For decades, hydroquinone-based products were the only effective treatment options for pigmentation issues, such as melasma, and while these are still often considered the gold standard, many new therapies are emerging to help treat and prevent melasma and postinflammatory hyperpigmentation in skin of color. Here, experts from around the world share their favorite products and strategies for addressing these skin conditions.
Focus on SPF and Hyperpigmentation
As a Black dermatologist, I can tell you that pigmentation issues plague patients of all skin types. My patients with darker skin types (Black, Indigenous, People of Color – BIPOC) are often distressed by the discoloration that inflammation can leave behind after the flare has resolved. Conditions like acne, eczema, and seborrheic dermatitis are common, but often the reason patients seek treatment isn’t because of the inciting inflammatory skin problem. Instead, they seek care for the “stain it leaves behind,” as I call it. My lighter-skinned patients are more prone to pigmentation from sun damage and melasma, since they lack the inherent melanin that protects from sunburn and photodamage.
Aside from treating the underlying condition, which is always important, the next step is reducing the dark spots and providing a more even complexion. Sunscreen is paramount to treatment of any discoloration as the sun is a major influence on hyperpigmentation and melasma. The SPF should be in the range of 30-50. I tell my patients that anything more than 50 is a waste of money, and anything less than 30 is a waste of time. More important than the number on the bottle is whether or not the sunscreen is chemical or physical. Chemical sunscreens have been historically more elegant, but they are full of potential problems. A quarter of the population is allergic to one of the 10 or so common chemicals in sunscreens, and it seems as though every year we discover more about the ways that the chemicals impact our bodies beyond our skin. Physical sunscreens are mineral-based and non-allergenic. They were historically thick and opaque leaving a white cast or an iridescence on skin, particularly skin of color. Today’s formulations, however, have come a long way and are quite elegant, leaving no trace once properly applied. For these reasons, I exclusively recommend physical sunscreens to my patients
My favorites are:
Isdin Eryfotona Actinica. This fast-absorbing, ultralight emulsion contains zinc oxide. It spreads well, has a mild, pleasant smell and does not leave the skin feeling oily. It is a favorite of all skin types, especially those with oily skin and men. As a bonus, it contains an enzyme clinically proven to repair DNA existing damage.
SkinBetter SunBetter Sheer Sunblock Stick. This novel vehicle provides a transparent layer of broad-spectrum protection regardless of skin type. It protects against UVA, UVB and infrared light with 100 percent mineral actives and is water-resistant for up to 80 minutes.
La Roche-Posay Anthelios Mineral Sunscreen. This 100 percent mineral sunscreen with zinc oxide and titanium dioxide is ideal for sensitive skin. Packed with antioxidants, it is an efficient way to protect from the sun and prevent free radical formation.
When it comes to treating dark spots, a good daily retinol is always an important step to properly exfoliate and maintain the even complexion, but when first getting started, a lightening agent is a must.
My favorites are:
Cyspera. This latest entry to the pigmentation market is a unique cream that contains cysteamine. The only product of its kind on the market, Cyspera boasts head-to-head trials showing superiority when compared to prescription Tri-Luma. The latter contains hydroquinone, which has some potential safety concerns, and a steroid which cannot be used for long periods of time. Cyspera not only lightens dark spots but provides a more even overall complexion than hydroquinone products can. There is no risk of halo hypopigmentation with Cyspera and it is well tolerated even by those with sensitive skin. It has been a game changer for my patients and has become my go to treatment for melasma and post-inflammatory hyperpigmentation.
SkinCeuticals Discoloration Defense. Boasting the highest concentration of tranexamic acid, Skinceuticals Discoloration Defense offers a novel skin lightening agent that works well for melasma and hyperpigmentation with little to no irritation. Discovered by OB/GYNs when prescribed to women with heavy menstrual cycles, the oral version has a risk of blood clots. The topical form provides similar benefit without the risk.
AlumierMD Intellibright Complex. The unique mix of natural lightening agents like arbutin, kojic acid, licorice root extract, and others provides a great product that is free of chemicals. The vehicle is a soothing serum that provides hydration.
The Ordinary Azelaic Acid Suspension 10%. This product is unique due to the inclusion of azelaic acid, a pigment reducer that naturally occurs in skin and blocks the production of excess melanin in the skin. Known for its mild application, azelaic acid is also a key ingredient to keep rosacea and acne in check, so it accomplishes multiple skin goals.
