Hyperpigmentation from acne: how to fade dark spots

Is it a dark spot or an acne scar?

Postinflammatory hyperpigmentation, or PIH, means darkening after inflammation. Acne can trigger pigment producing cells to make extra melanin, the substance that gives skin its colour. The pigment can sit in the epidermis, the outer skin layer, or deeper in the dermis. Marks appear where the breakout healed and range from light brown to black. PIH affects any skin tone but is usually more intense and lasts longer in darker skin.2

A flat spot of colour after acne usually isn't a scar. A scar changes the skin's shape, leaving a depression or a raised area. A scar can also have discolouration: the colour usually fades over time, while the change in texture remains. Acne scars rarely disappear completely on their own. If you have both dark marks and indentations, fading the pigment will not address the whole problem.3

How can you manage hyperpigmentation from acne?

1. 1Address active acne first. Continue acne treatment as breakouts improve, rather than treating only the marks left behind.
2. 2Cleanse gently and use a moisturizer labelled noncomedogenic, meaning formulated not to clog pores. Supporting the skin barrier helps limit irritation from acne treatment.
3. 3Apply sunscreen every morning and before going outdoors. Protect all exposed skin, not just individual marks.
4. 4Choose a pigment treatment suited to your acne treatment and skin tolerance. Follow its directions rather than increasing applications to chase faster results.
5. 5Leave breakouts alone. Picking, popping and squeezing increase inflammation and the risk of infection, discolouration and scarring.

Which sunscreen helps acne dark spots?

Choose tinted sunscreen containing iron oxide, with broad spectrum protection, water resistance and SPF 30 or higher. Iron oxide protects against visible light, which can contribute to dark spots; look for it in the inactive ingredient list. For exposed pigmentation, SPF 50 or higher is a practical choice. Choose a tint that blends with your skin tone and a noncomedogenic formula if your skin is oily. Reapply every two hours outdoors and after swimming or sweating. A wide brimmed hat adds protection, and limiting exposure between 10 a.m. and 2 p.m. helps reduce further darkening.24

Which ingredients can fade the marks?

Pigment treatments include retinoids, azelaic acid, hydroquinone and vitamin C. Several different treatments share the dark spot shelf, so 'brightening' is a marketing adjective rather than a treatment plan.2

Retinoids are vitamin A derived treatments that address both acne and PIH. They reduce the processes that cause blocked pores and inflammation, while also helping pigmentation. Adapalene 0.1% gel and tretinoin 0.05% lotion have improved hyperpigmentation in studies involving darker skin tones. Retinoids can also cause dryness and redness, and irritation can create further pigmentation. Gradually increasing treatment and using moisturizer are ways to improve tolerance. The right formulation matters: adapalene 0.1% gel was better tolerated than tretinoin 0.025% gel in a study of healthy volunteers.1

Azelaic acid is another option used for acne and pigmentation. Other pigment treatments include vitamin C, kojic acid and glycolic acid. Topical treatments are mainly aimed at pigment in the outer skin layer, and meaningful improvement sometimes requires a carefully chosen combination. That is a reason to get help combining treatments, not to apply every active at once.124

When is hydroquinone an option?

Hydroquinone reduces production of new melanin and treats pigmentation in the outer skin layer, not the dermis. Creams and lotions contain concentrations of 1% to 5%; access and prescription requirements vary by country. Use the directions for your prescribed formulation, especially if it combines other medicines.5

1. 1Test a small 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 there is no irritation after one week, application can increase to twice daily.
3. 3Keep hydroquinone away from the eyes and mouth. Do not add other topical medicines, particularly benzoyl peroxide, unless your prescriber has arranged the combination.
4. 4Wait 10 minutes before applying sunscreen or cosmetics.
5. 5Assess treatment at three months. Stop if there has been no benefit; maintenance after improvement can involve twice weekly use.

Stop hydroquinone for excessive redness, scaling, itching or weeping. Do not use it if you are allergic to hydroquinone or its formulation ingredients. Long term, frequent use of high concentrations can cause ochronosis, an abnormal darkening of skin. Safety during pregnancy and breastfeeding has not been established, so discuss another approach with your clinician.5

How long does acne hyperpigmentation take to fade?

Once the cause is controlled, spots a few shades darker than your skin usually fade within 6 to 12 months. Deeper pigment can last years and often looks slate blue, grey or much darker brown. Treatment can speed fading, but complete clearance is not a reliable expectation for every treatment.46

Cosmetic camouflage can cover discolouration while you wait, because concealer does not need to negotiate with the treatment calendar.2

When should you see a dermatologist?

Get help for deep, painful acne, developing scars or dark spots that are not improving with treatment. Stop a skincare product that burns or stings. A dermatologist can assess pigment depth and combine treatments safely. Peels, lasers and intense pulsed light can help some superficial pigmentation, but treatment related injury can also worsen PIH. Laser treatment has cleared pigmentation in some people with darker skin tones, while others experienced worsening. Procedures are not an automatic next step when a cream disappoints.2346