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What’s Important?

  1. Skin can become pigmented from UV, blue, or infrared light.

  2. Patient education and compliance are critical for treatment success.

  3. Treating pigmentation is a multifaceted approach.

What’s New?

  1. Oral tranexamic acid is used to treat pigmentation disorders.

  2. Iron oxides in tinted sunscreens block blue light.

What’s Coming?

  1. There are recent questions about the safety of the sunless tanner DHA that need to be explored.

  2. Topical SIK2 inhibitors are being developed to increase skin pigmentation.

  3. Hydroquinone was banned in cosmetic products in 2020 leading to the pursuit of new options.

Several factors play a role in the perception of age, health, and attractiveness. Patients often focus on fine lines or skin radiance and are less cognizant of evenness of skin tone. However, many studies have shown that evenness of skin tone plays an important role in perceived skin health, age, and beauty. This chapter will discuss what colors contribute to skin tone, the importance of an even skin tone, and designing the best skincare routine to even skin tone.


Redheads have polymorphic changes in the MCIR gene that affect the ability of the melanocortin receptor to stimulate production of eumelanin. This MCIR polymorphism results in red hair, freckles, nevi, and an increased risk of melanoma. Redheads who avoid the sun have fewer nevi than those with more sun exposure. However, the number of freckles seems to be entirely determined by genetics as shown in a twin study.1 For this reason, many redheads consider freckles as part of their identity and want to keep them. Freckles do not cause a perception of poor health as other pigmented lesions do. The studies described below did not evaluate the presence of freckles; rather, they considered solar lentigos, melasma, and post-inflammatory hyperpigmentation that lead to an uneven skin tone.


Vitiligo is an autoimmune skin condition in which antibodies destroy melanocytes leading to depigmented patches of white skin. This frequently affects the face and can affect self-esteem. Recognizing and treating vitiligo early improves the prognosis. Discussion of the diagnosis and treatment of vitiligo is beyond the scope of this book but it is mentioned here because those with vitiligo need excellent sun protection and options to camouflage the white patches with cosmetics.2 In extensive vitiligo, some patients choose to depigment the remaining pigmented areas with agents discussed in Chapter 41 (Depigmenting Ingredients) but this can lead to health risks. Fortunately, the recent popularity of models with vitiligo has led to a decreased stigma and increased acceptance of this skin disorder.


An even skin tone is perceived as healthier than an uneven skin tone. A 2011 study looked at two different facial images of 61-year-old British women. In one image, the skin surface topography of ...

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