Melanin is the culprit behind the dark spots that give us an uneven complexion. It is a brown pigment found in the basal layer of the epidermis.
This pigment is synthesised by melanocytes. The process of melanin synthesis is termed melanogenesis. Melanocytes go through different stages of maturation, becoming more pigmented at each stage.
Certain stimulants trigger a gene to produce more of tyrosinase, a copper-containing enzyme that converts tyrosine into melanin. Stimulants that activate the melanocyte include hormones, inflammation (such as acne) and external environmental conditions (ultraviolet light that causes the production of free radicals).
One simple way to reduce melanin production is to use broad-spectrum sunscreens with zinc oxide, titanium dioxide or iron oxide. These substances help block UVA and UVB light, thus impeding the stimulation of melanocytes.
Common hyperpigmentation disorders that involve the darkening of an area of skin due to increased melanin include melasma, lentigo, and post-inflammatory hyperpigmentation.
Melasma is usually caused by chronic exposure to ultraviolet radiation or a spike in hormones due to pregnancy or the use of oral contraception. It can be found at the epidermis, dermal layer or mixed, depending on the location of the pigment.
A lentigo is a light or dark brown area of discoloration that can range from 1mm to 1cm across, and is caused by an increased number of melanocytes. Its outline is usually discrete, but can also be irregular. Simple lentigines arise mostly during childhood on areas not exposed to the sun. Solar (or senile) lentigines are found on the backs of hands or on the face, most commonly after middle age.
Post-inflammatory hyperpigmentation (PIH) is the skin’s response to inflammatory skin disorders. Common causes are acne and atopic dermatitis. PIH is caused by the overproduction of melanin caused by skin inflammation.
Hydroquinone: For 50 years, hydroquinone has been the gold standard treatment for hyperpigmentation. This compound inhibits tyrosinase activity, thus limiting the amount of melanin to be produced. It also alters melanosome formation, possibly degrading melanocytes.
However, prolonged use of topical hydroquinone has shown to have side effects such as ochronosis and permanent depigmentation. Ochronosis is a disorder with blue-black discoloration. As such, hydroquinone is banned in cosmetic formulations and only available through a prescription that should be carefully managed by an accredited dermatologist.
Retinoids are forms of vitamin A that can treat acne, photodamage and PIH. They have various pathways that lead to skin lightening effects, such as accelerating epidermal turnover, reducing pigment transfer and slowing the production of tyrosinase.
With common side effects being erythema, skin irritation, dryness and scaling, it is recommended to use a retinoid only under the supervision of an accredited dermatologist. Corticosteroids (steroid hormones) have anti-inflammatory abilities and are often prescribed along with retinoids to prevent excess irritation.
Arbutin is a botanically derived compound found in cranberries, blueberries, wheat and pears. Though arbutin is a derivative of hydroquinoine, it has shown to be a more controlled way of inhibiting the synthesis of melanin as it does not permanently destroy melanocytes.
Kojic acid is a naturally occurring fungal substance. Its skin-lightening ability works by inhibiting the activity of tyrosinase. However, frequent use can cause side effects of contact dermatitis or erythema (redness of the skin).
Azelaic acid is known to be effective for treating PIH and acne. Azelaic acid depigments the skin in several ways. It can inhibit tyrosinase or reduce levels of abnormal melanocytes. This means that azelaic acid does not influence normal skin pigmentation but only acts on the proliferation of unwanted melanocyte activity. Side effects are mild and only last for a short period of time. Irritation, burning sensation or mild erythema may emerge, taking 2 to 4 weeks to subside.
Niacinamide is a derivative of vitamin B3. It works by decreasing the transfer of melanosome to keratinocytes. Niacinamide is a stable ingredient as it is unaffected by light, moisture or acids. This ingredient is often incorporated into cosmeceuticals due to its safety profile.
