Why Does It Take So Long to Treat Hyperpigmentation?

Skin Care

One of the most bothersome and disfiguring characteristics of cutaneous inflammatory conditions such as acne and rosacea is not the condition itself, but the residual discoloration or hyperpigmentation that is left behind. Even with efficacious treatments, this hyperpigmentation can linger for months.

But why is that? How can pimples disappear after one week, while the resulting postinflammatory hyperpigmentation remains present after ten weeks?

The answer lies in the functional mechanisms of the various skin lighteners that are used in topical therapy, and how they work to combat melanogenesis.

How Is Melanin Produced?

Melanin synthesis can be triggered by a variety of oxidative and inflammatory compounds. The most notable instigator is of course UV radiation, which is a source of oxidative free radical damage. This free radical damage triggers DNA repair, which is in turn what stimulates melanogenesis. However, free radical damage can lead to the increase of inflammatory mediators such as the interleukins and prostaglandins, which have been shown to also trigger melanogenesis. In inflammatory conditions, these mediators are prevalent throughout the skin.

As we learned in What Is the Biology of Skin Color, after contact with the aforementioned various triggers has been made, cells called melanocytes will begin to produce melanin. After the melanin is made, vesicles called melanosomes distribute the melanin throughout the epidermis. Once they reach the target area, the melanin is deposited—this is what you see on the skin.

So What’s with the Delay?   

Sometimes, I think pimples are better.

Unfortunately, almost every well-documented and effective at-home topical treatment inhibits the steps of melanogenesis, rather than the melanin that’s already been produced. Remember, THAT’S the source of the hyperpigmentation!

Whether you’re using hydroquinone, retinoids, niacinamide, L-ascorbic acid, etc., those compounds mostly inhibit future and ongoing hyperpigmentation, rather than what’s currently present.

The only notable topical ingredient that can diminish existing hyperpigmentation is glycolic acid, and to an extent, salicylic acid. These hydroxy acids (primarily the former) induce chemoexfoliation of the entire surface of the skin. By increasing “cellular turnover” by stimulating the skin to shed the outer layer of cells, glycolic acid quickens the eventual shedding of the excess melanin that’s sitting at the bottom of the epidermis. However, there is one caveat to this ingredient: in order to induce this type of controlled damage; at-home glycolic acid products (5 – 20%) do not possess the necessary strength to significantly improve hyperpigmentation.

What does that Mean?

It can feel like it is taking an eternity to treat hyperpigmentation. However, this doesn’t mean that whitening and brightening ingredients aren’t effective; rather, they are in fact quite effective Hundreds, if not thousands, of studies have proven that they can provide statistically-significant reductions in hyperpigmentation compared with baseline values. Just don’t expect drastic results when dealing with moderate to serious hyperpigmentation.

The most important thing that you can do is to be patient and allow your skin to naturally fade any hyperpigmentation, while consistently using sunscreen and the various topical remedies available—in this case, the more the merrier.

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  • Rubes

    I underwent a chemical peel on my arms about 6 months ago directly after laser hair removal. I am of Asian decent and discovered after the fact that my skin should have been prepared before the peel. It had not been. This resulted in severe post inflammatory hyperpigmentation. I have been using HQ and retin A with minimal results. What more should I be doing? I’ve read that in most cases the pigmentation should clear in between 6 to 12 months. Should I be worried that it has barely lightened in 6 months?

  • Marcia

    I’ve heard about Whitening Caviar, from LA PRAIRE. Odes it work? And EVEN BETTER DARK SPOT from clinique? I have melasma in my face and I have used some creams that make my face with “red vains”?? Something like red fine lines (my english is not good, sorry)

  • @Kelly

    The reason why the vitamin C product is labeled as such isn’t because of the vitamin C content. It’s actually the caffeic acid content that has some minor implications. It’s not a potent teratogenic agent like retinoids; in fact, caffeic acid will most likely have no influence on fetuses when applied topically due to the fact that it’s not used in very high concentrations in skin care, and will most likely not enter the bloodstream.

    The single study that suggest some teratogenic influence occurred only when caffeic acid was consumed in a beverage and underwent nitrosation: http://www.ncbi.nlm.nih.gov/pubmed/10910474 Ironically, caffeic acid was also shown to inhibit phenytoin-induced teratogenesis: http://www.ncbi.nlm.nih.gov/pubmed/2493687. Another study also supports the latter study: http://www.ncbi.nlm.nih.gov/pubmed/9434860.

    So yeah, I wouldn’t worry too much about this. The label just states that warning to cover their own rear ends.

    Still, when dealing with this issue, it’s best to minimize risks if possible. Why take this small risk anyways? There are other vitamin C products out there.

    So don’t stress out about this because that definitely not good for anyone! 🙂

  • Kelly

    Hello again. Thanks for the previous reply and I have another question. You state that vitamin c is ok to use for expectant mothers. Is it ok to use futurederm vitamin ce caffeic serum? The product description says it shouldn’t be used if pregnant or nursing. Thanks again.

  • @Kyle

    Thanks for the compliment!

    As for the V-Beam laser treatment, I’d recommend going in for a consultation to just ask questions because while it can be super effective for a variety of symptoms, it may not be the best for postinflammatory hyperpigmentation (PIH).

