Treatment for Hyperpigmentation (Dark Spots) on the Face
For facial hyperpigmentation (dark spots), topical hydroquinone 4% cream is the most effective first-line treatment, applied twice daily for up to 6 months to gradually bleach hyperpigmented skin conditions. 1, 2
First-Line Treatments
- Hydroquinone 4% cream works by inhibiting the enzymatic oxidation of tyrosine to 3,4-dihydroxyphenylalanine (dopa) and suppressing other melanocyte metabolic processes 1
- Apply hydroquinone twice daily to affected areas for up to 6 months 2
- Sunscreen application (SPF 15 or greater) is essential during treatment to prevent repigmentation, as even minimal sunlight exposure sustains melanocytic activity 1
- Treatment efficacy can be enhanced by combining with a retinoid applied nightly and a mid-potent steroid applied twice daily for 2 weeks, then weekends only 2
Treatment Approach Based on Extent
- For a few isolated dark spots: Use spot therapy targeting only the affected areas 2
- For widespread hyperpigmentation: Use field therapy covering the entire affected region 2
Alternative Treatments
- Topical calcineurin inhibitors (tacrolimus, pimecrolimus) can be considered as alternatives to topical steroids, particularly for facial application, due to their better safety profile 3
- Natural alternatives with some evidence of efficacy include:
- Soy extracts
- Licorice extracts
- Kojic acid
- Arbutin
- Niacinamide 4
Advanced Treatment Options
- For resistant cases, consider:
- Autologous platelet concentrates (APCs) have shown promising results for melasma treatment, typically requiring three treatments spaced at least 21 days apart 3
Important Precautions
- Test for skin sensitivity before full application by applying a small amount to an unbroken patch of skin and checking within 24 hours 1
- Avoid contact with eyes and mucous membranes 1
- Hydroquinone has been associated with concerns about carcinogenicity in animal studies, though the carcinogenic potential in humans remains unknown 1
- Hydroquinone is not recommended during pregnancy (Category C) unless clearly needed 1
- Safety in children under 12 years has not been established 1
- The most common side effect is mild irritation, which can be managed with topical steroids or a short treatment break 2
Maintenance and Prevention
- Continue sunscreen use even after treatment to prevent recurrence 1
- Consider maintenance therapy with once-daily or weekend-only application after achieving desired results 2
- Patients should be advised on a good home care routine and counseled on adequate sun protection and avoiding damaging habits such as smoking 3
Special Considerations
- For patients with extensive vitiligo (>50% depigmentation) who cannot or choose not to seek repigmentation, depigmentation therapy with monobenzyl ether of hydroquinone (MBEH) may be considered to make skin tone appear more even 3, 5
- This approach should be reserved only for adults with severe vitiligo affecting cosmetically sensitive areas who can accept the permanence of never tanning 3