune system on melanocytes. Vitiligo is a localized loss of melanin. The affected area appears as smooth, white skin patches, often found around the mouth and eyes, and frequently on the back of the hands; some patients show the loss of melanin in patches all over the body. Vitiligo is associated with autoimmune diseases such as thyroid disease and diabetes, and may appear after an injury or bad sunburn. Wood's light examination (365nm) can distinguish hypopigmentation from depigmentation. The depigmentation of vitiligo fluoresces ivory-white and other lesions of hypopigmentation do not.

Tinea versicolor – Tinea versicolor is a very common skin condition caused by a yeast organism on the skin. This yeast can be found in relatively oily areas of the skin that include the neck, upper chest, and back. It is easily diagnosed by typical scaly, mottled appearing lesions from pale to tan mostly on the upper back. Most frequently it is seen in the summer when individuals try to tan. Since the yeast produces a tyrosinase inhibitor, melanin is not formed and areas of contrasting light and dark spots appear. Shining a Wood’s light on the area will reveal bright yellow-green areas indicating the presence of the causative organism.

Traumatic Hypopigmentation – Many diseases can cause hypopigmented skin lesions. Some are common and some are rare: pityriasis alba (frequently in children, no known cause), tinea versicolor, lupus vulgaris, and several other rather complex medical disorders. Many traumatic injuries such as burns or chemical spills can produce temporary hypopigmentation. Often transient white spots will appear as post-inflammatory and post-traumatic hypopigmentation where skin lesions associated with rashes such as pityriasis rosea have occurred. These white spots will usually return to normal without treatment.

Disorders of Hyperpigmentation

Moles, Freckles, and Lentigines – Moles are usually brown or black and can appear anywhere on the skin. They start appearing in early childhood and continue to appear for the first 20 years of a person's life, until somewhere between 10 to 40 moles are present by the time we are adults. Moles appear when melanocytes grow in clusters rather than as single cells. While most moles are benign, two groups should be watched: those that look different than other existing moles and those that make their appearance after age 20. Moles that do not change over time are usually benign, but any change in an existing mole, or if a new mole appears, should be seen by a dermatologist. Freckles are little brown spots usually seen on the face and arms; they are extremely common and are more often seen in the summer. Light-skinned people, or people with light or red hair are most often seen with freckles. Freckles appear to have some genetics basis, but they are harmless and rarely increase without the benefit of ultraviolet light exposure. Seborrheic keratoses are brown or black raised lesions found on the chest, back, and head; and are derived from keratinocytes. No one knows the cause of seborrheic keratoses though they are more often seen as people get older. Seborrheic keratoses are benign and rarely malignant. Lentigines are flat spots on the skin that are darker than the surrounding skin. The name comes from the Latin word for the lentil bean. They are most frequently seen on individuals with white skin. The major cause is from sun exposure, though lentigo simplex is seen at birth and in early childhood, while solar lentigo is caused by sun exposure.

Melasma – Melasma affects mainly women but men can also have this pigment disorder. It is prevalent in men and women of Native American descent occurring on the forearms, and in men and women of German/Russian and Jewish descent on the face. Typically melasma, also known as chloasma, appears as brown patches on the forehead, cheeks, nose, and chin, as well as on the upper lip. It is most often associated with pregnancy, birth control pills, and hormone replacement therapy (HRT). One factor that makes melasma difficult to treat is that it presents as dermal pigmentation, or as a combination of both dermal and epidermal pigmentation. You can distinguish the two types with a Woods’s light. Dermal pigmentation will either not show under the Wood’s light or will decrease in intensity. Epidermal pigmentation always appears darker under the Wood’s light. Melasma is brought on by estrogen and progesterone stimulation of melanocytes, which will produce more melanin pigments when the skin is exposed to sun. Women with a light brown skin type who live in areas with intense sun exposure are much more prone to developing melasma. There is evidence that a genetic predisposition is also a major factor in developing melasma. Certain conditions such as thyroid disorders are associated with an increase in melasma, but stress is a possible factor since it is often coupled with an increase in melanocyte-stimulating hormone.

Ochronosis – There are two types of ochronosis – endogenous ochronosis, which is of genetic origin and exogenous ochronosis. Exogenous ochronosis, like pigmentation, may occur after the topical application of hydroquinone, but only the sites of application show the discoloration. The hyperpigmented areas vary from dark brown to black, often with gray-blue patches. They are most often noticed over the malar areas and central face. Over time the hyperpigmentation may fade slightly if the causative agent is discontinued, however the discoloration is usually permanent.

While exogenous ochronosis most commonly is associated with the use of hydroquinone, a few other chemicals such as resorcinol, phenol, mercury, picric acid, and antimalarials are known to be associated with this type of hyperpigmentation. It takes about six months of continual product use before hyperpigmentation usually appears. South Africans have the highest reported incidence of ochronosis.

