What are the treatment alternatives for hyperpigmented scars?

Treatment of Hyperpigmented Scars

For hyperpigmented scars, initiate triple combination therapy with hydroquinone 4%, tretinoin, and a topical corticosteroid as first-line treatment, combined with mandatory broad-spectrum SPF 50+ sunscreen reapplied every 2-3 hours during sun exposure. 1, 2

First-Line Topical Regimen

The most effective initial approach combines three agents:

• Hydroquinone 4% is FDA-indicated for gradual bleaching of hyperpigmented skin conditions and should be applied twice daily for up to 6 months 2, 3
• Tretinoin 0.05-0.1% enhances hydroquinone efficacy and should be applied nightly 1, 4
• Mid-potent topical corticosteroid applied twice daily for the first 2 weeks, then weekends only, to suppress irritation and enhance depigmentation 1, 3

Critical caveat: Do not use topical corticosteroids beyond 2 months due to risk of skin atrophy 1. After the initial 2-week period, limit steroid application to weekends only 3.

Essential Sun Protection Foundation

• Apply broad-spectrum sunscreen with minimum SPF 50+ daily, reapplying every 2-3 hours during sun exposure 1, 5
• Sun protection is non-negotiable and must be maintained throughout the entire treatment course 1, 4
• Failure to use adequate photoprotection will result in treatment failure regardless of other interventions 4

Alternative First-Line Agents

If hydroquinone is not tolerated or contraindicated:

• Azelaic acid 15-20% is particularly effective for darker skin types (Fitzpatrick IV-VI) and causes less irritation than hydroquinone 1, 4
• Topical tranexamic acid 3% serum can be used as an alternative, though evidence is stronger for oral formulations 5

Second-Line Systemic Therapy

For refractory hyperpigmented scars not responding to topical therapy after 3-6 months:

• Oral tranexamic acid 250 mg twice daily demonstrates significant efficacy for persistent hyperpigmentation 1
• This is particularly effective when combined with continued topical therapy 1

Advanced Procedural Options

Reserve these for cases failing topical and oral therapies:

Platelet-Rich Plasma (PRP)

• PRP injections demonstrate significant improvement in hyperpigmentation within 6 weeks as measured by modified MASI scores 1
• Microneedling delivery is more effective than intradermal PRP injections alone for hyperpigmented skin 1
• Combining PRP with oral tranexamic acid shows higher efficacy and lower recurrence rates compared to tranexamic acid alone 1
• Typical protocol: 3 treatments spaced at minimum 21-day intervals, then maintenance every 6 months 6

Laser Therapy

• Fractionated 1550 nm non-ablative erbium-doped fiber laser is effective for hyperpigmented scars, particularly in darker skin types (Fitzpatrick III-IV) 7
• 755 nm alexandrite laser with MultiPass (MoveoPL) emission shows superior results compared to single-pass emission, with better safety profile in skin types I-IV 8
• MultiPass emission is safer for darker skin types (III-IV) where traditional lasers risk worsening hyperpigmentation 8

Critical warning: Avoid Q-switched lasers, ablative resurfacing, and aggressive chemical peels in darker skin types, as these may paradoxically worsen hyperpigmentation 7

Treatment Monitoring

• Measure efficacy using the Melasma Area and Severity Index (MASI) or modified MASI (mMASI) to objectively track improvement 1
• Hyperpigmented scars should be managed as a chronic condition requiring regular follow-ups and maintenance therapy 1
• Expect visible improvement within 6-12 weeks of initiating topical therapy, with maximal benefit at 6 months 2, 3

Common Pitfalls to Avoid

• Do not use clascoterone for hyperpigmented scars—it is a topical antiandrogen indicated only for acne vulgaris and has no role in treating melanocyte dysfunction 1
• Do not continue topical corticosteroids beyond 2 months due to atrophy risk; transition to weekend-only application after initial 2 weeks 1, 3
• Do not use aggressive ablative procedures (Q-switched lasers, deep chemical peels) in darker skin types without extreme caution, as these frequently worsen hyperpigmentation 7
• Counsel patients to avoid smoking, as this impairs treatment outcomes 1
• If irritation occurs with hydroquinone, use a short drug holiday (3-5 days) or increase topical steroid frequency temporarily rather than discontinuing treatment 3