Complex Hyperpigmentation Problems

[Robin H]

I am half Asian and half caucasian.  I have oily, extremely sensitive skin with a tendency to break out, redden, freckle,  burn and also a tendency to hyperpigment.

A few years ago, I developed melasma from the pill. I quit the pill, and it kind of came and went for a while. I used Retin-A and sometimes hydroquinone (which seemed to help at first, but then seemed to stop helping). I no longer use Retin-A, as my skin has become increasingly intolerant of it.

A year ago, I decided to try a new very low hormone version of the pill, thinking it might help my oily skin. Unfortunately, my melasma came back (it was almost gone before that point).

In January I had 2 microdermabrasions and one photorejuvenation session. I was very happy with how much my melasma had improved.

After this was over, I began to use a lightening product to continue the improvement. I chose a 2% hydroquinone and 2%salicylic acid product from Paula's Choice (no fragrance or known irritants other than the active ingredients, of course).  I had not used a hydroquinone product in at least two years (since it had seemed to stop working for me). About three weeks after beginning treatment with this product, I noticed my skin suddenly darken (both in the areas of my previous melasma and some other areas too). In addition, I had about 3 black speckles emerge on my right cheek (something I have never had before). (by the way, this whole time I'd been indoors with spf 15 product, so sun exposure was not the cause).

I immediately stopped using the product two weeks ago, as I suspected I might be having a reaction to the hydroquinone.  I was going to have another microdermabrasion done, but now I wonder if it could be a post-inflammatory hyperpigmentation from the microdermabrasion itself? Is this possible?

I have been using an over-the-counter product containing glycolic acid and some alternative lightening agents (Doctor's Dermatologic Formula). My skin looks better than it did two weeks ago, but I'd still like to get back to my improved condition a couple of months ago. The problem is, now I am afraid to use the hydroquinone OR to get another microdermabrasion treatment, because I have no idea which one I reacted to!

So, basically the main questions are:

1) What is your best guess as to the cause of this worsening after my symptoms had improved so much?

2) I'm thinking about contacting a dermatologist about a tca peel, but would like your feelings on this before going in for an expensive office visit. Given my skin type, is a tca peel more risky than it's worth?

3) Do you have any other advice, or can you tell me how to find a dermatologist in my area that specializes in (or has a lot of experience in) successfully treating complex hyperpigmentation problems?

Okay, sorry this is so long and complex. I appreciate your time in answering these questions.

[Alan Rockoff, MD]

Melasma is a frustrating condition that's hard to assess.  Basically, I don't know why your skin darkened.  In theory, hydroquinone can darken skin, but that complication has been reported mainly in Africa and rarely here, despite the frequency of the use of this medication.  Besides, you have had been using it for a long time.  The same is true of microdermabrasion--I can't see why it would start to bother you now, when it hasn't before and rarely does.

I think you should indeed see a dermatologist.  I don't know that any specialize in melasma, but every clinician will have considerable experience with pigment issues.  Perhaps a dermatologist who does a fair amount of cosmetic work--laser, peels, and the like--will be your best bet.

You'll need patience, of course, as indeed you have already shown you have.  But your problem should be able to be improved.

Take care.

Dr Rockoff

[Robin H]

My concern about the tca peel was specifically about the risk of hyperpigmenting (how often, in your experience, do Asians tend to get this reaction to this procedure?).

thanks,

[Alan Rockoff, MD]

Not often at all, actually.

Dr. Rockoff

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