The mechanism of this hyperpigmentation is thought to involve one effect on the enzyme tyrosinase, which is essential to melanin formation. The chemical involved in the discoloration is homogentistic acid, which requires an enzyme called homogentistic acid oxidase to metabolize it and break it down. If homogentistic acid accumulates, it binds to collagen and can produce the blue-black color associated with ochronosis. It is believed that hydroquinone inhibits the essential enzyme called homogentistic acid oxidase that breaks down the homogentistic acid.

Peter T. Pugliese, MD has been the undisputed pioneer of cosmetic research, formulation, and education in the field of skin health. He has spent more than 50 years dedicating his life to research and science. His research in the field of anti-aging and skin physiology has given him numerous awards, patents, and discoveries which have influenced the course of professional skin care around the globe. Pugliese has contributed chapters to over a dozen books and published over 60 scientific papers. He has authored four books, including, in 1990, the first textbook written for aestheticians by a physician, Advanced Professional Skin Care, to bridge aesthetics and medicine with a common language. His newest publication is Advanced Professional Skin Care – Medical Edition.

An Aesthetician's Role in Inprovement

by Michelle D’Allaird

At this point, you have an understanding of how pigmentation is produced, as well as the various types of skin conditions that can arise from either excess melanin production, or a lack thereof. The next step, as I am sure you are wondering, is what to do to treat it…, well, we don’t “treat” anything, so let’s just say, have an “improvement” on it.

Treating hyperpigmentation entails various approaches. The first is obviously to improve the appearance of the skin, usually to minimize excess pigment. The second step is to prevent further pigment production. The final step is protection.

First Step: Improving the appearance of the skin can be achieved by either chemical or mechanical means. The use of lasers, microdermabrasion, and peeling agents such as lactic acid, glycolic, Jessners’, and TCA are all fabulous. All require training and experience in order to properly analyze the client’s skin, determine their pigmentary needs, and perform the service.

You must take into account the cause of the pigmentary concern, health and lifestyle of the client, as well as their commitment to achieving results. You then must determine the amount of treatments required, the aggressiveness of the treatment protocol, and any possible side effects. In many instances, a series of chemical peels may show improvement; yet combining those peels with microdermabrasion will deliver heightened results. In some cases, Intense Pulse Light may be the answer.

Almost every one of these treatment options has one thing in common… can you guess? Each of them causes an inflammatory response within the skin. As we have learned, an inflammatory response will trigger melanin production. This will lead right into our next step…

Some of these treatment options may not fall within your scope of practice, or within your current practical abilities; but knowledge of them will guide you in the process of improving your client’s skin.

Second Step: Impeding further pigmentation. The “influenced” keratinocytes send messages to the melanocyte that they are in need of assistance. Upon receiving the signals, the melanocyte starts to produce enzymes and proteins needed to create the pigment; this is known as tyrosinase. The tyrosinase enzyme then acts to catalyze

a number of biochemical reactions to produce melanin. Once produced, the melanin is transferred into the keratinocytes, resulting in darkened skin.

It is within these processes that so many wonderful ingredients can play key roles. The majority of skin care ingredients use tyrosinase inhibitors; they are ingredients that block the production of tyrosinase. But as you just read, there are a few steps that occur prior to the tyrosinase production. It is in these steps that melanin formation can also be influenced or prevented.

Black cohosh can be used to block the message being sent from the keratinocytes, to the melanocyte. Vitamin C and lotus root have been used to block the stimulation of the tyrosinase enzyme. Licorice and bearberry are known to impede melanin production by tyrosinase. Wheat Germ has the ability to have a mild influence over the type of melanin produced – eumelanin or pheomelanin. In laboratory studies, plum has been shown to block the transfer of melanin from the melanocyte into the keratinocytes.

Third Step: Prevention. SPF. Sun protection is an absolute necessity. The use of skin lightening ingredients all play a similar role in some way, shape, and form, which is to turn off the body’s natural protective mechanism of melanin production. Remember, melanin production is stimulated in an effort to protect epidermal cells from damage. Therefore, if we are turning off these protective mechanisms, we must have a plan in place to protect the epidermal cells…sunscreen. Skin lightening ingredients should not even be a consideration without the accompaniment of an SPF 30 on a daily basis.

It is also important to remember that proper home care is 80 percent of the condition of the skin, and 95 percent of the results of any of your professional treatments. It is much like going to the gym and then hitting the greasy burger stand on the way home.

Skin lightening treatments absolutely require home care and sunscreen, no questions asked!

Pigmentation concerns are the greatest skin care concern seen in many spas, clinics, and medical settings. As professional aestheticians, we are often the first answer, line of defense, and solution for our clients. It’s exactly what our job entails!

Michelle D’Allaird is a New York State licensed aesthetician and International CIDESCO Diplomat. She is the owner of the Aesthetic Science Institute aesthetic schools in Syracuse and Latham, N.Y. She is a consultant and educator for international cosmetic companies around the world. D’Allaird is a contributing author to major industry trade magazines, as well as a host and speaker for International Congress of Esthetics & Spa conferences in Miami, Philadelphia, Dallas, and Long Beach. She is also a co-author of Salon Fundamentals aesthetic textbook. Her expertise lies in education and curriculum development for aesthetic, medical, and laser courses.