Vitamin C or L-ascorbic acid is a naturally occurring antioxidant that helps with skin lightening. It prevents tyrosinase from converting tyrosine to melanin. Vitamin C is also favored for its anti-inflammatory and photoprotective properties. However, L-ascorbic acid is highly unstable and rapidly oxidized. It is not used in the treatment of PIH.
Stable forms of vitamin C include magnesium ascorbyl phosphate or sodium ascorbyl phosphate. For safe and effective results, consider a dermatologist-formulated serum VITA C GOLD™ Serum,a formulation tested for bio-activity in a laboratory.
As seen above, there are various treatment options to treat common hyperpigmentation disorders. Recognizing the underlying cause for pigmentation is critical for proper treatment and choosing the best-suited therapy. Visit an accredited dermatologist for effective and safe treatments catered to your condition.
With the term “organic skincare” gaining popularity among the masses, I was recently asked, more than once by different people, what I felt were the benefits relating to organic skincare and why people should be using that. Perhaps my answers would surprise people but I feel that it is time the public gets a honest take on this topic by a dermatologist.
Let me first clarify my position, I am an accredited dermatologist and practice evidence-based medicine, whereby specialist recommendations are always made based on peer-reviewed journal publications or at least on an international consensus of the medical community. The terms “organic skincare”, “all-natural”, “chemical-free”, “pregnancy-safe” skincare are rampant in mass media these days, so I certainly don’t fault the lay person or even beauty writers who get the impression that this is the real thing.
In light of these, I seek to discuss “organic skincare” in this article. You will discover my choice of putting the term in parentheses and hopefully this will open your eyes to what the term really means, and does not, information only your dermatologist would tell you about . Without bias, I personally formulate a cosmeceutical skincare line myself as an adjunct to my cosmetic dermatology practice, with natural ingredients which are also evidence-based for anti-ageing and skin rejuvenation, but by the end of the article you will discover for yourself why I do not label any of the skincare as “organic”, and why “organic” is not exactly my key priority when it comes to skincare.
1.To a dermatologist, organic skincare does not exist
First and foremost, the term “organic skincare’’ itself is not regulated and from a dermatologist perspective, organic skincare does not exist as anything more than a marketing fad. Organic is a term relating to food or farming practices, and is applied correctly to vegetables or other crops which are grown without the use of chemical pesticides. If organic skincare manufacturers are keeping to the above definition at all, what this should mean is that were plant derived ingredients are used in skincare, these are grown in a chemical pesticide-free environment. What would be surprising to the lay person is that neither the FDA or HSA (in Singapore) makes any provision in their regulation of cosmetics for labelling “organic skincare”. As such, any skincare label touting this would be responsible for their own definitions of such and the consumer should be wary of such claims and what it implies.
2.There are no specific benefits to skin of using an organically-derived skincare brand
Contrary to popular belief, there are no specific dermatological advantages of using such a brand over any ordinary skincare. In fact, most of these eco-skincare brands often go untested and unquestioned as well. Often, these organic skincare brands boast plant or nature derived ingredients, without “preservatives” and parabens, also being touted as “home-made”. Despite the seemingly positive branding surrounding these skincare, the associated pitfalls are not different from any other cosmetic skincare — they all have the ability to cause irritation, or allergic reactions in individuals who are susceptible, such as those with sensitive skin i.e. atopic dermatitis.
3. An important factor to consider in anti aging skincare is the effectiveness measured by bioactivity of the active ingredients,as well as the scientific literature surrounding it
Plant-derived ingredients, depending on the source and type, may have anti-oxidant or moisturising properties, but simply including it in the skincare does not guarantee that it is effective. Bioactivity has to be measured by a trained chemist or scientist, which is when the extract is carefully distilled or harvested from the plant in such a way that the effectiveness is proven in the laboratory and can be measured.
