What is the recommended evaluation and stepwise treatment approach for hyperpigmentation?

Evaluation and Stepwise Treatment of Hyperpigmentation

For hyperpigmentation, begin with topical hydroquinone (2-4%) combined with a retinoid and strict broad-spectrum photoprotection (SPF 50+), then escalate to chemical peels (glycolic acid 20-70% or salicylic acid 20-30%) every 15 days for 4-6 months if topical therapy fails after 3 months. 1, 2, 3

Initial Evaluation

Determine the Type and Depth of Pigmentation

• Assess whether hyperpigmentation is epidermal versus dermal using Wood's lamp examination—epidermal pigmentation becomes more pronounced under Wood's light, while dermal pigmentation does not change significantly 4
• Identify the underlying cause: post-inflammatory hyperpigmentation (PIH), melasma, drug-induced, or systemic disease-related 5, 6
• Document skin phototype (Fitzpatrick classification) as this directly impacts treatment selection and risk of complications 5, 4
• Obtain serial photographs to objectively track treatment response 7

Key History Elements

• Temporal relationship to inflammatory skin conditions, procedures, or medication use 8, 6
• Hormonal factors (pregnancy, oral contraceptives) suggesting melasma 8
• Sun exposure patterns and current photoprotection practices 1, 2
• Previous treatments attempted and their responses 4

Stepwise Treatment Algorithm

Step 1: Universal First-Line Management (All Patients)

• Initiate strict photoprotection immediately: broad-spectrum sunscreen SPF 50+ reapplied every 2-3 hours during sun exposure, plus physical sun avoidance 1, 2
• Start topical hydroquinone 2-4% applied twice daily to affected areas—this remains the gold standard for epidermal hyperpigmentation 5, 4
• Add a topical retinoid (tretinoin 0.025-0.1%) at night to increase keratinocyte turnover and enhance hydroquinone penetration 1, 8
• Monitor at 4-6 week intervals for signs of irritation, contact dermatitis, or ochronosis (with prolonged hydroquinone use) 3

Important caveat: Hydroquinone has been banned from over-the-counter use in Europe due to safety concerns, though carcinogenicity remains debated 3. Limit continuous use to 3-6 months, then take treatment breaks.

Step 2: Alternative First-Line Agents (If Hydroquinone Contraindicated or Not Tolerated)

• Azelaic acid 15-20% twice daily—particularly effective for PIH secondary to acne 1, 8
• Topical tranexamic acid 3% serum twice daily—emerging evidence supports efficacy for resistant hyperpigmentation 2
• Kojic acid or glycolic acid preparations as adjunctive agents 8, 6

Step 3: Procedural Interventions for Resistant Cases (After 3-6 Months of Topical Therapy)

Chemical peels are the most effective procedural intervention for resistant hyperpigmentation, demonstrating superior results compared to other modalities. 1

• Glycolic acid peels (20-70%) or salicylic acid peels (20-30%) applied every 15 days for 4-6 months 1, 2, 3
• Salicylic acid peels are particularly effective for acne-related PIH 1
• Apply anti-inflammatory agents (0.1% prednisolone solution or topical corticosteroids) immediately after peels to reduce post-procedural inflammation that can worsen pigmentation 1, 3

Step 4: Advanced Interventions for Refractory Cases

• Intradermal platelet-rich plasma (PRP) injections provide superior reduction of hyperpigmentation scores compared to intradermal tranexamic acid, with high patient satisfaction 2
• Fractionated 1550 nm erbium-doped fiber laser is the preferred laser modality, particularly for darker skin types (Fitzpatrick III-IV) 2

Critical Treatment Pitfalls to Avoid

Contraindicated Treatments

• Never use cryotherapy for cosmetic treatment of hyperpigmented scars on extremities—it causes permanent scarring and paradoxical worsening of pigmentation 2
• Avoid ablative laser modalities (CO₂ and erbium:YAG lasers) in darker skin types (Fitzpatrick III-VI) due to high risk of persistent hypo- or hyperpigmentation 2

Common Errors

• Inadequate photoprotection is the most common reason for treatment failure—UV and visible light exposure must be rigorously controlled throughout treatment 1, 2
• Premature discontinuation of therapy—visible results typically require 3-6 months of consistent treatment 2
• Failure to counsel patients about expected initial worsening with retinoids, which is temporary 2

Maintenance Therapy

• Continue photoprotection indefinitely—hyperpigmentation should be managed as a chronic condition requiring regular follow-ups 2
• Consider maintenance with non-hydroquinone agents (azelaic acid, retinoids) after initial improvement to prevent recurrence 1
• Schedule follow-up visits every 2-3 months during active treatment, then every 6 months for maintenance 1

Special Considerations for Skin of Color

• Higher risk of post-inflammatory hyperpigmentation with aggressive treatments necessitates more conservative initial approaches 5, 4
• Test treatments on small areas first before widespread application 4
• Lower concentrations and longer intervals between chemical peels may be necessary 8