How to treat hyperpigmentation in eczema & topical steroid withdrawal (TSW) – The Eczema Podcast (S5E22)

Do you suffer from hyperpigmentation caused by eczema or topical steroid withdrawal (TSW)? Have you wondered how you can treat it naturally? In this episode, you’ll learn about hypopigmentation and treatments for hyperpigmentation (including lasers, topical remedies, and alternative remedies) to help discoloration of the skin from eczema and topical steroid withdrawal (TSW). Our skin naturally produces melanin, a pigment that gives color to the skin. However, when it produces too much melanin in certain areas, it can result in dark patches on the skin. Hyperpigmentation can often be seen as a result of having eczema or topical steroid withdrawal (TSW). What is Hyperpigmentation? Hyperpigmentation is a common dermatologic condition that is seen in all skin types, but it is also very prominent and common in eczema and topical steroid withdrawal (TSW) patients. Hyperpigmentation isn’t necessarily harmful – but it is a term that describes the skin that appears darker. It can occur in small dark patches on any part of the body. Hyperpigmentation occurs when the skin over produces melanin. This can make spots or patches of skin that appear darker than surrounding areas, leaving the skin uneven. Why Does Hyperpigmentation Occur During Eczema? In this podcast episode, Dr. DJ Sims shares that: “There are two types: there’s hyperpigmentation and hypopigmentation that people deal with.” Hypopigmentation is the loss of skin color. In this case, melanin in under produced (such as in cases of vitiligo). Hyperpigmentation, on the other hand, is the over or hyper production of melanin in a specific area that makes the skin darker than other areas of the body. Hyperpigmentation during eczema is caused by inflammation. Inflammation in the epidermis stimulates the melanocytes to increase melanin synthesis (the process of making skin pigment). This increase in synthesis results in pigment being transferred to the skin epidermis (the top layer of the skin). If the skin is damaged by scratching or rubbing the melanin, pigment can be released. This is why darker skin types are more prone to hyperpigmentation during eczema or topical steroid withdrawal (TSW) flares.

• Post-inflammatory pigmentation

Post-inflammatory hyperpigmentation can happen after an eczema or TSW flare settles and is seen as a darker patch where the eczema lesions have healed. The darker patch can linger for months, even if the eczema does not return. It can occurs in all skin types, but is more noticeable in darker skin. Another common feature of hyperpigmentation is wrinkling under the eyes, known as Dennie-Morgan folds, which is often accompanied by dark circles. This post-inflammatory hyperpigmentation can also be stimulated by sunlight, so sun protection is important, as it can prevent it from happening. Thankfully, over time, the post-inflammatory pigmentation can fade.

• Lichenification

Lichenification is a term to describe hard, thickened areas of skin that often occur due to repeated rubbing or scratching during eczema or topical steroid withdrawal (TSW). These areas of skin are can often become hyper-pigmented. In pale skin, it may appear dark pink, while in darker skin it may be grey – but always dry, scaly and leathery. The scratching and rubbing is often unconscious and psychological. Over time, it can even become a habit. Other parts of the body where lichenification is common, include the back of the scalp, neck, the wrists and forearms, lower legs and genitals.

• Inflammation

Skin trauma from eczema, topical steroid withdrawal (TSW), cuts, scrapes, scratching or friction from vigorous rubbing, can cause inflammation. Inflammation can send pigment-producing cells into high gear, leaving behind dark spots after it heals.

• Sun Exposure

The sun’s UV rays hitting your skin can trigger extra melanin production as a way to depend your skin from damage. The extra melanin is what gives you a tan. However, when the sun exposure is frequent or excessive it can make dark ‘sun’ spots appear.

• Medical Conditions

Hyperpigmentation can also be due to medical conditions like Addison’s disease, an adrenal gland disorder that can increase melanin production or a chronic disease like Eczema.

• Medications

Certain drugs, including topical corticosteroids can create “corticosteroids induced hyper-pigmentation.” This research paper shares that: “Prolonged and unsupervised use of topical corticosteroids leads to skin atrophy and reappearance of hyper-pigmentation patches…topical corticosteroids has been reported most commonly misused drug for hyper-pigmentation in studies conducted in the last 10 years.” Is Hyperpigmentation Fatal? Hyperpigmentation can be a symptom of eczema and topical steroid withdrawal (TSW), but it is often not fatal. It cannot harm any parts of your body nor affect your normal bodily functions. Treatment for Hyperpigmentation Although hyperpigmentation is harmless, most people wish to get rid of it. There are a range of possible treatment methods and home remedies that people can try. With any treatment you take, keep in mind to go low and slow. DISCLAIMER: Please note that some of the treatments below should be avoided if you have any pre-existing flare ups, rashes, or inflammation on your skin, as it can cause more irritation. Always consult with a professional to determine which treatment will work best for your current skin before trying them.