4. The safety of organic skincare is not guaranteed, and could be even riskier than normal skincare with chemical preservatives
Brands touting “organic skincare”, especially when home-made, lack the stringent quality controls present in a laboratory setting, which is required for the formulation of dermatologist-grade cosmeceutical skincare. One real danger of certain types of “organic skincare”’ is that they are not regulated for safety, in terms of bacterial contamination. Preservatives such as parabens have gotten some bad press in recent years but the overall consensus in the dermatological community and by the FDA is that they are still regarded as safe and necessary to reduce bacterial growth in applied creams. The lack of “preservatives” is again a questionable label because this means that something else should be added to the product to increase the shelf-life of such a product which is meant for public sale. If not, this product should state the expiry of within 2 weeks to a month maximum of opening, because bacterial contamination will set in and this will cause problems when applied to skin.
Furthermore, the current Singapore Health Sciences Authority — HSA requirements for cosmetic skincare distributed via public sale, requires that the production facility acquires a basic certificate of Good Manufacturing Practices (GMP) before it is allowed approval. Home-made formulas that are sold online or by individual proprietors are hence on a “at your own risk basis”, and as a dermatologist, I do not recommend using any home-made or naturally derived products (from plants etc.) on a DIY basis because the irritation and allergy risk, i.e. phototoxic or photoallergic risks are high. Besides, the benefits of plant ingredients can only be harvested and extracted under a controlled laboratory setting with proper testing, as in the case with cosmeceutical skincare. Anything else, the public would be better off with a simple dermatologist-recommended pharmacy-brand moisturiser that is free from fragrances.
5. Problem-skin can’t be treated with ANY type of skincare but can be worsened with certain products
If you have problem skin, no amount of good skincare can treat medical skin conditions such as acne, eczema (dry sensitive skin) or rosacea (a condition that results in red flushed face with pimples). Such conditions require treatment with prescription medications and can be well controlled. These also do not disappear on their own so waiting to “outgrow” the condition, no matter what age you are at, is not a wise idea. Also, avoid consulting the internet, or beauty forums as suggestions there are not based on medical evidence and could even result in worsening of the condition or create a new problem, such as skin irritation or allergies from these DIY remedies.
I have encountered patients who developed phototoxic or photoallergic reactions from citrus (lemon/ orange juices) applied to their skin. A common misconception is that these DIY home remedies are ‘’natural and organic” but from a dermatologist perspective, this is not true. There are no skin benefits to applying lemon or orange juice such as vitamin C, which is only beneficial when one ingests it as a fruit or a juice. Topically applied vitamin C needs to be in a certain formulation, either ascorbic acid or Sodium Ascorbyl Phosphate — I incorporate a nano-formulated form of SAP in the cosmeceutical Vita C Gold which I prescribe in my practice for it to have brightening and anti-oxidant properties for skin.
Applying orange or lemon juice directly will simply result in skin irritation due to the acidic nature of these juices, worse still, some individuals may react to sunlight (UVA component) with the citrus component and develop a severe skin allergy that can result in scarring or pigmentation.
6. Facials, organic or not, makes no difference to your acne-prone skin
The above also applies to skincare services (e.g. facials) similarly labeled with the “organic” term, that organic skincare does not offer any true differentiation from any ordinary cosmetic skincare. Similar to any individually-applied skincare products, it is pertinent to know what is in the products applied during facials and skincare services. As your skin absorbs whatever you apply on them, it is important to always read through the labels and ingredient list, conduct prior research and then a patch test on the inner part of your arm. This helps to prevent any form of skin allergy and sensitivity you might get from trying such new products.
Besides, most aestheticians and facialists use instruments such as extractors and needles which are not medically sterilised (i.e. autoclaved, there is a difference between a new clean needle vs a sterilised instrument). This may lead to infections and scarring, besides having absolutely no benefit in the treatment of acne. Acne is primarily a inflammatory process, worsened by hormones, genetics and oil production. Treatment of acne by dermatologists involves addressing inflammation using oral or topical medications, as well controlling hormonal and oil production factors, via medications or certain cosmeceuticals. Comedonal extraction is only sometimes performed by dermatologists, as the preferred method of eliminating comedones is by the use of retinoids, which modulate the way skin turnovers, as well as with chemical peels whereby the top layer of skin dissolves with glycolic, lactic and salicylic acids, preventing the accumulation of keratin (read: dead skin cells) which can worsen comedonal acne.
