What are the recommended treatments for hyperpigmentation in individuals with black skin?

Treatment of Hyperpigmentation in Black Skin

First-Line Topical Therapy

For hyperpigmentation in individuals with black skin (Fitzpatrick types IV-VI), topical tyrosinase inhibitors combined with rigorous photoprotection should be initiated immediately, as postinflammatory hyperpigmentation (PIH) affects darker-skinned patients with greater frequency and severity. 1

• Hydroquinone 4% remains the gold standard depigmenting agent, though non-hydroquinone alternatives containing epidermal growth factor, tranexamic acid, vitamin C, arbutin, and niacinamide have demonstrated 28.5% superior improvement compared to hydroquinone with significantly better tolerability 2

• Alternative tyrosinase inhibitors include azelaic acid, kojic acid, arbutin, and licorice extracts, all of which effectively lighten hypermelanosis in darker skin types 1, 3

• Topical retinoids (tretinoin) should be added to the regimen for enhanced efficacy, particularly for epidermal PIH 1, 3

• Niacinamide, N-acetyl glucosamine, and soy provide additional depigmenting effects with minimal irritation risk 1

Critical Sun Protection Requirements

• Broad-spectrum sunscreen must be applied daily as UV exposure is a primary trigger for hyperpigmentation in darker skin types, and failure to use photoprotection will result in treatment failure regardless of other interventions 1, 3

Second-Line Procedural Interventions

For recalcitrant hyperpigmentation not responding to topical therapy after 2-3 months, superficial to medium-depth chemical peels are particularly effective and well-tolerated in dark-skinned patients. 3

• Glycolic acid peels with frequent applications have demonstrated superior efficacy in darker skin types when combined with topical depigmenting agents 1, 3

• Laser therapy should be approached with extreme caution in black skin due to high risk of paradoxical worsening of PIH from treatment-induced inflammation 1

Management of Melasma in Darker Skin

• Autologous platelet concentrates (PRP) have shown promising results for melasma in darker skin types, with significant reduction in modified MASI scores and high patient satisfaction 4

• Three treatment sessions spaced at minimum 21-day intervals are typically required, with maintenance treatments every 6 months 4

• Intradermal PRP injections demonstrated higher efficacy than tranexamic acid in comparative studies for melasma management 4

• Home care routine and sun protection counseling are essential, as melasma should be managed as a chronic condition requiring regular follow-up 4

Vitiligo Considerations in Black Skin

For vitiligo in darker skin types, narrowband UVB phototherapy should be strongly preferred as the cosmetic impact is greatest and treatment response is superior in patients with higher melanin content. 4, 5

• NB-UVB is ideally reserved for darker skin types (IV-VI) where depigmentation is most visible and distressing 4

• Evidence is lacking to define upper treatment limits for skin types IV-VI, unlike the 200-treatment limit established for lighter skin types 4

• Serial photographs every 2-3 months are essential for monitoring treatment response objectively 4, 5

Critical Pitfalls to Avoid

• Never use aggressive treatments without patch testing as darker skin is more prone to developing PIH from the treatment itself, creating a vicious cycle of worsening hyperpigmentation 1, 6

• Avoid excessive irritation from any topical agent as inflammation will paradoxically worsen PIH in black skin 1

• Do not proceed with laser treatments without extensive experience in treating darker skin types, as the risk of treatment-induced hyperpigmentation is substantially elevated 1

• Never neglect the psychological impact of pigmentation disorders in darker-skinned patients, as dyschromias are among the most common reasons this population seeks dermatologic care 1

Treatment Algorithm Priority

1. Start early with topical depigmenting agents plus photoprotection to hasten resolution 1
2. Manage underlying inflammatory condition first, as PIH is a sequelae of inflammation 1
3. Escalate to chemical peels if topical therapy fails after 2-3 months 3
4. Reserve laser therapy only for truly recalcitrant cases with experienced practitioners 1