Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

doi: 10.4103/0378-6323.140283
PMID: 25201835

Not too dark, not too light, the quest for skin, that's just right

Amit G Pandya
 Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA

Correspondence Address:
Amit G Pandya
5323 Harry Hines Blvd, Dallas, Texas
How to cite this article:
Pandya AG. Not too dark, not too light, the quest for skin, that's just right . Indian J Dermatol Venereol Leprol 2014;80:387-388
Copyright: (C)2014 Indian Journal of Dermatology, Venereology, and Leprology

Witness the grand quest for perfect complexion. We see it in advertisements for beauty products promising healthy, even skin with a lustrous glow noticed by all. The success of these efforts is reflected in the billions spent on skin products, particularly those that lighten skin. But as dermatologists, we wonder, what is being treated? Is it melasma, post-inflammatory hyperpigmentation (PIH) from acne, lentigines, dark circles or just overall skin tone? In this issue of the IJDVL we learn it is all of the above, as well as some, which are currently a mystery.

Hourblin et al. should be commended for having performed a large study which sheds light on the problem of uneven skin among Indian women. [1] Some results were expected, including the findings that lentigines, postinflammatory hyperpigmentation, seborrheic keratoses, melasma and dark circles around the eyes are very common in this population. Interestingly, the mean age of women with melasma was 51, which is higher than most previous reports. [2] The fact that melasma persists in Indian women even after menopause is also unique, as this disorder usually fades in post-menopausal years. The sheer numbers are quite impressive, with the vast majority of women having lentigines, peri-orbital dark circles and seborrheic keratoses. The fact that over 80% of women over the age of 40 had dark circles around the eyelids helps to explain the huge demand for lightening products that are gentle to the skin and is a wake-up call for dermatology researchers to explore these uncharted waters more thoroughly.

But the authors also discovered other, more puzzling, pigmentary problems. The so-called "ill-defined pigmented macules" were seen in an alarming 70% of the subjects, and the prevalence of these asymmetrical lesions increased with age. We have all seen these dark macules, which are poorly marginated and often grayish in color. What is this entity? Could some have a form of acanthosis nigricans associated with hyperinsulinemia? [3] How about a form of hypersensitivity to topical formulations, systemic medication or the sun? Many theories exist, but clearly we need more careful research for this disfiguring disorder. Perilabial pigmentation, particularly at the commissures of the mouth was seen in 72% of subjects and a large number had pigmented marionette lines as well. This figure naturally begs the question: Why does this occur? Is it due to inflammation, seborrheic dermatitis, perleche or movement of facial muscles? Surely with such high prevalence there should be further research into this peculiar problem. Finally, the authors reported pigmentation at the angle of the nose in 46% and a line across the nose in 25%, which increased with age. Again, entities not easily discoverable during a literature search, yet so common among the patients in this study. Transverse nasal grove has been reported in one series from India as a groove, line or ridge across the nose and may be associated with a seborrheic diathesis. [4]

A commonly held belief which was challenged by this article is that Indian women become darker as they age. Using careful objective measurements with a Chromameter, the authors showed the darkness (LFNx01) value of the cheek doesn′t change much when measured in women of different ages except in Chennai, where complexion is darker overall. So perhaps the focus should be on treating the various disorders described above rather than lightening of the entire surface of the face to help the patient achieve a more even complexion. Particular attention should be placed on lentigines and seborrheic keratoses, which had an early onset of just 30 years of age in Indian women. Differences in skin tone among the different cities may be explained by the different skin types among the populations of each city. However, it is interesting that Mumbai, a cosmopolitan city with a diverse population, had subjects with much lighter skin than the other cities.

Any effort to help patients with dyschromia should be tempered by careful counseling regarding safety issues. Misuse of topical skin-lightening agents containing tyrosinase inhibitors, keratolytic agents and corticosteroids is frequent worldwide and patients in India have been reported to present with erythema, irritation, telangiectasias, steroid acne, hypertrichosis, erythema, confetti depigmentation and rosacea as a result of this overuse. [5] Unfortunately, the easy availability of depigmenting creams without a prescription promotes the use of these products without proper supervision by a physician. Although some efforts are under way in India to promote natural skin color, the desire to be lighter is ancient and does not appear to be likely to abate any time soon.

Patients will continue to seek our help for dyschromia. We have learned to first determine if there is a particular disorder that requires a unique treatment, such as post-inflammatory hyperpigmentation from acne. But unfortunately, many disorders, such as melasma and periorbital dark circles, are not so easy to manage, probably due to the fact that their etiology is still not clear. Some disorders, such as ill-defined macules and dark lines across the nose have barely been explored, much less subjected to controlled trials with therapeutic agents. The subject highlighted in this article is important and gives pause for reflection, but it is also a call to action. Our patients deserve it. Will there be some answers for doctors who treat patients struggling with dyschromia? We continue to hope for the discoveries of tomorrow as we put down our journal and turn toward our next patient, who likely has a pigmentary disorder for which she has come for our help.

Hourblin V, Nouveau S, Roy N, de Lacharrière O. Skin complexion and pigmentary disorders in facial skin of 1204 women in 4 Indian cities. Indian J Dermatol Venereol Leprol 2014;80:395-401.
[Google Scholar]
Ortonne JP, Arellano I, Berneburg M, Cestari T, Chan H, Grimes P, et al. A global survey of the role of ultraviolet radiation and hormonal influences in the development of melasma. J Eur Acad Dermatol Venereol 2009;23:1254-62.
[Google Scholar]
Veysey E, Ratnavel R. Facial acanthosis nigricans associated with obesity. Clin Exp Dermatol 2005;30:437-9.
[Google Scholar]
Sathyanarayana BD, Basavaraj HB, Nischal KC, Swaroop MR, Umashankar PN, Agrawal DP, et al. Appraisal of transverse nasal groove: A study. Indian J Dermatol Venereol Leprol 2012;78:439-42.
[Google Scholar]
Kandhari R, Khunger N. Skin lightening agents - Use or abuse?-A retrospective analysis of the topical preparations used by melasma patients of darker skin types. Indian J Dermatol Venereol Leprol 2013;79:701-2.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections