In short: After skin inflammation, for example from acne, the skin can form dark spots. Specialists call this post-inflammatory hyperpigmentation. First the cause of the inflammation is treated, together with daily sun protection. Lightening creams are used over months. The spots also partly fade without treatment. For many treatments the evidence is limited.

Overview

After skin irritation or inflammation, the skin can react with dark spots. Possible triggers are acne or treatments such as peels and lasers.¹ This reaction is called post-inflammatory hyperpigmentation, PIH for short.

The most important first step is to treat the cause of the inflammation, for example the acne.¹ If the inflammation is not controlled, new spots can keep appearing.

The spots can also become lighter without treatment. In a review of studies in darker skin types, the pigmentation partly improved without treatment in about 62 out of 100 people.² The authors write that the effect of the treatments studied is not clearly proven overall.²

Treatment options

Sun protection

Every day, a water-based sunscreen with broad-spectrum protection (UVA and UVB) and sun protection factor 30 or higher.¹ For skin types III to VI, a tinted product with iron oxide can be particularly helpful because it also blocks visible light.¹ Sun protection is also important before and after laser treatments.¹

Lightening creams

Hydroquinone 4% is considered the standard treatment and is applied once or twice daily for three months.¹ A combination cream of hydroquinone, tretinoin and a mild cortisone preparation worked better than hydroquinone alone.¹ Another option is azelaic acid 15% as a gel, in one study twice daily for 16 weeks.¹

Vitamin A creams (retinoids)

Tretinoin, adapalene and tazarotene can be effective, especially when the spots have developed after acne.¹ At first the skin may peel, burn or feel dry.² In the review, the spots partly improved with retinoids in about 64 out of 100 people treated, and completely in none. Follow-up lasted 4 months on average.²

Chemical peels

Peels can themselves trigger post-inflammatory hyperpigmentation.¹ In people with darker skin types this risk is higher.² As a treatment for the spots, peels performed less well than other treatments in the summary of the review.² They are therefore not among the first treatments.

Laser

Lasers are a second choice when creams are not enough.³ In dark skin there is a high risk of new pigment disorders and scars, so lasers are used with caution. A small area is tested before treatment.¹ In the review, the spots partly improved with laser in about 66 out of 100 people treated and completely in about 26 out of 100. With repeated treatments, new pigmentation is reported in 11 to 17 out of 100 cases.²

What is important to know?

Patience is needed. Hydroquinone is usually used for about three months, azelaic acid in one study for 16 weeks.¹
The evidence is limited: small studies, inconsistent evaluation and no uniform measure for PIH.²
You should only discuss and use hydroquinone, peels and lasers with your dermatologist.

Together with you, we plan a multi-layered treatment concept to prevent hyperpigmentation.

Sources

Frazier et al., Dermatologic Conditions in Skin of Color, American Family Physician, 2023.
Mar et al., Systematic review of the treatment of post-inflammatory hyperpigmentation in more pigmented skin types, Journal of Cutaneous Medicine and Surgery, 2024.
Sowash and Alster, Laser treatment of post-inflammatory hyperpigmentation, American Journal of Clinical Dermatology, 2023.

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This is literature-based patient education. It does not replace a medical consultation and is not to be understood as a treatment recommendation.