Hyperpigmentation is an umbrella term used to define common skin conditions — including post-inflammatory hyperpigmentation (PIH), melasma and sun spots — in which patches of skin become darker than the surrounding area. The darkening of the skin results from an excess in melanin — the natural pigment that determines skin, hair and eye color — and frequently appears on the face, hands and other parts of the body regularly exposed to sunlight.
Common hyperpigmentation triggers include UV-ray exposure, heat (for melasma), hormonal changes and taking certain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and tetracyclines. While usually treated topically at home, most hyperpigmentation also can be treated in-office with chemical peels; only certain mild cases can be treated with lasers, because light and inflammation can trigger more hyperpigmentation.
Most forms of hyperpigmentation are not cancerous, according to Josh Zeichner, a New York-based dermatologist and director of cosmetic and clinical research in dermatology at Mount Sinai Hospital. However, he added, if you notice a new or changing dark spot on you skin, you should always touch base with your dermatologist for evaluation.
In Gould’s case, the dark spots were the result of PIH, in which inflammation to the skin (caused by acne, bug bites, scrapes, cuts, eczema, psoriasis or dermatitis) results in darkened marks.
PIH is most prevalent and more severe in people who have medium to dark skin tones, such as Gould, who has an olive complexion and is a 4 on the Fitzpatrick Scale, a classification system measuring how much pigment is in the skin, ranging from 1 (ivory) to 6 (darkest brown). The condition results from the overproduction of melanin or an irregular dispersion of pigment after inflammation, and can be worsened by picking, scratching or rubbing at the site.
“The best way to think about post-inflammatory hyperpigmentation, or PIH, is that anyone with skin of color will get it. There is no way to avoid it,” said Hope Mitchell, a dermatologist based in Perrysburg, Ohio. The depth or thickness of the hyperpigmentation or the darkness of the hyperpigmentation, she said, is going to depend on the inflammation. “So, if you compare two people with similar skin tones that have been bitten by an insect, the one that did the most scratching and rubbing is going to have subsequent darker hyperpigmentation, than the one that just left it alone.”
Mitchell said that some patients come in to see her because they are concerned about the hyperpigmentation rather than the underlying inflammatory condition: “They don’t go to a dermatologist’s office to treat their acne; they are there to treat their uneven skin tone.” Education, she said, is key. Dermatologists “must teach their patients to treat the primary condition first.”
PIH is not the only form of hyperpigmentation Gould has. When she was growing up, she and her family spent many weekends at the beach, which left her with sun damage-induced sun spots (also known as liver spots or solar lentigines) on her chest.
And two years ago, she noticed darkened pigment above her lip, which her dermatologist told her was melasma, a chronic form of hyperpigmentation that is usually seen in women and can be triggered by UV exposure, heat, genetics and hormonally influenced conditions such as pregnancy, menopause and use of birth-control pills. Often referred to as the mask of pregnancy, melasma usually shows up on the face (though it can affect any area exposed to light) and can fade after childbirth or cessation of oral contraceptive usage.
Gould’s hyperpigmentation, especially her melasma, is triggered by sun exposure, and unfortunately, she now lives in Florida where, she said, “walking to the mailbox is too much sun.” But even if she avoided the outdoors at all costs, according to Dallas-based cosmetic and procedural dermatologist DiAnne Davis, it might not leave her melasma-free. “It can definitely sneak up on you, through visible light from your lightbulbs, computer screen and cellphone.”
Melasma is difficult to control, said New York-based dermatologist and psychiatrist Evan Rieder. “If you have melasma and you are good about avoiding heat and the sun for 364 days of the year, all it takes is 30 minutes at the beach to undo all that hard work,” he said, “so it’s really a tough condition to go through.”
All the experts agreed broad-spectrum sunscreen is the most important tool in preventing the development of additional hyperpigmentation in melasma and sun spots. And while the number one treatment for PIH is “definitely going to be addressing the primary cause of the inflammation,” Davis said, the secondary treatment is sunscreen to minimize further hyperpigmentation.
Sunscreen can be a hard sell, however. “It’s definitely tougher for my darker patients to believe the hype about why they should use sunscreen,” said Tiffany Clay, a dermatologist in Atlanta. “Generationally growing up, you hear ‘Black don’t crack’ or that ‘we have built-in sunscreen,’ ” she said. Yet once her patients with hyperpigmentation find a sunscreen they like and start using it regularly, she said, they are happy with their more even skin tone.
In the case of melasma, Zeichner recommends tinted mineral sunscreens such as EltaMD UV Physical Broad-Spectrum SPF 41, because they contain iron oxide-based pigments (used to hide the white of the UV blockers), which have been shown to “have therapeutic effects because they block visible light exposure.”
While sun protection is your first line of defense against triggering or worsening hyperpigmentation, applying antioxidants such as topical vitamin C can help treat existing hyperpigmentation and prevent new hyperpigmentation from forming, the experts said.
Zeichner advises his patients with all kinds of hyperpigmentation to layer a topical vitamin C serum such as Skinceuticals C E Ferulic or BeautyStat Universal C Skin Refiner under sunscreen every morning: “Vitamin C is your go-to ingredient if you have hyperpigmentation.” A true multi-tasker, it protects the skin from UV light and free-radical damage, and blocks production of abnormal pigmentation, he said.
Nighttime skin care for all hyperpigmentation is all about hydration, repair and speeding up cell turnover, according to Zeichner, which can be done with hydroxy acids such as glycolic acid or “I am currently using AlphaRet Overnight Cream, which combines a retinoid with lactic acid (an alpha hydroxy acid).” Zeichner said he also likes PCA Skin Clearskin Moisturizer with niacinamide and Vitamin A and the Ponds Rejuveness line because “it’s affordable and has brightening vitamin B3 and a retinol complex.”
You can’t talk about hyperpigmentation treatments without mentioning hydroquinone — a controversial depigmenting agent that can bleach dark patches on the skin — which has been used for more than 40 years to treat hyperpigmentation. The ingredient, which was available without a prescription in up to a 2 percent concentration, was banned by the Food and Drug Administration in over-the-counter sales in September 2020.
The FDA action was prompted by a study — in which rats were given hydroquinone orally — that found the ingredient to be a potential carcinogen. Another concern was overuse that can lead to skin irritation, rebound effects and potentially a rare skin condition called exogenous ochronosis.
Clay said she gets a lot of requests for hydroquinone prescriptions from her patients because their relatives swore by it, and it used to be so readily available. “People think because their aunts recommended it and they could get it from the beauty supply store that it obviously can’t do them harm.” Clay tries to educate patients that there are alternative ingredients to hydroquinone such as cyspera, azelaic acid and kojic acid. “I want patients to know that, yes, hydroquinone used correctly is beneficial, but there are also these alternatives that don’t carry the same potential side effects.”
Gould has seen the biggest improvement in her skin from hydroquinone but is currently taking a three-month break from it. Despite the positive results, she said, it’s never enough. “Seeing improvement in my hyperpigmentation has been a slow process so it can be frustrating and a bit depressing at times.”
Janna Mandell is a San Francisco-based journalist covering the beauty industry.