What is hyperpigmentation and how to treat it?

As a dermatologist when patients come to us for the treatment of dark spots or hyperpigmentation, the first step is to understand that not all dark spots are the same. Dark spots can be caused due to several reasons (melasma or drug reactions or chronic sun exposure) however post-inflammatory hyperpigmentation (PIH) is the appearance of dark spots after skin inflammation from another rash or most commonly acne/eczema.

The depth of skin involvement corresponds to actual color of dark spots and dictates treatment. Light to dark brown color is suggestive of superficial skin (epidermal) involvement and can be treated using topicals. Blue gray/black color means deeper skin (dermal) involvement and laser treatment is more appropriate.

Treating dark spots

The treatment for dark spots can be categorized under three different groups: topical over-the-counter products, topical prescription products and in-office treatments. In general, a combination therapy with multiple topical creams may be more effective than a single treatment therapy. It is also important to be patient with the treatment of dark spots and understand that it takes at least 8-12 weeks to see results.

The best way to prevent and treat dark spots is to use “broad-spectrum” sunscreen with both UVA and UVB coverage with SPF 30 or higher. Tinted sunscreens also have iron oxide which protects from visible light which is known to cause hyperpigmentation in those with darker skin. Also seek shade and wear hats and sun protective clothing.

Topical over-the-counter products

Retinol/retinoids 

Retinol and retinoids are a form of Vitamin A that promote skin renewal resulting in even skin tone and texture. Retinols are usually weaker than retinoids, albeit with lesser side effects of skin redness, dryness and peeling. They also help treat wrinkles/fine lines, mild acne and improve overall skin quality and texture.

Tranexamic acid 

Transexamic acid is effective in brightening skin complexion and for minimising dark spots caused due to hormonal changes such as melasma.

Vitamin C/Ascorbic acid 

Topical Vitamin C has several benefits as it is an anti-oxidant, however it also brightens skin by inhibiting tyrosinase which is a key enzyme required for melanin production.

Azelaic acid
Azelaic acid is a great choice to minimize dark spots during pregnancy given that it is safe. 

Alpha Hydroxy acids
AHAs such as glycolic acid, lactic acid, mandelic acid exfoliate and remove dead skin cells on the surface, leading to an overall brightening effect on the skin and visibly reducing dark spots

Other options for treating hyperpigmentation include Kojic acid, Niacinamide, N-acetyl Glucosamine, Soy, Liquorice, Arbutin, Green Tea, Aloesin, Mulberry, Coffeeberry, Grape Seed Extract and Polypodium Leucotomos

Topical prescription products
Prescription medications include hydroquinone at different concentrations or compounded medications with hydroquinone and retinoids. 

In-office treatments
In office procedures include chemical peels or even laser treatment.