Hyperpigmentation causes and treatment

What causes dark spots and patches?

How to start treating hyperpigmentation

1. 1Address the trigger first. Treat active acne, eczema or psoriasis, and replace irritating skin or hair products with gentler options.
2. 2Before going outdoors, apply tinted, water resistant, broad spectrum sunscreen with SPF 30 or higher to uncovered skin. Choose one containing iron oxide for protection against visible light, and wear a wide brimmed hat.
3. 3Reapply sunscreen every two hours outdoors and after swimming or sweating.
4. 4Consider a fading product containing azelaic acid, glycolic acid, kojic acid, vitamin C or a retinoid. These ingredients can fade existing spots. Follow the individual product's directions.
5. 5Stop a skincare product if it burns or stings. Irritation can cause further dark spots.

Could a medicine be causing the pigmentation?

Medicines associated with pigmentation include antimalarials, chemotherapy medicines, minocycline, amiodarone, some anticonvulsants, antipsychotics and nonsteroidal anti inflammatory drugs. Medication related pigmentation can affect any skin type. It can involve skin, nails or the lining of the mouth, and the color and location depend on the drug. Some medicines alter melanin production; others or their breakdown products accumulate in skin.4

Do not stop a prescribed medicine yourself. Ask its prescriber whether pigmentation is a side effect and whether a change is appropriate. Assessment uses your medication history, the timing of the change and the pigmentation's location, color and distribution. A clinician sometimes uses a skin biopsy to exclude other causes. If the medicine can be stopped safely, pigmentation often fades gradually, but some changes persist or become permanent. Sun protection helps prevent worsening; persistent cases sometimes benefit from hydroquinone, retinoids or azelaic acid.45

When is hydroquinone useful?

Hydroquinone reduces new melanin production and lightens pigmentation in the epidermis, the outer skin layer, but not pigment in the deeper dermis. It is used for melasma, marks after inflammation and some other pigmentation disorders. Creams and lotions contain concentrations of 1 to 5%; availability and prescription requirements depend on the country. Melasma often needs several treatments rather than hydroquinone alone.6

For a clinician agreed hydroquinone course, follow the prescribed product instructions. General application guidance is:

1. 1Test an area about 1 cm across and wait 24 hours for redness or irritation.
2. 2Apply a thin film only to pigmented skin, initially once daily. If tolerated after one week, frequency can increase to twice daily.
3. 3Keep it away from the eyes and mouth. Avoid other topical medicines, particularly benzoyl peroxide, unless your clinician directs the combination.
4. 4Wait 10 minutes before applying sunscreen or cosmetics.
5. 5Review treatment at three months. Stop if there has been no benefit; some people maintain improvement with twice weekly use.

Stop hydroquinone for excessive redness, scaling, itching or weeping. Do not use it if you are allergic to hydroquinone or a formulation ingredient. Concentrations above 4% can irritate skin. High concentrations used repeatedly for years can cause ochronosis, a persistent discoloration. Safety during pregnancy and breastfeeding is not established.6

Are peels and lasers better than creams?

Chemical peels, lasers and dermabrasion are options for some pigmentation problems, but the choice depends on the cause. These procedures can also produce unwanted lighter patches, called hypopigmentation. Skin of color has a greater risk of hypopigmentation after dermabrasion and after peels that target deeper skin layers. Laser resurfacing can also leave treated areas lighter. For medication related pigmentation, laser treatment can cause either darkening or lightening and should be performed by someone experienced in treating it.47

How long does fading take?

After the trigger stops, a spot a few shades darker than your skin usually fades within 6 to 12 months. Deeper pigment can take years. Treatment can speed fading, but clearing existing spots does not prevent every future episode. Medication related pigmentation has its own timetable: minocycline related changes can take several years to clear after stopping the drug, while amiodarone related pigmentation can take up to a year.45

Makeup can hide discoloration while treatment addresses it, which makes the concealer a stand in rather than the lead.3

When should you get the pigmentation checked?

Have new or changing discoloration assessed, especially a mole or mark changing in size, shape, texture or color. Melanoma can appear as a new dark spot or in an existing mole. A clinician will ask when the change started, whether it has changed and whether you have other symptoms or medical conditions. Depending on the findings, assessment can include a skin examination, a Wood lamp examination, a biopsy or blood tests. If a medical condition is responsible, treating that condition can improve the discoloration.3

See a dermatologist if treatment is not helping. Never apply liquid bleach to skin. Some imported fading products have contained unlisted mercury or steroids; choose a product recommended by your dermatologist.5