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84 ASCP Skin Deep Spring 2025 ESTY PROTOCOLS Hyperpigmentation Assessment, peels, and management by Lira Clinical HYPERPIGMENTATION IS ONE of the most common skin concerns encountered by skin care and medical professionals. It manifests as darker areas or patches on the skin and can be attributed to various causes, including hormonal changes, inflammation, and exposure to harmful ultraviolet (UV) rays. These changes occur due to an overproduction of melanin, the natural pigment responsible for skin, hair, and eye color. Understanding the mechanisms behind hyperpigmentation and the strategies to manage it is crucial for effective treatment. TYPES OF HYPERPIGMENTATION Hyperpigmentation presents itself in multiple forms, and the cause of its occurrence determines the best way it can be treated. Melasma Melasma is linked to hormonal fluctuations and is especially common in women, earning it the nickname "pregnancy mask." It often appears as dark patches or spots on the forehead, cheeks, nose, upper lip, and chin. It can also be intensified by sun exposure. Postinflammatory Hyperpigmentation Postinflammatory hyperpigmentation (PIH) occurs when the skin darkens in response to injury or inflammation, such as wounds from acne, rashes, burns, or chronic skin conditions. PIH is often seen as temporary discoloration arising from the body's natural healing process. For such cases, early intervention is critical in preventing long-term discoloration. Freckles and Sun Damage Freckles and sun-induced spots (sunspots) are heavily influenced by both genetics and UV exposure. Repeated sun exposure accelerates pigmentation, leading to permanent skin spots and uneven tone. This is often exacerbated by aging. HOW TO ASSESS HYPERPIGMENTATION The skin hyperpigmentation index (SHI) is a tool used to assess the severity and extent of hyperpigmentation. This index quantifies pigmentation changes, making it useful for evaluating the presence of hyperpigmentation and monitoring its progress. No Pigmentation (SHI Score 0) A score of zero refers to no pigmentation, meaning no visible discoloration. Light Hyperpigmentation (SHI Score Between 1 and 2) This score refers to a mild increase in skin pigmentation, where the color of the skin is slightly darker than the surrounding unaffected areas. It typically shows subtly and is often seen in early stages of hyperpigmentation or after minor skin irritation or inflammation. Excessive or disorganized melanin distribution in response to perceived damage—be it inflammation or sun exposure—leads to hyperpigmented areas. Common characteristics of light hyperpigmentation include: • Pigmentation that is generally confined to small areas • Faint brown or tan spots • Contrast between affected and unaffected skin that is subtle. Medium Hyperpigmentation (SHI Score Between 2 and 3) This score indicates a moderate increase in skin pigmentation, with noticeable dark patches that contrast with the surrounding skin and cover a larger area. It is commonly seen in cases of melasma, sunspots, or PIH. Common characteristics of medium hyperpigmentation include: • Darker spots that are more prominent • Light brown to dark brown (sometimes tan) patches • Boundaries of hyperpigmented areas that are somewhat defined but larger and more noticeable Severe Hyperpigmentation (SHI Score Between 3 and 4) This score is characterized by a significant increase in pigmentation. The affected skin appears much darker, with large, well-defined patches easily distinguishable from normal skin. Severe hyperpigmentation is often associated