What is the treatment for facial pigmentation in an adult patient?

Treatment for Facial Pigmentation

Determining the Type of Pigmentation

The first critical step is distinguishing between hyperpigmentation (excess pigment) and hypopigmentation (loss of pigment), as treatments differ fundamentally 1, 2.

For Hyperpigmentation (Dark Spots/Patches)

Start with topical hydroquinone 2-4% as first-line therapy, ideally combined with tretinoin 0.05-0.1% and strict broad-spectrum sunscreen use (SPF 15 or greater). 3, 4

First-Line Topical Regimen:

• Hydroquinone 2-4% works by inhibiting tyrosinase enzyme, blocking melanin production through reversible depigmentation 3
• Combination therapy with tretinoin 0.05-0.1% enhances efficacy, particularly for melasma and photoaging-related pigmentation 4
• Mandatory sun protection is essential—even minimal sunlight sustains melanocyte activity and reverses treatment effects 3
• Apply to affected areas avoiding eyes and mucous membranes; test on small skin patch first for 24 hours 3

Alternative Topical Agents:

• Azelaic acid 15-20% is as effective as hydroquinone but causes less irritation 4
• Kojic acid (alone or combined with glycolic acid or hydroquinone) inhibits tyrosinase effectively 4
• These alternatives are particularly useful if hydroquinone causes irritation or sensitivity 4

Procedural Options:

• Chemical peels (trichloroacetic acid, Jessner's solution, alpha-hydroxy acids, kojic acid) show good results, especially in darker skin types 4, 5
• Combination regimens with frequent superficial-to-medium depth peels are particularly effective and well-tolerated in dark-skinned patients with melasma 5
• Laser therapy has shown inconsistent results and can paradoxically induce hyperpigmentation or recurrence 4

Critical Precautions:

• Hydroquinone has demonstrated mutagenic and clastogenic properties in animal studies; carcinogenic potential in humans is unknown 3
• Avoid in pregnancy (Category C) and children under 12 years 3
• Discontinue if excessive inflammation, vesicle formation, or severe itching occurs 3
• Avoid photosensitizing medications during treatment 3

For Hypopigmentation (White Spots/Patches)

For vitiligo, narrowband UVB phototherapy is the preferred treatment for widespread disease in darker skin types, while potent topical corticosteroids are first-line for localized, recent-onset disease. 6, 7

Localized Vitiligo (Recent Onset):

• Potent or very potent topical steroids for trial period of no more than 2 months 6
• Common side effect is skin atrophy with prolonged use 6
• Topical pimecrolimus or tacrolimus are alternatives with better short-term safety profiles (no atrophy risk) 6

Widespread Vitiligo:

• Narrowband UVB phototherapy is preferred over oral PUVA due to greater efficacy 6
• Reserved for patients who cannot be managed with conservative treatments or have significant quality of life impact 6
• Ideally for darker skin types (IV-VI) where depigmentation is most visible and distressing 7
• Monitor with serial photographs every 2-3 months 6, 7

Combination Therapy:

• Fluticasone combined with UVA achieved 31% mean repigmentation versus only 9% with steroid alone 6

No Treatment Option:

• For patients with pale skin (types I-II), consider no active treatment beyond cosmetic camouflage and sunscreens after discussion 6

Extensive Disease (>50% involvement):

• Depigmentation with monobenzone is reserved for adults with extensive vitiligo (>50% body surface area or extensive facial/hand involvement) who cannot or choose not to pursue repigmentation 6, 8
• Depigmentation is permanent and irreversible—patients will never tan again 8
• Onset occurs within 4-12 months; approximately 36% experience repigmentation requiring retreatment 8

For Tinea Versicolor (Fungal Hypopigmentation)

• Diagnose with potassium hydroxide (KOH) preparation showing characteristic short, stubby hyphae and spores 9
• Wood's light examination helps delineate extent of disease 9
• Treat the underlying fungal infection with antifungals (not detailed in provided evidence but standard practice)

Common Pitfalls to Avoid

• Failing to use sunscreen during hyperpigmentation treatment will negate all therapeutic effects 3, 4
• Prolonged topical steroid use (>2 months) for vitiligo causes skin atrophy 6
• Starting depigmentation therapy without ensuring patient fully understands permanence 8
• Misdiagnosing vitiligo as tinea versicolor or vice versa—use KOH prep and Wood's light to differentiate 9
• Using laser therapy as first-line for melasma—high risk of worsening hyperpigmentation 4