Introduction to hyperpigmentation

Post-inflammatory hyperpigmentation, often described as dark spots or red spots that are left after acne lesions heal is a common difficulty that acne sufferers with non-Caucasion skin share.1-3 Hyperpigmentation is common among people of African, Asian, and Latino descent, as well as other forms of "ethnic" skin.4 Various forms of acne therapy are often mistakenly blamed for the creation of these marks, but it is the skin's inflammatory process which creates them. These marks can take months, and in rare cases years, to fade.5 Although they are often referred to as "scars," they are not permanent. Nonetheless, they cause many people intense distress. Often, people with hyperpigmentation describe this issue as more concerning than the acne itself.

Picking at acne lesions is perhaps the worst culprit when it comes to these marks. Absolutely do not pick at acne lesions. Properly pop a pimple, and then leave the lesion alone. Also, while it may seem intuitive to scrub marks away, harsh scrubbing will only prolong their duration and should be avoided. Next, wearing a sunscreen is a huge help in getting these marks to fade as fast as possible.1,4,6 But the best way to prevent the marks is to treat the acne itself, thus preventing future acne lesions and any hyperpigmentation that they might leave behind.7 Acne is treated the same regardless of skin color and responds extremely well to proper topical treatment. When acne is severe, widespread, and deeply scarring, Accutane (isotretinoin) is also an option.

  • Retinoids: Tretinoin (Retin-A®). This topical treatment can help fade marks.8 Azelaic acid (Azelex®) may prove even better because it may have a hypopigmentary (lightening) effect by inhibiting melanin (skin pigment).2-3,9
  • Hydroquinone: (Bleach Eze®). This is the only lightening treatment approved by the FDA. It is normally used at 4%. In higher concentrations it can cause "spotted halos" around marks. It may have other negative effects as well. The addition of ascorbic acid (Vitamin C) to a topical hydroquinone treatment may help minimize the oxidation of hydroquinone.2-3 Also, the efficacy of hydroquinone may be increased by the addition of a retinoid and mid-potent steroid.10 Be certain to work closely with your physician or dermatologist if you decide to use hydroquinone.
  • Peels: Salicylic acid peels, Jessner's® peels, TCA peels, and mandelic acid peels are all mentioned in medical literature as treatments for hyperpigmentation. These peels must be administered by professionals.1-3,9
  • Dry ice cryotherapy: Doctors will sometimes use application of dry ice to help the mark fade.
  • Lasers: If topical treatment does not suffice, doctors may sometimes elect to try laser therapy. Laser therapy tends to produce statistically effective results on par with topical treatment.11-12
  • In one article doctors also describe regular topical application of lactic, kojic, and glycolic acid as helpful.3
  • In the same article, a doctor spoke about how he uses a combination of hydroquinone/retinoid/corticosteroid to apply directly to dark spots.3
  • Nicotinamide is mentioned once in the literature as a helpful treatment for inflammation.
  • Microdermabrasion: Performed at salons and estheticians' offices, microdermabrasion helps remove the upper layers of skin cells. However, abrading the skin can cause irritation and perpetuate the acne cycle, and should be avoided in acne-prone individuals.2-3

  1. Dunwell P and Rose A. "Study of the skin disease spectrum occurring in an Afro-Carribean population." International Journal of Dermatology. 2003; 42(4): 287-9.
  2. Alexis AF and Lamb A. "Concomitant therapy for acne in patients with skin of color: A case-based approach." Dermatology Nursing. 2009; 21(1): 33-36.
  3. Yahya H. "Acne vulgaris in Nigerian adolescents - prevalence, severity, beliefs, perceptions, and practices." International Journal of Dermatology. 2009; 48(5): 498-505.
  4. Jacyk WK. "Adapalene in the treatment of African patients." Journal of the European Academy of Dermatology and Venereology. 2001; 15(Suppl 3): 37-42.
  5. Taylor SC, et al. "Acne Vulgaris in Skin of Color." Journal of American Academy of Dermatology. 2002; 46: S98-S106.
  6. Halder RM and Nootheti PK. "Ethnic Skin Disorders Overview." Journal of American Academy of Dermatology. 2003; 48: 143-148
  7. Shah SK and Alexis AF. "Acne in skin of color: Practical approaches to treatment." Journal of Dermatological Treatment. 2010; 21(3): 206-211.
  8. Woolery-Lloyd HC, Keri J and Doig S. "Retinoids and azelaic acid to treat acne and hyperpigmentation in skin of color." Journal of Drugs in Dermatology. 2013; 12(4): 434-7.
  9. Davis EC and Callender VD. "A review of acne in ethnic skin: Pathogenesis, clinical manifestations, and management strategies." The Journal of Clinical and Aesthetic Dermatology. 2010; 3(4): 24-38.
  10. Chandra M, Levitt J and Pensabene CA. "Hydroquinone therapy for post-inflammatory hyperpigmentation secondary to acne: not just prescribable by dermatologists". Acta Dermato-Venereologica. 2012; 92(3): 232-5
  11. Kane A, et al. "Epidemiologic, clinical, and therapeutic features of acne in Dakar, Senegal." International Journal of Dermatology. 2007; 46(Suppl 1): 36-8.
  12. Poli F. "Acne on pigmented skin." International Journal of Dermatology. 2007; 46(Suppl 1): 39-41.

Further Reading

  1. Alexis AF, Sergay AB and Taylor SC. "Common dermatologic disorders in skin of color: a comparative practice survey." Cutis. 2007; 80(5): 387-94.
  2. Arfan-ul-Bari and Khan MB. "Dermatological disorders related to cultural practices in black Africans of Sierra Leone." Journal of College of Physicians and Surgeons Pakistan. 2007; 17(5): 249-52.
  3. Arsouze A, et al. "[Presenting skin disorders in black Afro-Carribean patients: a multicentre study conducted in the Paris region]." Annales de Dermatologie et de Venereology. 2008; 135(3): 177-82.
  4. Czernielewski J, Poncet M and Mizzi F. "Efficacy and cutaneous safety of adapalene in black patients versus white patients with acne vulgaris. Cutis. 2002; 70(4): 243-8.
  5. Mosam A, et al. "Quality of life issues for South Africans with acne vulgaris." Clinical and Experimental Dermatology. 2005; 30(1): 6-9.