Corey L. Hartman, MD, FAAD
Skin Wellness Dermatology
When treating Melasma and PIH, I am an ardent champion of combination therapies that are customized for each individual, factoring in the correct diagnosis, skin type, severity of the condition, history, goals, and other considerations. Taking a multi-modality approach is especially important in treating pigmentary disorders in more melanized skin to ensure patient safety and optimal outcomes. My combination therapies feature a carefully curated mix of products for photoprotection, topical lightening agents, paired with resurfacing treatments if needed. Adequate photoprotection is key and 100 percent essential. I am a big proponent of using physical sunscreens. Recent studies now document the role of visible light for induction of persistent hyperpigmentation in skin types IV through VI. Hence, it is important to incorporate visible light protection when possible. Iron oxide has been shown to be very beneficial in blocking visible light, it can be used alone or in combination with Zinc and Titanium.
Dumbuya, Grimes et al documented the impact of iron oxide containing formulations against visible light-induced skin pigmentation in skin of color individuals in a study in Journal of Drugs in Dermatology.
While hydroquinone is the gold standard or “mothership” for treating pigmentation disorders such as melasma or post-inflammatory hyperpigmentation, there is an emerging paradigm spectrum of non-hydroquinone ingredients to incorporate into treatment regimens including cysteamine, tranexamic acid, and resveratrol to name a few. Standard non-hydroquinone ingredients that are frequently used include azelaic acid, kojic acid, niacinamide, arbutine, licorice, retinoids, and alpha hydroxyl acids.
Regarding resurfacing procedures, I personally prefer peels, particularly in darker racial ethnic groups. They have a broader safety profile. I use lasers for cases that are more recalcitrant.
In summary, disorders of pigmentation such as melasma and post-inflammatory hyperpigmentation can be challenging, however new and effective treatments are emerging.
Pearl E. Grimes, MD
Director, The Grimes Center Of Medical And Aesthetic Dermatology
Director, The Vitiligo & Pigmentation Institute of Southern California in Los Angeles
Pair OTCs with Rx
For hyperpigmentation, I recommend 5% cysteamine cream (Cyspera), a novel formulation that is a great alternative to hydroquinone (HQ). It should be used in a short-contact fashion, washing it off after 15 minutes.
I also recommend multimodal topical containing tranexamic acid, phenylethyl resorcinol, plankton extracts, tetrapeptide-30, niacinamide, marine exo-polysaccharides (Lytera 2.0). A blinded split-faced study at Skin of Color Center comparing this formulation to hydroquinone 4% in the treatment of melasma showed significant improvement from baseline and statistically comparable results to hydroquinone.
Azelaic acid 15% foam (Finacea) is an alternative to HQ.
Hydroquinone 4%/fluocinolone 0.1%/tretinoin 0.05% (Tri-Luma) is the gold standard with grade A evidence. It is a first-line treatment for melasma but also useful for PIH and other hyperpigmentation disorders.
Andrew F. Alexis, MD, MPH
Professor and Chair, Department of Dermatology
Mount Sinai West and Mount Sinai Morningside
Director, The Skin of Color Center at Mount Sinai in New York City
Think Vitamin C
Topical treatment using cosmetic products is recommended as a prevention for mild hyperpigmentation conditions. Ingredients of choice include Vitamin C and Arbutin (a glucoside of hydroquinone). Vitamin C in its natural form (Ascorbic Acid) is unstable so modern skincare uses stabilized forms of the molecule, which have proven stable, safe and effective like Ascorbyl Palmitates and Ethyl Ascorbic Acid.
Dr. Age Microlift Cream and Serum contains Vitamin C Tetraisopalmitate with an excellent safety profile, that acts against photoageing, hyperpigmentation, tissue inflammation and promotes tissue healing. The depigmentation effect—inhibition of Tyrosinase Activity & Inhibition of Melanogenesis—can work very well on all skin types that present post-inflammatory hyperpigmentation. This specific form of Vitamin C has a superior percutaneous penetration because of its lipid-solubility. After skin penetration, it is converted to Vitamin C and liberates all its properties.
