Fundamentals of Hyperpigmentation Disorders: Causes, Concerns, and Treatment Strategies, Particularly in Skin of Color Patients
October 2026 | Volume 25 | Issue 10 | 926 | Copyright © October 2026
Published online September 29, 2026
Susan Taylor MDa, Seemal R. Desai MDb,c, Cheri Frey MDd, Nada Elbuluk MD MSce, Pearl E. Grimes MDf, Andrew Alexis MD MPHg
aDepartment of Dermatology, University of Pennsylvania, Philadelphia, PA
bDepartment of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX
cInnovative Dermatology, Plano, TX
dDepartment of Dermatology, Howard University Hospital, Washington DC
eDepartment of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA
fThe Grimes Center for Medical and Aesthetic Dermatology, Vitiligo and Pigmentation Institute of Southern California, Los Angeles, CA
gDepartment of Dermatology, Weill Cornell Medicine, New York, NY
Abstract
Background: Pigmentary disorders, including hyperpigmentation, are among the most common dermatologic diagnoses in individuals with skin of color (SOC), particularly individuals with African, Asian, or Hispanic heritage, and often carry a significant quality-of-life burden. Although the evidence base has grown, gaps persist in epidemiology, in pathophysiology-driven treatment selection, and in the appropriate representation of Fitzpatrick skin types III to VI in clinical studies.
Methods: A comprehensive review of PubMed and Medline-indexed hyperpigmentation literature published between 2000 and 2026 was reviewed, with priority given to randomized controlled trials, meta-analyses, large epidemiologic series, and consensus statements.
Results: Our current understanding of hyperpigmentation has extended well beyond melanocyte hyperactivity alone. Across the major hyperpigmentation disorders, visible light acting through opsin-3 (OPN3), inflammatory and hormonal signaling, and, in melasma, basement-membrane disruption with a senescent dermal microenvironment contribute to pigment formation and treatment resistance, findings that highlight the importance of both UV radiation and visible-light photoprotection. Clinical and meta-analytic evidence supports a multimodal therapeutic approach, consistent with recent international consensus recommendations. Quality-of-life impairment is consistent across populations, a pattern that should inform counseling, while commonly used diagnostic tools and machine-learning algorithms continue to underperform in skin of color.
Discussion: Treatment of hyperpigmentation remains a multimodal therapy with the need for routine assessment of patient-reported quality of life impact.
Conclusion: Closing the evidence gap for skin of color is the next priority in treatment of hyperpigmentation and will require inclusive trial design, validated diagnostic tools, and standardized outcome measures.
INTRODUCTION
Pigmentary disorders, including cutaneous hyperpigmentation, are among the most common dermatologic diagnoses in individuals with SOC, particularly individuals with African, Asian, or Hispanic heritage.1,2 The principal hyperpigmentation conditions include melasma, post-inflammatory hyperpigmentation (PIH), solar lentigines, drug-induced and infectious pigmentary changes, maturational dyschromia, and acquired dermal macular hyperpigmentation (ADMH). In a cross-sectional analysis of 41,283 patients, melasma was significantly more prevalent in Asian and Hispanic populations, and was strongly comorbid with rosacea and atopic dermatitis.3
For the clinician, the central difficulty is rarely diagnosis; it is the management of a chronic and relapsing condition, the disproportionate burden carried by patients with deeply pigmented skin, and the gap between the populations enrolled in clinical trials and those encountered in practice. This review summarizes the state-of-the-science on hyperpigmentation, with a particular focus on SOC patients, that should help guide treatment approaches.