• Lightening creams and Brighteners

Lightening creams are over-the-counter (OTC) treatments that contain ingredients to help decrease pigmentation (some are also available in stronger prescription forms). They’re usually applied once or twice a day to help lighten the skin over time. Common ingredients found in OTC lightening products include:

• hydroquinone
• licorice extract
• N-acetylglucosamine
• vitamin B-3 (niacinamide)

Hydroquinone, in particular, is a skin-lightening agent. This, along with other lightening creams, can be used – but should not be used in high doses. Hydroquinone decreases the production of melanin by inhibiting tyrosinase, an enzyme needed for melanin production, to decrease the appearance of hyperpigmentation. However, it can destroy your melanins and have harmful side effects. According to Dr. Sims, start with 1% of hydroquinone or 2% if you are a person of color and use it only for a short period of time. You can also have post-inflammatory hyperpigmentation from over using treatments for hyperpigmentation. A major key to hydroquinone is short-term use. At the three-month mark, you should set it aside. If you’re having flares, you should keep off from most brighteners and bleachers. Instead, use treatments that will not irritate your skin. Some options are Vitamin E oils or Vitamin A oils, as Vitamin E don’t irritate or trigger eczema.

• Chemical Peels

Chemical peel uses acids at stronger concentrations to treat hyperpigmentation by removing the epidermis. Although many chemical peels are available over-the-counter, you can also get professional-grade peels at your dermatologist’s office (which are more powerful and yield quicker results). Unfortunately, due to their strength, they can also increase your risk for side effects. Possible risks with both at-home and in-office chemical peels include redness, irritation, and blistering. Chemical peels can also cause your skin to be more sensitive to the sun. Talk to your dermatologist about your risks. Once again – you should avoid peels if there are any current rashes or inflammation on your skin. In this podcast episode, Dr. Sim suggests that you should first visit an aesthetician before you use any chemical peel. Peels can increase your skin turnover and help the skin heal faster. Dr. Sims shares that:

“Skin grows from the inside out and over 20 to 30 days. It will overturn itself and you’re going to get new skin. You need to be healthy on the inside, but at the same time, you want to get some of that old, dead skin cells off. I love chemical peels if they’re light and they’re done by a professional. Get a good aesthetician that’s familiar with your skin of color. You can get a chemical peel once a month – but start with one, especially with eczema because you can flare from the ingredients in the peel. Make sure it’s  a low percentage and see how your skin reacts. Then you can do home things, such as a face wash that has a little bit of kojic acid and vitamin C in it.”

Glycolic Peels and TCA Peels (which stands for trichlorecetic acid) are great ways to start.

• Topical Creams and Serums

Serums with Vitamin C, kojic acid and azelaic acid also helps lighten the skin. You can also custom-make your own serum with the help of a pharmacist. They can add 2% to 4% on each acid for each cream. It will slowly brighten and exfoliate the skin, and also help produce more collagen over time.

• Acids

Face acids (or skin acids) work by exfoliating or shedding, the top layer of your skin. When you exfoliate your skin, new skin cells underneath it emerge to take the place of the old ones. The process helps even out your skin tone. There are many popular face acids are available over the counter that include:

• alpha hydroxy acids (such as glycolic, lactic, citric, malic, or tartaric acid)
• azelaic acid
• kojic acid
• salicylic acid
• vitamin C (in the form of l-ascorbic acid)

Keep in mind not to use these if you currently have any rashes on your face – as it can cause stinging or inflammation. You can also check with an aesthetician or a professional before using these. In this episode, Dr. Sims also shares that:

“We can use those daily acids in the kojic acid and we can use all the alpha hydroxy acid washes. All of those water washes with very mild acids are amazing and light (and in most cases, you don’t have inflammation). It helps with skin turnover and helps brighten it without bleaching it.”

• Medical Procedures

1. Microdermabrasion
2. Lasers 

Laser peel (resurfacing) treatments use targeted beams of light to reduce hyperpigmentation. There are 2 types of lasers: ablative and non-ablative. Ablative lasers are the most intense because they remove layers of your skin. Non-ablative procedures target the dermis to promote collagen and tightening effects. Ablative lasers are stronger, but they may cause more side effects. Keep in mind that lasers can cause dryness when there is eczema or inflammation present – and may not always be the first choice for many aestheticians to turn to.

1. Micro-Needling
2. PRP (Platelet Rich Plasma) Treatment (can be used with micro-needling)
   1. PRP has been shown to help increase pigmentation (according to studies like this)
   2. PRP has been shown to help increase skin atrophy (see below).

