What is the best treatment for a 40-year-old woman with hyperpigmentation on her face, who has a history of facial palsy (Bell's palsy) that has improved?

From the Guidelines

For hyperpigmentation in a 40-year-old woman with a history of facial palsy, I strongly recommend starting with a conservative, topical treatment approach, prioritizing sun protection and potentially progressing to procedural interventions, as aggressive treatments may pose risks given her medical history. When considering treatment options, it's crucial to weigh the benefits against potential risks, especially in patients with a history of facial palsy, where sensitivity and skin integrity might be compromised. Given the available evidence, a topical regimen including a retinoid (such as tretinoin 0.025-0.05% cream applied nightly) combined with a tyrosinase inhibitor like hydroquinone 4% cream applied twice daily for 8-12 weeks (with breaks to prevent ochronosis) could be beneficial 1. Alternatively, using azelaic acid 15-20% or kojic acid if hydroquinone isn't tolerated, alongside vitamin C serum (10-20% L-ascorbic acid) in the morning for antioxidant protection and skin brightening, is advisable. Strict sun protection using SPF 50+ broad-spectrum sunscreen reapplied every 2 hours when outdoors is essential to prevent further hyperpigmentation. For more resistant cases, chemical peels (glycolic acid 30-70%), microdermabrasion, or laser therapy (like Q-switched Nd:YAG or fractional lasers) performed by a dermatologist could be considered, with caution due to the potential for side effects such as hypopigmentation and scarring, as noted in studies on laser therapy for actinic keratosis 1. The goal is to inhibit melanin production, increase cell turnover, and protect against UV radiation, which triggers melanogenesis, while minimizing risks associated with her history of facial palsy. Results from these treatments typically take 8-12 weeks to become noticeable, and maintenance therapy will be needed long-term to sustain improvements. Key considerations include:

• Starting with conservative, topical treatments to minimize risk
• Gradually progressing to more invasive procedures if necessary
• Ensuring strict sun protection to prevent further hyperpigmentation
• Monitoring for side effects, especially given the patient's history of facial palsy.

From the FDA Drug Label

HYDROQUINONE USP, 4% SKIN BLEACHING CREAM is indicated for the gradual bleaching of hyperpigmented skin conditions such as chloasma, melasma, freckles, senile lentigines, and other unwanted areas of melanin hyperpigmentation. The best way to treat hyperpigmentation on the face in this patient is to use hydroquinone cream, as it is indicated for the gradual bleaching of hyperpigmented skin conditions.

• The patient's history of facial palsy is not directly relevant to the treatment of hyperpigmentation.
• Hydroquinone can be used to treat hyperpigmentation, but it should be used under the guidance of a healthcare professional 2.

From the Research

Treatment Options for Hyperpigmentation

The woman's history of facial palsy, which is now better, may not be directly related to the hyperpigmentation, as there is no clear evidence linking the two conditions 3. However, the hyperpigmentation can be treated with various methods, including:

• Topical agents, such as hydroquinone, kojic acid, and glycolic acid 4, 5
• Chemical peels, which can be combined with topical maintenance therapies for greater efficacy 6
• Laser therapy, which can be used as a second-line approach 5
• Novel formulations, such as solid lipid nanocarriers, liposomes, and phytochemicals, which are emerging as alternative treatments for hyperpigmentation 5

Considerations for Treatment

When choosing a treatment option, it is essential to consider the potential risks and limitations, such as:

• Prolonged use of hydroquinone has been associated with cancer risk and exogenous ochronosis 4
• Chemical peels and laser therapy can cause erythema, skin peeling, and drying 5
• Novel formulations may have varying degrees of efficacy and safety, and more research is needed to fully understand their potential 5

Alternative Depigmenting Agents

Alternative depigmenting agents, such as thiamidol, Polypodium leucotomos, and glutathione, can be rationally combined to achieve desired treatment goals in the management of hyperpigmentation 4. These agents may offer a safer and more effective alternative to traditional treatments, but more research is needed to fully understand their potential.