Topical Treatments for Melasma and Post-inflammatory Hyperpigmentation

November 2023 | Volume 22 | Issue 11 | 1118 | Copyright © November 2023


Published online October 30, 2023

doi:10.36849/JDD.7754

Neil Sadick MDa,b, Sukhmani Pannu MDb, Zehara Abidi MDb, Suleima Arruda MDb,c

aWeill Cornell Medical College, New York, NY
bSadick Dermatology, New York, NY
cArruda Dermatology, Sao Paolo, Brazil

Abstract
Background: Dyschromia is one of the most common reasons for patients to seek dermatological care, especially among individuals with skin of color. Most cases present as melasma or post-inflammatory hyperpigmentation (PIH); both are chronic issues requiring long-term treatment. While many pharmaceutical (topical or systemic) or procedural (lasers/chemical peels) options are available, some treatments are not safe/tolerable for long-term use or can induce/exacerbate PIH. 
Methods: This qualitative review provides an overview of topical treatments for melasma and PIH, including recent data from an investigator-initiated trial of the retinoid tazarotene. 
Results: Topical hydroquinone (HQ) in the form of triple combination HQ 4%/tretinoin 0.05%/fluocinolone acetonide 0.01% cream is the gold-standard treatment for melasma and PIH but should not be used long-term due to safety concerns. Efficacy data for OTC/cosmeceutical products are limited or lacking. Topical retinoids are efficacious and safe, though dose and formulation differences may affect tolerability. Tazarotene 0.045% polymeric emulsion lotion demonstrated good efficacy, safety, and tolerability over 24 weeks in adult female patients with moderate-to-severe melasma and/or PIH.
Conclusions: There are multiple topical treatments available for dyspigmentation. However, many are lacking efficacy data and others are limited by tolerability or safety concerns. Retinoids, such as tazarotene, may be an efficacious and safe treatment for melasma or PIH.

J Drugs Dermatol. 2023;22(11):1118-1123     doi:10.36849/JDD.7754

INTRODUCTION

Dyschromia is one of the most common reasons for patients to seek dermatological care, especially among individuals with skin of color.1,2 The majority of cases present as melasma or post-inflammatory hyperpigmentation (PIH),3,4 acquired hyperpigmentation disorders that most frequently affect patients with darker skin types (Fitzpatrick III-VI).4-7 Melasma is seen more often in reproductive-aged female or adult patients,5,6 whereas PIH can affect male or female patients of any age.4,7 Melasma and PIH can negatively impact quality of life.8,9

MATERIALS AND METHODS

Presentation and Diagnosis
Melasma and PIH present as pigmented macules and patches most often located on the face.1,7 In melasma, these symmetric, brown-to-gray pigmented areas occur mainly on sun-exposed skin.7 With PIH, pigmented areas are irregular/non-symmetric and may not be limited to sun-exposed skin; lesions range from light brown to dark gray/black in color and tend to occur at the site of cutaneous injury or inflammation.4  The color of melasma and PIH lesions varies depending on the cutaneous depth of the pigmentation alterations.4,7

Melasma and PIH are diagnosed clinically, though Wood’s lamp evaluation, dermoscopy, or biopsy can confirm the diagnosis or determine the depth of pigment deposition (ie, epidermal, dermal, mixed, or indeterminate [melasma]; dermal versus epidermal [PIH]).4,7 Pigmentation depth can affect treatment choices, as dermal melasma and PIH are more difficult to treat than epidermal.7

Pathogenesis
The skin pigment melanin is produced in melanocytes and stored in melanosomes, which are found in both melanocytes and keratinocytes.10 The enzyme tyrosinase is required for melanin synthesis.10 In dyschromia, there is dysregulation of intrinsic factors that regulate pigmentation, including signals from keratinocytes, endothelial cells, and fibroblasts as well as hormones from inflammatory cells and the nervous system.10 Exposure to ultraviolet (UV) radiation is a well-known extrinsic factor that increases skin pigmentation through upregulation of these intrinsic factors.10
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