“Make sure you always patch test, even if it’s natural, because my eczema patients are very sensitive to their environment. Any little thing can set your skin off, so I always say “low and slow”. If it causes your skin to be flaky and burning, discontinue it. It should not cause any inflammation or anything you don’t want. The more your skin flakes and burns, the more liable you are to have hyperpigmentation,” says Dr. Sims.

• Retinoids

Retinoids are derived from Vitamin A, and are among some of the oldest over-the-counter skincare ingredients used. Their small molecular structure allows them to penetrate deep into the skin below your epidermis. Retinoids can come in either a prescription or OTC formula. However, OTC versions tend to be weaker. It’s also important to note that retinoids are more often used to treat wrinkles than hyperpigmentation. This means that retinoids may not be the best first-line treatment. Please note that retinoids should also be avoided if you have flare ups, rashes, or inflammation on your skin, as it. can cause more irritation. Other natural alternative treatments for hyperpigmentation for eczema or topical steroid withdrawal (TSW):

• Organic Brighteners (Glycolic acids, Kojic acids and Vitamin C)
• Vitamin E and Vitamin A Oils
• Omega 3 Oils
• Coconut Oil
• Turmeric

What Should You Avoid for Hyperpigmentation?

• Avoid putting peels or creams all over your face or body. Put it only on the affected area. Some peels or creams contain strong chemicals that can irritate your skin.
• If you are having an eczema or TSW flare, avoid using a lot of skin care products. You need to put as minimal products as possible.
• Check the ingredients of the products you are using to see if they are safe and effective.
• Never use high percentage brighteners or bleacher – e.g. as high as 6%.
• Never use products that trigger your allergies and eczema

The Best Way to Get Rid of Hyperpigmentation

“I always tell my patients, you have to have the ability to make healthy skin, so it’s not just about bleaching on top. What I’ve discovered is that when you cleanse the liver, heal the gut and eat nourishing foods, the skin will turnover faster and healthier. If we give it the proper tools to heal, the skin will heal from the inside out. Internally, we have to be healthy so that we can make healthy skin” shares Dr. Sims.

In our 12 week personalized coaching program, we take a “root cause” approach in helping cases of eczema & topical steroid withdrawal (TSW) have gone on a really restrictive diet (including a histamine diet) and have not been able to solve the problem. This is why we believe in taking . We look into other causes that may be causing your skin to flare. Book a complimentary call with us or look into our coaching program to see how we can help you. Healing by Diet and Lifestyle

• Eat fruits and vegetables with antioxidant and collagen properties, such as carrots, sweet potatoes, broccolis, pumpkin, grapes, blueberries, cranberries and strawberries.

“Eating more of the fruits that are orange, red, purple and blue and the vegetables, and eggplant, can give you the properties that you need to grow healthy skin, as well as taking college and supplements and eating, you know, bone broth and things like that,” stated by Dr. Sims.

• You can take collagen supplements prescribed by your doctor. You can also get collagen and amino acids from animal meats like beef and fish which are essential for skin healing. But never take supplements for rest of your life.
• You can also apply mild creams and serums with Vitamin C to the affected area. But remember to consult your dermatologist first.

Other Types of Hyperpigmentation There are several types of hyperpigmentation, but the common ones are melasma, sunspots, and post-inflammatory hyperpigmentation.

• Melasma

Melasma is believed to be caused by hormonal changes and may develop during pregnancy. Areas of hyperpigmentation can appear on any area of the body, but they appear most commonly on the stomach and face.

• Sunspots

Sunspots are also called liver spots or solar lentigines. They are related to excess sun exposure over time. Generally, they appear as spots on areas that are exposed to the sun, such as the hands and face. They are common on some eczema patients.

• Post-inflammatory Hyperpigmentation (PIH)

Post-inflammatory hyperpigmentation is a commonly a side effect of over peeling after treating hyperpigmentation itself or other skin disorder. A common cause of this type are acne and eczema. Sources and Reference https://pubmed.ncbi.nlm.nih.gov/28917452/ https://dermnetnz.org/topics/postinflammatory-hyperpigmentation?fbclid=IwAR3IZpvmFw8qzqM8wlXEmoWLYLQLMZ5K5Rg9SSxxC-fisZG56KmCOb5yk6g https://www.medicalnewstoday.com/articles/323808?fbclid=IwAR2nJlhLMzPMRw7NBJqicRMExBgvKfEmUOaQUMq-w7ErNl8mzwnxKHNVLZg#types-and-symptoms https://pubmed.ncbi.nlm.nih.gov/21925372/