Nikolaos Metaxotos MD, PhD
Plastic Surgeon, Athens, Greece
Explore New Ingredients
The mainstay of melasma and PIH treatment remains prevention of exposure to sunlight and depigmenting topical agents. Photoprotection must include protection against blue light as its role in pigmentation disorders is now well recognized. Broad-spectrum sunscreen should be applied regularly to sun-exposed areas of melasma or PIH.
Various topical agents have been proposed to interfere at different steps in melanogenesis. The main mechanisms of action of these agents include inhibition of melanin production and melanosome transfer, increased keratinocyte turnover, and anti-inflammatory and antioxidant effects.
Useful cosmeceuticals include a combination of vitamin C, phytic acid, green tea leaf extract and grape seed extract that helps improve dark spots (Melaclear, Isdin*). Use of Melaclear twice a day together with sunscreen (Eryfotona Actinica, Isdin) for 12 weeks has been shown to prevent signs of aging and improve skin quality on the face. Other non-hydroquinone depigmenting agents are 4-butylresorcinol, hydroxyphenoxy propionic acid and niacinamide. These actives are well tolerated and reduce the appearance of dark spots.
Glycolic acid, an alpha-hydroxy acid (AHA) with exfoliating properties, helps to smooth the skin, diminishing the appearance of imperfections. It is a highly effective treatment treatment for pigmentation disorders in darker skin types. In studies on skin explants, glycol concentrations of 8% to 25% (Glicoisdin, Isdin) have been shown to induce a desquamative effect and increase dermal collagen levels in a dose-dependent manner.
Mane Course: Tips for Hair Care
When it come to hair products for his patients, Dr. Hartman recommends:
LivSo Moisturizing Pack. This trio of products promotes healthy manageable hair by first providing comfort and balance to the scalp through exfoliation, repair and moisturization. Consisting of a shampoo, conditioner and moisturizing lotion, LivSo provides hydration and promotes strength of the hair shaft and reducing irritation of the scalp found commonly in seborrheic dermatitis. It is ideal for all hair textures including curly and textured hair and provides moisture without weighing the hair down.
Old Spice Thickening System Treatment. Inevitably if a person lives long enough, hair thinning will occur. But that doesn’t mean that it cannot be treated. Infused with biotin, the shampoo lifts hair to ultimate fullness while gently cleansing. The conditioner contains vitamin C, a potent antioxidant designed to keep hair strong and provide defense against ultraviolet light. The leave-on treatment contains castor oil, which increases hair’s thickness and volume. It’s a great, easy way to effortlessly promote a thicker head of hair.
Viviscal Pro Vitamins and Thin-to-Thick Elixir. This system of oral vitamins and topical serum are a crowd favorite in my practice. The vitamins strengthen the hair to promote growth and reduce breakage in an easy tolerated pill that doesn’t cause nausea. Its blend of vitamin C, flax seed extract, and zinc help hair to grow for longer periods.
In-office procedures such as chemical peels have also been proposed in the management of PIH and melasma; however, patients must be carefully selected because of the risk of skin irritation.
More recently, systemic approaches for the treatment of PIH and melasma have been proposed. There is a growing interest in oral antioxidant supplements like extract of Polypodium leucotomos, green tea extract and vitamin C. These ingredients improve photoprotection by decreasing oxidative stress and limiting its effects.
In difficult-to-treat melasma, we published a case series of patients treated with chemical peels and a home treatment schedule. Each morning they applied a depigmenting serum containing 4-butyl resorcinol, hydroxy-phenoxy propionic acid and niacinamide (Pigment Expert, ISDIN ampoules); a specific SPF 50+ sunscreen; and took an oral supplement containing 480 mg of Polypodium leucotomos, green tea extract, Vitis vinifera, vitamins C, E, and D, and carotenoids (Sunisdin, Isdin). At night, they applied a triple combination compounded medication with 4% hydroquinone, 0.025% tretinoin and 1% hydrocortisone in a gel-cream for a duration of 16 weeks. With this treatment protocol, we observed very good results with no relapse at the 12-week follow-up, with continued daily home therapy.
Jaime Piquero-Casals, MD, PhD
Dermatologist in private practice, Dermik Clinic, Barcelona, Spain
*Dr. Piquero-Casals is a Medical Advisor for ISDIN SA.