Hyperpigmentation, or darkening of the skin, is a major concern for patients. There are different reasons to develop hyperpigmentation. In this article we will discuss postinflammatory hyperpigmentation (PIH) which is the most common form.
PIH occurs as a result of inflammation or injury to the skin. Any person who has the ability to tan has the ability to develop PIH. If there is prolonged redness or obvious damage to the skin, when it heals, the injury site will produce more melanin (read about melanin) which results in PIH. There is an initial fading period of the dark spot/PIH over the next 3 months; however, complete resolution is often not achieved naturally.
Prevention of PIH is always easier than treatment. I counsel patients to try to reduce as much trauma and irritation to the skin as possible. Acne bumps, picking lesions, leaving chemicals on the skin overnight (benzoyl peroxide, toothpaste, witch hazel, alcohol) often lead to dark spots. Also if there are any reasons for inflammation such as acne, ingrown hairs, cysts, or keloids try to treat those conditions first so you aren't chasing after new PIH lesions that may occur.
When patients present with PIH I first find out the reason for the PIH and develop a timeline of when the PIH started. Pigment changes that developed years ago are more difficult to treat. More recent PIH has a better chance of completely fading with the help of lifestyle changes and medications. Below I have listed common treatments for PIH by commercial products, prescriptions and procedures.
Suncreen is very important to prevent further darkening of PIH lesions. I tell patients to protect in the morning (with sunscreen) and treat at night. Applying a sunscreen with an SPF30 every morning is necessary. Imagine every time you walk outside the skin naturally tans to a small degree. If the PIH areas get the same amount of sunlight, they too will tan and remain darker for a longer duration of time. There are many brands of sunscreens that are mild and oil-free . Avoid sunscreens containing pure titanium dioxide or zinc oxide if you have a richer skin tone because they will look white or greyish blue on your skin. If you have particularly sensitive skin, try Cetaphil, Cerave, or specifically Vanicream which is a hypoallergenic hygienic product line (can be purchased at Walgreens).
Hydroquinone (HQ 2% is the ingredient in Ambi fading cream) is used as a night time spot treatment. It is not recommended as a full area treatment because it not only fades PIH but it will also fade normal skin color. Consequently, if you treat outside the PIH spot, you will notice a halo of light colored skin between the PIH and your normal skin tone. If this occurs, a tincture of time will allow the normal skin tone to create melanin and even out. HQ can be very effective for some individuals and knowing when to stop using the medication is important. A potential side effect with long-term use of HQ is the development of ochronosis, a permanent deep blue-black color of the treated skin. I counsel patients to use this medication for a few months and then take a break to reduce the risk of developing ochronosis.
Retinol is a more selective with removing melanin from the dark spots only and leaving the normal skin tone unaffected. Retinol also has the added benefits of stimulating collagen in the skin to help fade out fine lines, reducing oil production, exfoliating the skin to help with skin glow, and removing whiteheads and blackheads. Retinol should be part of a night time regimen. Due to the exfoliating nature of retinol, external elements may irritate the skin a little easier. Sunscreen should be worn daily to prevent sun burn and rough exfoliators should be avoided while using this product.
Kojic Acid is found in brightening creams and helps with fading PIH.
Vitamin C and Copper work by reducing inflammation so the skin is less susceptible to produce PIH. Glycolic acid can be found in wipes and facial cleansers and acts to fade out dark spots.
Natural ingredients include soy, niacinamide, and sour milk, and lignen help fade out PIH by limiting the amount of melanin being transferred to skin cells.
Retinoids are the stronger version of retinols. Retinoids can produce more intense exfoliation, collagen stimulation, and fading of PIH. Sunscreen should be used with this product.
Hydroquinone 4% and stronger are prescription strength fading formulations. Strict sun protection is important.
Compounded medications that may include retinoids, hydroquinones, and topical steroids can help fade PIH quicker. Caution should be noted with the use of topical steroids to treat PIH. Side effects of steroids include lightening of the skin but also include development of stretch marks and thinning of the skin. Needless to say you don't want to use creams with steroids for a long duration of time.
Chemical peels are used for superficial and deep exfoliation to remove stubborn PIH. There are different strengths of chemical peels depending on the type and the depth of the pigment being treated. I advocate seeing a dermatologist for your peels so if you have complications you are in a location to treat such complications.
Lasers can reduce the intensity of deeper PIH but require specific lasers to treat skin of color to reduce risk of complications such as burns, pigment loss, and worsening PIH.
It is important to mention that using multiple chemicals at once can lead to irritation and possible chemical burns on the skin. You should always discuss your facial regimen with a physician to ensure you are not using a combination of chemicals that may lead to aesthetically upsetting complications. And remember, protect in the morning with sunscreen and treat at night.
Please use the comment section below for questions, comments or concerns related to this topic.
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Dr. Hill strives to answer one question per week, assuming the questions are straight forward and does not require extensive research. Duplicate and/or similar questions and topics will be consolidated.