    Because your marks are forms of PIH, further inflammation, as induced by peels or lasers, could worsen the process. This is why topical options are the primary source of treatment for those with PIH. Unfortunately however, these topical agents aren’t that produce significant results, at least not in a short period of time. The most important thing is to avoid the sun and to use super high SPF and UVA-PF sunscreens if you must go into the sun. And have patience because these things take time to fade. 🙂

  • Kyle

    Great post !
    I have red marks from cystic acne for a while now, im using 8% aha daily,i can see a small improvment.
    I’ve been thinking of doing V-Beam laser tratment.what do you think John?

  • @Kelly

    Sure, there are plenty of safe skin-lightening ingredients that can be used during pregnancy and breast feeding. Stick with any of the following: niacinamide, hydroxy acids, N-acetyl glucosamine, vitamin C, azelaic acid, licorice, soy, etc… The only ones you really have to avoid are retinoids and hydroquinone. 🙂

    Does that make sense? Congrats on the baby by the way!

  • Kelly

    Hello, I was wondering if there’s any safe cream for hypermigmentation during pregnancy and safe to use when breast feeding?

  • @Simona (Sânziene si Mătrăgună)

    Well, since you plan to use it every 2 days, consider alternating it with the 8% AHA gel every day.

  • @janine

    Wow, fail. I completely missed this comment.

    But anyways, the Obagi NuDerm system’s main strengths come from the several products that include 4% hydroquinone, an AHA product, a 0.5% hydrocortisone cream, and several good sunscreens.

    However, none of those thing are exclusive (except for the 4% HQ since that is Rx only), and many other brands too far better and/or less expensive versions.

  • HI John,

    As usual, a great post! Thank you!

    I am also fighting now some (barely visible) hyperpigmentation on my cheek, and , besides my homemade lotions and toner with niacinamide, I am also using Paula’s Choice 8% AHA gel and her RESIST pure radiance skin brightening treatment. I have also bought the 2% hidroquinone + 2% BHA from Paula, but I have no idea how to best introduce it into my daily routine. I am thinking to use them every 2 days, during this winter and Spring. Hopefully there will be some changes 🙂

  • ok, so i keep waiting for someone to bring up the Obaji NuDerm system………There is such buzz about how effective it is, particularly for hyperpigmentation. I am dying to know what you think of it, John.

  • @Peach

    Well, it’s best to not use retinol with any hydroxy acid together. Here’s why: http://thetriplehelixian.com/2012/09/10/part-ii-retinol-metabolism-contd-retinol-degradation-and-strength-combination-use-of-hydroxy-acids-and-retinol-v-0-03/ When I mean together, I mean at the same time.

    They can certainly be used in the same routine however! Or you could wait 30 minutes between applications. And it really depends whether or not you can use those three ingredients in the same routine. They can be too irritating, or they may not be.

    Does that make sense?

  • @Erika

    You’ll want to use both ingredients together, as I noted to both Kristina K and Casey!

  • @Casey

    I have not seen any comparative studies done on the efficacy of lactic acid versus mandelic acid. 🙁

    And there’s no way to know how many peels will be enough for you. It varies in terms of the severity of hyperpigmentation, the strength of the peel, and other factors. You’ll have to ask your performing dermatologist.

    Finally, as I said to Kristina K, it’s best to use these two types of ingredients together. You should use lactic acid AND hydroquinone.

  • @Kristina K

    Well it depends. All I’m saying that deeper chemical peels are effective at removing EXISTING hyperpigmentation. However, since the skin is constantly producing melanin, inhibiting the process will make the hyperpigmentation fade as well, albeit via a different mechanism and at varying “speeds.”

    Here’s a metaphor for this explanation:

    You’re in a boat that has a small hole in the floor. Naturally, water is rushing in. Using hydroquinone or anything that inhibits melanogenesis, would be like putting your hand over the hole. You’re stopping the process of more water coming in (or melanogenesis), but you’re doing nothing about the water that’s already in the boat. Using a chemical peel would be like scooping the water out of the boat with a bucket. You’re removing the water in the boat, but not preventing more from coming in.

    Does that make sense? So the best way is to combine both types of ingredients: tyrosinase inhibitors and hydroxy acids. Cover the hole AND scoop water out.

    Even better would be to add something that inhibits mlenosome distribution, such as niacinamide. It’s best to tackle hyperpigmentation (and any skin condition) with combination rather than mono-therapy.

  • Peach

    is it a bad idea to use lactic acid peels when using retinol and 2% salicylic acid at the same time? or should we just discontinue the retinol and SA for a couple of days before the lactic acid peel?

  • Erika

    ^Thought I’d chime in….I have experience with chemical peels (MUAC is the best!) and they’re great! I’d also like to know if John recommends lactic acid peels, etc. over hydroquinone. I know that it’s really easy to accidentally burn yourself, etc, cause more damage than intended with chemical peels so be careful!!

  • Casey

    @ KristinaK…do you use muac chemical peels? i’ve been thinking of buying the 55% lactic acid peel from them to help my hypigmentation. i don’t know whether or get the lactic acid or the mandelic acid.

    john, do you know if lactic acid is more effective than mandelic acid when it comes to hypigmentation? and how many peels does it take till i get fading results? i’ve been using hydroquinone but i’m thinking of switching to lactic acid peels if those are more effective.

  • Kristina K

    Hmmmm… interesting. Does that mean chemical peels (at-home ones…like from MUAC) are more effective than hydroquinone?

  • @Sarah

    Glad to hear that you’re thinking about seeing a dermatologist. 😉

  • Sarah

    Yes, it all totally makes sense. