What is the best approach to manage hyperpigmentation on the face of a male patient?

Management of Facial Hyperpigmentation in Men

Start with triple combination therapy containing hydroquinone 2-4%, tretinoin 0.05-0.1%, and a topical corticosteroid (limited to 2 months maximum), combined with mandatory daily broad-spectrum SPF 50+ sunscreen reapplied every 2-3 hours during sun exposure. 1, 2

First-Line Treatment Algorithm

Topical Therapy Foundation

• Apply triple combination formulation (hydroquinone + tretinoin + corticosteroid) as the most effective initial regimen for facial hyperpigmentation in men 1
• Hydroquinone 2-4% can be used alone or combined with tretinoin 0.05-0.1% for enhanced efficacy 1, 2, 3
• Mequinol 2%/tretinoin 0.01% topical solution achieved complete clearance in 4 of 5 men with melasma at 12 weeks, with minimal side effects and good compliance due to the vehicle formulation 4
• Azelaic acid 15-20% serves as an effective alternative or adjunct, particularly beneficial for darker skin types due to lower irritation potential compared to hydroquinone 1, 3

Critical Sun Protection Protocol

• Apply broad-spectrum sunscreen SPF 50+ daily and reapply every 2-3 hours during sun exposure—this is non-negotiable and foundational to any hyperpigmentation treatment 5, 1, 2
• Wear wide-brimmed hats and UV-protective clothing during peak sun hours (10 AM-4 PM) 5
• Even minimal sunlight sustains melanocytic activity and prevents treatment success 2

Important Safety Considerations for Hydroquinone

• Test for skin sensitivity before full application by applying a small amount to an unbroken patch of skin and checking within 24 hours 2
• Minor redness is acceptable, but itching, vesicle formation, or excessive inflammation contraindicates further use 2
• Avoid contact with eyes and mucous membranes 2
• Limit topical corticosteroid use to maximum 2 months to prevent skin atrophy 1

Second-Line and Adjunctive Options

Oral Therapy for Refractory Cases

• Add oral tranexamic acid 250 mg twice daily for persistent or refractory hyperpigmentation, which increases total efficacy to 90.48% compared to 73.68% with topical therapy alone, with lower recurrence rates 5, 1
• Combining topical/intradermal tranexamic acid with oral tranexamic acid provides superior outcomes 5

Additional Topical Agents

• Topical tranexamic acid can be added to the regimen but must be combined with rigorous sun protection 5
• Topical niacinamide may provide additional benefit as an adjunct 1
• Kojic acid alone or combined with glycolic acid or hydroquinone has shown good results through tyrosinase inhibition 3

Advanced Procedural Interventions

When Topical Therapy Fails

• Intradermal platelet-rich plasma (PRP) injections demonstrate superior efficacy with 53.66% mMASI reduction, representing the most effective treatment when topical therapy fails 5, 1
• PRP combined with oral tranexamic acid shows higher efficacy with lower recurrence rates 1
• Microneedling may be more effective than intradermal PRP for delivering treatments to hyperpigmented skin 1
• Chemical peels using trichloroacetic acid, Jessner's solution, alpha-hydroxy acids, or kojic acid have shown good results 3

Laser Therapy Considerations

• Laser therapies have not produced completely satisfactory results and can induce hyperpigmentation with frequent recurrences 3
• Avoid laser as first-line treatment; reserve for carefully selected refractory cases 3

Monitoring and Maintenance

Objective Assessment

• Measure treatment efficacy using the Melasma Area and Severity Index (MASI) or modified MASI (mMASI) to objectively track improvement 1
• Document baseline with serial photographs and monitor every 2-3 months 1

Long-Term Management

• Hyperpigmentation is a chronic condition requiring maintenance therapy—expect to continue treatment for months and consider maintenance every 6 months 5, 1
• Do not discontinue treatment prematurely as recurrence is common 5
• Counsel patients to avoid smoking as this impairs treatment outcomes 1

Critical Pitfalls to Avoid

• Never use topical treatments without concurrent rigorous sun protection—treatment will fail without SPF 50+ reapplied every 2-3 hours 5, 2
• Do not use clascoterone for hyperpigmentation—it is only indicated for acne vulgaris and has no role in treating melanocyte dysfunction 1
• Avoid prolonged topical corticosteroid use beyond 2 months due to skin atrophy risk 1
• Do not apply photodynamic therapy (PDT) for hyperpigmentation—the evidence relates to actinic keratoses and photoaging, not primary hyperpigmentation disorders 6
• Recognize that genetic and hormonal factors may limit treatment success, requiring realistic patient expectations 1