What are the treatment options for dark spots?

Treatment of Dark Spots (Hyperpigmentation)

First-Line Treatment Approach

For post-inflammatory hyperpigmentation (PIH) and melasma, start with topical hydroquinone 4% combined with tretinoin 0.05% and a topical corticosteroid (triple combination therapy), applied nightly with strict daily broad-spectrum sunscreen use. 1, 2

Evidence-Based Treatment Algorithm

Initial Therapy (Weeks 0-12)

Topical Regimen:

• Triple combination cream (Tri-Luma®: fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) is FDA-approved specifically for melasma and represents the gold standard first-line treatment 1
• Apply once daily at bedtime to affected areas only 3
• Wait 20-30 minutes after washing face before application to minimize irritation 3
• Use a mild, non-medicated soap and avoid harsh scrubbing 3

Mandatory Photoprotection:

• Apply broad-spectrum sunscreen every morning, as UV exposure is the primary cause of recurrence 1, 2, 4
• Use non-comedogenic moisturizer with sunscreen daily 3

Alternative First-Line Options

If triple combination is unavailable or not tolerated:

• Hydroquinone 4% alone (FDA-approved for "bleaching of hyperpigmented skin") combined with tretinoin 0.025-0.1% 1, 5
• Azelaic acid 15-20% is particularly effective for PIH in darker skin types and has lower irritation potential 1, 5
• Kojic acid, arbutin, or licorice extracts as tyrosinase inhibitors for patients avoiding hydroquinone 5

Expected Timeline and Management

• Weeks 0-4: Expect possible mild irritation, peeling, or temporary worsening; this represents skin adjustment 3
• Weeks 6-12: Visible improvement should begin; continue treatment consistently 3, 1
• Week 12+: Reassess response; if inadequate, proceed to combination with procedures 1, 2

Second-Line: Procedural Interventions

Add procedures only after 12 weeks of topical therapy or for recalcitrant cases:

• Chemical peels (glycolic acid, salicylic acid, or trichloroacetic acid) enhance topical penetration and accelerate results 1, 2, 5
• Microneedling combined with topical agents improves delivery and efficacy 1, 2
• Fractional non-ablative lasers or intense pulsed light (IPL) for resistant cases 1, 4
• Q-switched or picosecond lasers target dermal pigment but carry higher risk of worsening PIH in darker skin types 1, 4

Critical caveat: Procedures must be combined with ongoing topical therapy and photoprotection, never used as monotherapy 1, 4

Emerging Oral Therapies

For extensive or refractory melasma:

• Tranexamic acid (oral) shows promising results for melasma 2
• Polypodium leucotomos and glutathione have demonstrated varying efficacy 2

Maintenance Therapy

After achieving clearance, continue tretinoin indefinitely with daily sunscreen to prevent recurrence 3, 1, 4

• Melasma can be controlled and improved but requires ongoing maintenance 1
• PIH can be cured in most cases with proper treatment 1
• Discontinuing treatment typically results in recurrence, especially with sun exposure 4

Critical Pitfalls to Avoid

• Never skip photoprotection: Sun exposure is the primary cause of treatment failure and recurrence 1, 2, 4
• Avoid excessive irritation: Over-washing, harsh scrubbing, or using too much medication worsens hyperpigmentation 3, 5
• Do not use procedures as monotherapy: Always combine with topical agents and photoprotection 1, 4
• Caution with lasers in darker skin: Aggressive laser treatment can paradoxically worsen PIH in skin of color 5, 4
• Start treatment early: Delayed treatment of PIH prolongs resolution time 5

Special Considerations for Darker Skin Types

• Azelaic acid is preferred over hydroquinone in darker skin due to lower risk of irritant contact dermatitis and paradoxical hyperpigmentation 5
• Chemical peels require lower concentrations and shorter contact times in darker skin to prevent worsening 5
• Avoid hydroquinone-induced ochronosis by limiting continuous use and monitoring for blue-gray discoloration 1