7. Environmentally friendly? Perhaps. Skin-friendly, not necessarily
Most people think organic skincare are either eco-friendly, natural or vegan. Here’s the catch, they can and cannot be. Organic skincare products can have components which are organically farmed and also approved by the FDA (which simply means it does not contain toxic or banned ingredients), but having the HSA or FDA approval does not necessarily mean that these are effective or deliver significant benefits. Organically farmed produce can be friendlier on the environment in general, as less pesticide use means less harmful release of chemicals to the environment which accumulates as waste and potentially harms wildlife. However, these can also come at a greater cost, and by no means does that translate into any real benefits when incorporated into skincare which is not consumed but applied.
In fact, organic skincare often boasts essential oils which can cause both allergic( in susceptible individuals) and irritant contact dermatitis( due to the concentration of most essential oils, it is not medically advisable to apply any type of essential oil directly to skin as it can result in a chemical burning type of reaction).
For patients with otherwise healthy skin, whether they are in their twenties, thirties or beyond and who are interested in maintaining youthful skin in a cost-effective manner, I would suggest getting started on cosmeceuticals, and regular medical grade chemical peels supervised by a dermatologist, who would determine the concentration and type of acid suitable for your skin. A chemical peel treatment is designed to improve the appearance of the skin by gently stimulating the top layer of skin cells (epidermis) by applying a solution composed of fruit derived acids such as alpha-hydroxy acids, glycolic acids, lactic and salicylic acids. This stimulates the skin to regenerate, smoothening out wrinkles.
Rounding up the discussion here, I hope readers have gained some insight on the labelling of skincare as “organic” and what that doesn’t mean. It is not a defined or regulated term in dermatology and can lead to great misconceptions by the public, in addition to brands riding on a fad which delivers no real benefits skin-wise. As a dermatologist, I am all for public education for skin health. Skin health is not about “aesthetics”, the skin is an organ of the body just like the heart, lungs and the liver, and these tend to degenerate due to genetics, age as well as poor lifestyle habits. Healthy skin certainly looks good, but in the pursuit of beauty, one should always be wise, consult a dermatologist if you have a skin issue such as acne or skin sensitivity, rather than trying all sorts of products. While there is no miracle product that exists that can cure your skin woes, non-dermatologist-tested cosmetic skincare can worsen problem skin. If you have healthy skin and desire some radiance and want to preserve your youth, then go for cosmeceuticals, instead of ‘‘organic skincare” or any other type of skincare fad.
The countless advertisements from skincare solution providers.. They started with just the beauty parlours but now has spread to ‘medical spas’ with doctors purportedly offering solutions to bad skin. How could one even start to differentiate what works from what doesn’t? Afterall, it never comes cheap.. And what more, with every single beauty or “medi-spa”claiming the “skin-specialist title?’’
Well if you ever felt confused by the sheer multitude of “acne scar treatment’’ providers, and “skin specialists”, in all honesty, as a dermatologist, I don’t blame you. I’ve been equally baffled by the proliferation of “skin specialists’’ in Singapore, all promising to make you beautiful, either with customised serums, peels or lasers, and of course, at a price.
On this note, if you’ve already decided you want some help for your skin, my role here is to formulate a quick guide (albeit slightly unconventional compared to your magazine beauty writers) as to how one can make an informed decision as to who to go to for skin treatments, and what the treatments are all about!
In the spirit of providing honest, unbiased objective reviews and advice from an insider point of view, I seek to shed some light on a dermatologist’s perspective on acne scar treatment in this article, which is the same kind of advice I personally give to my patients, friends and relatives.
1. Educate yourself first
I’m going to make a rather unusual illustration here and allude to how I purchased my audiophile sound system when I wasn’t exactly an audiophile.
