What medication helps to fade dark spots from post-inflammatory hyperpigmentation (PIH) such as acne?

Medications for Post-Inflammatory Hyperpigmentation from Acne

Hydroquinone 4% cream is the most effective first-line treatment for fading dark spots from post-inflammatory hyperpigmentation (PIH) caused by acne. 1

First-Line Treatments

Hydroquinone

• Mechanism of action: Inhibits tyrosinase enzyme, preventing conversion of tyrosine to DOPA in the melanin production pathway 1
• Dosage: Apply 4% cream twice daily to affected areas
• Duration: Can be used safely for up to 6 months 2
• FDA-approved: Specifically indicated for "gradual bleaching of hyperpigmented skin conditions" 1

Enhanced Efficacy Combinations

• Hydroquinone + Retinoid: Add a topical retinoid at night to enhance penetration and efficacy 2
• Triple Combination: Hydroquinone 4% + tretinoin 0.05% + fluocinolone acetonide 0.01% (Tri-Luma®) is FDA-approved specifically for hyperpigmentation 3
• Short-term steroid addition: A mid-potent steroid applied twice daily for 2 weeks, then weekends only, can enhance results 2

Second-Line Treatments

Azelaic Acid

• Beneficial for PIH, especially in patients with darker skin types 4
• Can be used as an alternative when hydroquinone is not tolerated
• Available in 15-20% formulations

Other Effective Topical Agents

• Retinoids: Tretinoin, adapalene, tazarotene - promote cell turnover and enhance penetration of other agents 4
• Kojic acid: Natural tyrosinase inhibitor
• Vitamin C (ascorbic acid): Antioxidant with depigmenting properties 5
• Niacinamide: Inhibits melanosome transfer 5

Treatment Approach Algorithm

1. Mild PIH (few lesions):

   • Start with hydroquinone 4% cream twice daily
   • Add sunscreen SPF 30+ daily (essential to prevent darkening)
   • Assess after 6-8 weeks 4

2. Moderate-Severe PIH (multiple lesions):

   • Hydroquinone 4% cream twice daily
   • Add retinoid at night
   • Consider short course of topical steroid for first 2 weeks
   • Strict sun protection
   • Assess after 6-8 weeks 4, 2

3. Recalcitrant PIH:

   • Consider fixed-dose combination products:
     • Hydroquinone 4% + retinol 0.3%
     • Mequinol 2% + tretinoin 0.01%
     • Triple combination therapy 6

Important Considerations

Monitoring

• Initial improvement should be noticeable within 3-6 weeks
• Maximum improvement typically occurs after 8-12 weeks 4
• Limit hydroquinone use to 6 months to avoid complications 2

Precautions

• Always use sunscreen with PIH treatments to prevent worsening
• Watch for irritation with hydroquinone; if it occurs, use a short drug holiday 2
• Avoid prolonged use of steroid-containing combinations on the face 2

Treatment Pitfalls to Avoid

• Inadequate sun protection: Can worsen PIH despite treatment
• Excessive irritation: Can paradoxically worsen PIH; start with lower concentrations if skin is sensitive
• Premature discontinuation: PIH treatment requires patience; results take weeks to months
• Overuse of hydroquinone: Long-term continuous use beyond 6 months may lead to ochronosis 3

By following this treatment approach, most cases of post-inflammatory hyperpigmentation from acne can be effectively managed, with significant improvement or resolution of dark spots.