9.1 Pigmentation Disorders

NIC Domain I, Scientific Concepts, is 55% of the scored National Esthetics Theory Examination. I.F is skin disorders and diseases. I.F.5 is skin pigmentation — hyperpigmentation and hypopigmentation. Illinois does not replace that national science. 68 Ill. Adm. Code 1175.710 still tests anatomy of the skin as it relates to applicable services under the Act, and 225 ILCS 410/3A-1 draws the legal line you will use on every pigment stem: you may give cosmetic advice; you may not give medical-treatment advice for diseases of the skin. Pigment is where those two rules meet on the facial bed.

Melanin and Melanocyte Activity

Melanin is the pigment that colors skin, hair, and eyes. It is made by melanocytes, which sit in the stratum germinativum (basal layer) of the epidermis. Melanocytes package melanin into melanosomes and pass them to surrounding keratinocytes. The exam does not ask you to count cells under a microscope. It asks what activity does. The NIC sample item is the model: melanocytes that are more active will produce darker skin, not lighter skin, not sebaceous skin, and not dry skin.

Activity is not the same as cell count. A client with deeply pigmented skin does not necessarily have “more melanocytes”; the melanocytes that are present are more productive. UV exposure, hormones, heat, inflammation, and some medications can push activity up. When activity drops, or when melanocytes are missing in a patch, the skin lightens. That is the entire hyper-versus-hypo split.

You will not diagnose why a patch is dark. You will recognize the pattern, choose a conservative cosmetic service or no service, and stay inside 3A-1.

Hyperpigmentation Versus Hypopigmentation

Hyperpigmentation is excess melanin: the skin looks darker than the surrounding tissue. Hypopigmentation is deficient melanin: the skin looks lighter. Memorize the named examples. The exam swaps the two headings and expects you to notice.

Hyperpigmentation You Must Name

• Melasma. Hormonally influenced brown patches, typically on the face — cheeks, forehead, upper lip, and chin. Sun, heat, pregnancy, and hormonal contraceptives commonly trigger it. Older texts call the pregnancy presentation chloasma or the “mask of pregnancy.” Treat the two labels as a pair: both are hyperpigmentation, both are cosmetic-camouflage territory, and neither is a peel you “cure.”
• Chloasma. Used interchangeably with melasma in many NIC-style items, especially a pregnancy-mask stem.
• Lentigines (singular lentigo). Small yellow-brown spots from UV and aging. Freckles and so-called liver spots sit in this family. They are not dirt, and they are not a reason to lancet the spot.
• Tan. A visible increase in melanin after UV exposure. It is a defense, not a health goal. A fresh tan is also a reason to postpone chemical exfoliation, because the skin is already in a UV-stressed state.
• Stain. An abnormal brown or wine-colored discoloration with a circular or irregular shape. A port-wine stain is the classic example. You do not scrub it off.
• Nevus. A birthmark or malformation of the skin from pigment or dilated capillaries. A pigmented nevus is a mole. Do not pick, freeze, or “lighten” it as a facial add-on. Changing nevi belong in the next section as a referral, not as an extraction.

Hypopigmentation You Must Name

• Albinism. A rare congenital condition with little or no melanin in skin, hair, and eyes. The client burns extremely easily. Services stay gentle. Sun-protection talk is cosmetic advice, not a medical treatment plan.
• Vitiligo. Irregular white patches that totally lack pigment. Patches can enlarge. You camouflage if the client wants makeup. You do not promise to repigment the skin, and you do not name a prescription.
• Leukoderma. Light, abnormal patches caused by congenital, systemic, or acquired destruction of melanocytes. Textbook leukoderma includes vitiligo and albinism as examples. If the stem says leukoderma, think hypopigmentation, not a stain.

None of these names authorizes you to treat a disease. Section 3A-1 says the term esthetics includes rendering advice on what is cosmetically appealing, but no person licensed under this Act shall render advice on what is appropriate medical treatment for diseases of the skin. “Use this hydroquinone protocol to reverse your melasma” is medical-treatment advice. “A mineral sunscreen and a tinted moisturizer can even the look of the patch” is cosmetic.

Post-Inflammatory Hyperpigmentation After Extractions and Peels

Post-inflammatory hyperpigmentation (PIH) is extra melanin laid down after injury or inflammation: a pimple, a too-aggressive extraction, a peel that ran hot, a burn, or a pick. The mark is flat and darker than the surrounding skin. It is not a scab you should keep extracting.

Fitzpatrick types IV, V, and VI are especially prone to PIH. That is the service-planning fact, not a diagnosis of race. After an extraction that went too deep, or a chemical exfoliant that was too intense for that client’s melanocyte activity, the melanocytes respond by overproducing pigment. The “correction” students reach for — a stronger peel next week — is the wrong answer. More inflammation produces more PIH. The Illinois overlay is the living-layer rule from chapter 2: a superficial peel that stays in the stratum corneum can be cosmetic; a peel intended to injure living epidermis to “erase” pigment is medical, and it is also a PIH factory on darker skin.

Practical exam rules:

• Type the skin before you choose exfoliation intensity.
• On Fitzpatrick IV–VI, start conservative: lower acid strength, shorter contact, fewer passes, longer intervals.
• Do not extract inflamed lesions. 1175.115 already forbids working on inflamed or infected skin.
• After any allowed extraction or superficial peel, stress sun avoidance and broad-spectrum SPF as cosmetic aftercare. UV on a freshly inflamed site drives PIH.
• Do not promise to “remove” PIH. You may even tone with makeup and support the barrier. A physician treats pigmentary disease.

Why Fitzpatrick Typing Changes Chemical Exfoliation

NIC II.A.2 lists Fitzpatrick skin types, conditions, and characteristics as part of skin analysis. The scale estimates UV response. Learn the poles and the middle.

The scale is not a permission slip to peel type I harder because “they can take it,” and it is not a ban on all exfoliation for type VI. It is a risk map.

• Types I–II burn. They also carry higher long-term UV-damage and skin-cancer risk. Watch the face, hairline, ears, and décolleté while you work. That observation feeds section 9.2; it is not a cancer diagnosis.
• Types IV–VI tan deeply and rarely burn, but melanocytes that are more active will produce darker skin — and they will produce PIH if you over-exfoliate. Intensity must drop, not rise, when the goal is even tone.

A “medium peel for stubborn melasma” is outside Illinois esthetics even on type II skin, because medium peels affect living layers (IDFPR Statement on Prohibited Practices, 04/06/2026). Superficial exfoliation that stays in the stratum corneum is in 3A-1. Fitzpatrick typing tells you how aggressively you may use that in-scope tool. It does not move a medical peel onto your menu.

Illinois: Cosmetic Advice In, Medical-Treatment Advice Out

225 ILCS 410/3A-1 is the sentence to recite. Esthetics includes rendering advice on what is cosmetically appealing. No licensee shall render advice on what is appropriate medical treatment for diseases of the skin. Melasma, vitiligo, a spreading stain, and a changing nevus can all be diseases or medical conditions. You may:

• Describe what you observe in ordinary language (“this patch is darker than the skin around it”).
• Recommend cosmetic camouflage, gentle cleansing, and sun protection.
• Refuse a service that would inflame the area.
• Refer the client to a licensed medical professional.

You may not:

• Name a prescription.
• Tell the client which laser, peel depth, or injectable will “treat” the pigment.
• Market a facial as a cure for vitiligo or melasma.
• Diagnose.

That split is the Illinois answer on every pigment stem that tries to turn you into a dermatologist. Recognize. Camouflage if asked. Refer. Do not treat the disease.