I’m not sure about you but one of the ways I make decisions on a lot of things I buy, is really first to find out all the information out there. I try to understand myself how the “science behind it works”. I’ll let you in on this little secret on how to win my consumer heart: I usually am most impressed by a vendor that best explains how best that product fulfils a need in my daily life, for example, and actually being able to try it myself, rather than attractive packaging or freebies.
Along the way I go through a bunch of reviews on what actual consumers have to say about the product. Needless to say, all these are often what we find on the Internet.
I don’t stop there, I research the brand thoroughly, from the origins, the certifications, and well, generally if I’m looking for an audiophile sound system, I don’t go to a general electronics store selling washing machines and furniture to boot, or necessarily to the most beautifully built soundbox out there. For months, I spoke first to all the audiophiles I knew, read reviews on geek websites and auditioned several stores, trained my ears and finally decided on my final buy.
Honestly, I am thankful for all that. I have had so many different speakers before but 1000 of those could not compare to the single, solid, smooth system I have now. It wasn’t exactly the cheapest, but it was worth every single cent. Point is, as consumers, we should look for true value and substance, not marketing and packaging. It’s never easy in today’s world, but one way easy way is to check out certifications and do brand research.
Now, if that didn’t put you to sleep yet, let me translate that into the world of acne scar treatment.
Now, there are 2 types of acne scars — Post-Inflammation Hyperpigmentation (PIH) and dermal acne scars (otherwise known as ice pick, rolling or box car-type scars). It’s probably useful to know these terms which your dermatologist would tell you about in the discussion of your scar treatment.
What I share with my patients is this : Imagine your skin as having 2 layers, and now it has certain defects which are visible. Like a piece of pottery, PIH occurs in the top layer like the cracked glaze, while dermal scars in the second layer are like huge dents in the pottery which occurred during the moulding process.
Now if you were tasked to restore this clayware to its ideal form, what would you do? It’s intuitive to think one could paint over the cracks, or sand it off till it’s smooth. For the dents, well, how about filling it in with a huge clunk of new clay, maybe with superglue and paint it over again and pray no one would have noticed it.
A master potter, on the other hand, would assess first the defects and the overall aesthetic of the object, and determine how to most efficiently restore it without it looking artificial or fake, without damaging more parts of the clayware, and essentially, simply make it what it should look like — more beautiful. Most importantly, he understands the characteristics of clay when it is dry or when it is wet, the tools he has and how to use them, because he’s had years of experience training in that at far more complex levels, he also knows what it takes to make the final product look good, without making a bigger mess in the process. He would also be honest enough to tell you upfront if some defects simply cannot be corrected in a single treatment.
3. Tools — Ablative CO2 fractional lasers? Chemical peels? Carbon peels? Radiofrequency? Skinboosters?
All of the above are clinically proven to improve the appearance of acne scars. Now what that means is that a body of evidence exists behind this, with clinical studies that support the use of these methods, and that a good proportion of dermatologists agree with these safety and effectiveness of these studies before the machines are cleared by FDA for the treatment of acne scars.
There are recommendations for settings which are given by the manufacturers, but far from being a cut-and-dried formula, the best effects are realised with the correct choice of treatment, the correct combination, timing as well as personal experience/expertise with the use of these machines, tailored to the individual patient’s skin type and response. Otherwise, a robot could also treat your acne scars, better still, without human error (pun intended).
Did you know, for example, that the darker skinned you are, the more heat from the laser your skin absorbs, and hence the higher the risk of scarring from treatments itself? This applies to all Singaporeans out there, whether you are of Chinese, Indian or Malay or any other asian heritage, you have much higher amounts of melanin (pigment colour in your skin) than your counterparts in Europe or America (where most of these technologies were discovered and used). It is important for your doctor to carefully watch how your skin reacts to the laser, to achieve the desired endpoint (which shows the treatment has reached an effective level) without causing unwanted heat damage.
