How should I evaluate and manage acquired hyperpigmentation in an adult patient?

Evaluation and Management of Acquired Hyperpigmentation in Adults

Begin with a focused clinical assessment to determine whether the hyperpigmentation is epidermal versus dermal, as this distinction fundamentally determines treatment success—epidermal pigmentation responds well to topical therapies while dermal pigmentation requires procedural interventions. 1

Initial Diagnostic Evaluation

Clinical History to Obtain

• Document the patient's Fitzpatrick skin type, as darker phototypes (IV-VI) experience more persistent hyperpigmentation and require modified treatment approaches 2
• Inquire about personal or family history of autoimmune thyroid disease, particularly in adults, as 34% of vitiligo patients have concurrent thyroid dysfunction—consider screening thyroid function tests when autoimmune disease is suspected 3, 2
• Identify triggering inflammatory conditions (acne, eczema, psoriasis), prior trauma, medication use (especially minocycline, antimalarials, chemotherapy), and hormonal factors (pregnancy, oral contraceptives) 4, 5, 6
• Assess sun exposure patterns including occupational and recreational UV exposure, as this drives both development and persistence of hyperpigmentation 2

Physical Examination Techniques

• Perform Wood's lamp examination to differentiate epidermal (enhanced under Wood's lamp) from dermal (unchanged or less visible) pigmentation, particularly useful in fair-skinned patients 2, 1
• Use dermoscopy to characterize pigmented lesions and exclude melanoma or atypical features requiring biopsy 2
• Take serial photographs to objectively monitor treatment response over time 2

When to Refer to Dermatology

Refer immediately for atypical presentations, concern for malignancy, or diagnostic uncertainty after initial clinical assessment 2. Consider multidisciplinary referral to endocrinology if systemic disease like Addison's disease is suspected based on diffuse hyperpigmentation with constitutional symptoms 2, 4.

Treatment Algorithm Based on Pigmentation Depth

For Epidermal Hyperpigmentation (Most Common)

First-line therapy is triple combination cream containing hydroquinone 4%, tretinoin 0.05%, and a topical corticosteroid (fluocinolone acetonide 0.01%), which represents the most effective topical regimen 7. This addresses multiple pathways: tyrosinase inhibition, accelerated keratinocyte turnover, and anti-inflammatory effects.

Alternative First-Line Options:

• Hydroquinone 4% alone or combined with tretinoin for patients who cannot tolerate triple therapy 7
• Azelaic acid 15-20% is particularly effective in darker skin types and addresses both hyperpigmentation and post-inflammatory changes 7, 8
• Topical retinoids (adapalene, tretinoin, tazarotene) normalize keratinocyte turnover and reduce melanin deposition 7, 8

Critical Adjunctive Measure:

Prescribe broad-spectrum sunscreen SPF 50+ for daily application, reapplied every 2-3 hours during sun exposure—this is non-negotiable as UV exposure will negate all treatment efforts 2, 7. Sun protection is the foundation upon which all other therapies depend.

Important Caveat:

Limit topical corticosteroid use to maximum 8 weeks to avoid skin atrophy, then transition to maintenance with retinoid and sunscreen alone 7.

For Refractory or Moderate-to-Severe Cases

Add oral tranexamic acid 250 mg twice daily for persistent melasma or hyperpigmentation unresponsive to topical therapy after 8-12 weeks 7. This antifibrinolytic agent reduces melanocyte activity through plasmin inhibition.

Procedural Options:

• Chemical peels (glycolic acid, salicylic acid) are effective for epidermal pigmentation, particularly in combination with topical agents 5, 6
• Laser toning (low-fluence Q-switched lasers) can target epidermal melanin without significant downtime 1

For Dermal Hyperpigmentation (More Challenging)

Dermal pigmentation requires procedural interventions as topical agents penetrate poorly 1. Options include:

• High-fluence Q-switched lasers (1064 nm Nd:YAG preferred in darker skin) for drug-induced or post-inflammatory dermal pigmentation 1, 6
• Platelet-rich plasma (PRP) injections demonstrate significant improvement within 6 weeks, with microneedling delivery superior to intradermal injection 7
• Combination PRP plus oral tranexamic acid shows higher efficacy and lower recurrence compared to tranexamic acid alone 7

Monitoring and Maintenance

Use the modified Melasma Area and Severity Index (mMASI) to objectively track improvement at each follow-up visit 7. Re-evaluate treatment efficacy at 6-8 weeks and adjust accordingly 8.

Counsel patients that hyperpigmentation is a chronic condition requiring long-term maintenance therapy—typically a topical retinoid with strict sun protection—even after initial clearing 7, 5.

Common Pitfalls to Avoid

• Never use topical clascoterone for hyperpigmentation—it is an antiandrogen indicated only for acne vulgaris and has no role in melanocyte dysfunction 7, 8
• Do not perform aggressive procedures (medium-depth peels, ablative lasers) in darker skin types without extensive experience, as these carry high risk of worsening post-inflammatory hyperpigmentation 6
• Avoid prolonged hydroquinone use beyond 3-4 months continuously due to risk of ochronosis, particularly in darker skin 6
• Recognize that hormonal hyperpigmentation (melasma) often recurs despite treatment, requiring realistic patient expectations and maintenance strategies 5, 6

Quality of Life Considerations

Address the psychological impact of hyperpigmentation, including effects on self-esteem and social interactions, as these can be profound particularly in visible areas 3, 2. The severity of psychological distress does not always correlate with the extent of pigmentation, warranting empathetic counseling regardless of clinical severity.