Spots left behind from acne
(Post-inflammatory hyperpigmentation)

Post-inflammatory hyperpigmentation, also known 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 even 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.

How to prevent hyperpigmentation: 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 if you must, 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 the chance of any hyperpigmentation that they might leave behind.⁷ Acne is treated the same regardless of skin color and responds extremely well to The Regimen here at Acne.org. When acne is severe, widespread, and deeply scarring, Accutane is also an option.

How to treat hyperpigmentation: There are many ways to treat these marks. After the acne itself is successfully treated and under complete control, people sometimes opt to try one or more of the treatments listed below.

• Retinoids: Tretinoin (Retin-A®) - this topical treatment can help fade marks. Azelaic acid (Azelex®) may prove even better because it may have a hypopigmentary (lightening) effect by inhibiting melanin (skin pigment).^2-3,8 Retin-A® reviews. Azelex® reviews.
• 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
• Peels: Salicylic acid peels, Jessner's® peels, TCA peels, and mandelic acid peels are all mentioned in the medical literature as treatments for hyperpigmentation. These peels must be administered by professionals.^1-3,9 TCA peel reviews. Chemical peel reviews.
• Dry ice cryotherapy: Doctors will sometimes use application of dry ice to help the mark fade.
• Microdermabrasion: Performed at salons and estheticians' offices, microdermabrasion is a popular option. However, abrading the skin can cause irritation and perpetuate the acne cycle. I would personally avoid microdermabrasion.^2-3 Microdermabrasion reviews.
• Lasers: If topical treatment does not suffice, doctors may sometimes elect to try laser therapy. Researchers have so far studied the Q-switched laser (the same laser used in tattoo removal), the 595 nm LPDL laser, and the 1064 nm QSNd:YAG laser. All have produced statistically effective results on par with topical treatment.^10-11
• In one article doctors also describe regular topical application of lactic, kojic, and glycolic acid as helpful.³ Lactic acid peel reviews. Glycolic acid peel reviews.
• Interestingly, in one article, a doctor spoke about how he uses a combination of hydroquinone/retinoid/corticosteroid to apply directly to dark spots.³
• Lastly, nicotinamide is mentioned once in the literature as a helpful treatment for inflammation. Nicotinamide reviews.

Helpful link: Frances, one of Acne.org's earliest members, posted a nice overview of hyperpigmentation.