Omg, great info! I have suffered from hyper-pigmentation for most of my life. I plan to do a TCA peel soon to get rid of the small spots on my face from having acne. Dairy was the reason for my acne. So I don't drink milk as often as I used to. I've replaced it with almond milk. I have sensitive skin, so when I don't wear sunscreen when using a spot treatment, the area becomes sooo much darker than before. I've definitely learned my lesson.
Hi, I have a few questions. I don't have so much problems with hyper pigmentation so it is more for preventive reasons. You mention witch hazel as one of the chemicals that can harm the skin. Is that really considered a chemical? I dab my face with it every morning and leave it on for the rest of the day.
i have also used creams with kojic acid. You write that kojic acid is brightening the skin. I was told it is not. It is healing small trauma on the skin and bringing back your normal skin tone. Would be happy if you could sort that out as I don't want brighter skin. Love my colour. I ve heard that creams with less than 3% kojic acid is pointless as they have no significant effect. Can you recommend a cream with more % than that?
Hi lisainsweden, great questions. In the world of cosmeceuticals (cosmetic drugs) Kojic Acid is considered a brightener in skin care because it plays an inhibitory role in melanin metabolism. It is usually one of the alternative ingredients in "hydroquinone-free" products that are marketed as "bleaching" or "fading" or "brightening" creams. Kojic acid works by increasing the breakdown of pigment in skin cells called melanocytes and as a result removes the dark spot or lightens the skin (does not cause apparent "bleaching" of the skin" like hydroquinone). In addition, kojic acid has mild collagen stimulating ability and can help with wound healing. There are limited studies whether higher concentrations play a role in the abovementioned outcomes.
Aloe vera and witch hazel are natural anti inflammatory ingredients commonly used in acne regimens however I have had a number of patients develop darkening around acne lesions where they were treating with witch hazel. Whether the products had other ingredients or whether they were using additional things and didn't mention it to me are possibilities, but nonetheless, I caution to use them intermittently after seeing this pattern.
In skin of color, you have to be careful what is used in the products. For example, strong strength benzoyl peroxides and gels with alcohol content can lead to skin irritation. Persistent redness can lead to skin darkening in the area. I counsel patients about testing new products on the skin behind their ear to make sure they don't have a reaction to the product.
This is an exciting time. New chemical peels are coming out that are effective in removing dark spots and safe in skin of color (not too painful or irritating). I will probably do an update after summer about my experience with these peels.
Thanks for your lengthy reply. Very informative. I still wondering though if witch hazel is considered to be a chemical? I like kojic acid for the reason that it doesn't bleach the skin. Do you have a recommendation of a creme that has more than 4 % kojic in it?
I did let Dr. Hill know you replied back to her. She's been super busy so hopefully she's able to swing through soon.
My apologies in the delay in response. Kojic acid is an unstable ingredient in cosmetic products. So usually you may see it as an added ingredient but the company cannot guarantee a percent of kojic acid in that product by the time you purchase it. What companies are doing is substituting the unstable form of kojic acid with kojic dipalmitate which is more stable, however may not be as effective. I looked online and at medical grade skin products and they list kojic acid as an ingredient but not with a definitive percentage. A ingredient sheet of two products had the grams added to the product but percentage is relative to what else is in the product so I could not even start to find a cumulative percentage.
When you read about kojic acid there are conflicting reports of cancers, thyroid conditions, and liver growths; however these studies were in animals who were fed or injected with kojic acid at "extremely higher doses" than found in cosmetic products and no studies have reported these results in humans when used topically since 1980s when I did a quick literature search. It continues to be a common ingredient in many products.
I never wore sunscreen until having acne. My dermatologist told me the scars can darken in the sun. She didn't have to tell me twice. I've worn sunscreen ever since. Thanks for stopping by.
Thank you for the helpful hints, I plan to try a chemical peel very soon! I've finally gotten my acne under control using DIM, Milk thistle and Vitex. I also use honey to wash my skin and jojoba oil to moisturize. I still have some spots, but I 'm happy to not be breaing out. I will try a chemical peel and the spf 30 to get these dark spots all the way away!
I'm afraid of chemical peels because o hear it causes scarring of you're not careful. I'm glad you have your acne under control. That's a big deal.
I was hoping to see more natural remedies.
My skin was really scarred from acne and I used extra virgin coconut oil 2x daily. That helped a lot. Recently, I've been using rose hip seed oil and that works well too. Maybe those can help.
Great post. I'm currently using Hydroquinone on my scars and it's helping but one of my biggest concerns is finding something to help the dark pigmentation around my eyes. Not darkness under my eyes, but darkness above my eyes in the are where you'd apply eye shadow. I've looked on google and read an article about taking Zinc which I have but it hasn't really helped. Any pointers?
I don't have any pointers for that. I will research it though and let you know if I come up with something. I have seen that darkness before on others. I never knew what caused it but I know exactly what you're talking about.
Great article and very timely. I needed the reminder to not pick at my breakouts. I'm also due for another chemical peel. That's a staple for my skin care regimen.
It's so hard not to though. I have never had a chemical peel. I'm afraid of the end result.
Thank you so much for sharing this information. Skin care is very important and hyperpigmentation continues to be an issue in our community.
Oh my gosh, yes it does!
My mom has a few spots from acne. I think I'll pick up some retinol for her.