I personally use a combination of treatments- from ablative (CO2 laser, plasma nitrogen) to non-ablative (radiofrequency) fractional resurfacing for deeper scars and for a more dramatic effect, in combination with a well-timed chemical peel/microdermabrasion to prep the skin for best results. Pigment lasers work well for uneven skin tone. For a finishing touch, skinboosters work well to create a plump dewy skin texture.
On the topic of tools, not all laser machines are created equal, as those which are of more sophisticated engineering tend to be more precise, cause less potential side effects and downtime. For example, higher-end CO2 laser machines are different in terms of delivery of the shape of the pulse, the wave type and overall precision in delivering energy to the deeper layers of skin without burning the surface of skin. These also incorporate radiofrequency energy to enable higher energy delivery without increasing the risk of heat damage to the skin.
Superficial chemical peels are the commonest used type of peels. They comprise primarily of one of or a combination of these 3 — glycolic acids, salicylic and lactic acids. These can cause excessive irritation if the concentration or type of acid used is inappropriate and may lead to chemical burns, or if too mild, are simply not effective.
4. Maintenance — Proper skincare
So you finally restored that piece of beautiful pottery. Subject it to wear and tear, rough handling and you will be back to square 1. There is a true science behind evidence-based skincare. Go for reputable, dermatologist recommended brands formulated in laboratories rather than what your facial auntie recommends you or what the latest customised serum fad offers.
Obviously the scope of acne scar treatment is well beyond that of any article. What I’ve set out to do is to streamline the key factors, the “know-how” rather than the “what”, which I believe can help the lay person navigate a bit clearer on this cloudy path. There are way too many vendors selling their wares to acne-scar sufferers, adding more woe to their already battered self-esteem. Hope this helps!
By Dr. Teo Wan Lin, Consultant Dermatologist at TWL Specialist Skin & Laser Centre
Why do I get acne?
Acne occurs when the oil glands under the skin, known as sebaceous glands, become clogged with sebum, an oily substance. This process is known as inflammation, and it is often genetically determined. Hence, if you have a family history of acne, you are at high risk.
A normal amount of sebum usually keeps the skin healthy. Your oil glands become active once you reach adolescence due to hormones and this is when acne usually starts. When clogged, bacteria grow in the glands, and leads to bumps, swellings and visible blackheads and whiteheads on the skin’s surface.
Why do I tend to get acne on my chest, back and neck?
These areas have the highest numbers of oil glands and are acne-prone. Acne is not the only condition that can cause that. A fungal infection, known as pityosporum folliculitis, can also cause a similar condition. If you are developing bumps over these areas, it is important to see your dermatologist for diagnosis and treatment to prevent worsening and possible scarring.
As an adult, is it possible to still struggle with breakouts?
Acne can still affect adults. In fact, many adult females suffer from acne breakouts around the chin especially during certain times of their menstrual cycle. This should be differentiated from other conditions such as perioral dermatitis, which may look similar but is treated differently.
Is there a cure for acne, or do I just wait to outgrow it?
Acne can and should to be treated early to prevent worsening, secondary infections and scarring which may be permanent. It is definitely a fully treatable condition that no one should have to live with. Acne has an impact on one’s emotional well-being, and it is especially crucial during adolescent years and this should not be ignored. Severe forms of acne can result in bleeding, pus and more serious infections, a condition known as acne fulminans, which can result in complications.
What treatments are available for acne?
Under proper dermatologist care, acne can be fully treated with the correct medications, creams and light treatments. For patients who prefer not to be on oral medications, laser therapy is a safe and effective acne treatment method too. Specifically, blue light, a type of laser therapy is designed to treat acne when it is active, and another therapy, ablative resurfacing can cure the scarring after it subsides.
In addition to treatment, prevention against future acne breakouts are also crucial. Diet and proper skincare are also important factors in contributing to one’s acne condition. Therefore, holistic counselling with specific advice about how to manage your condition is important.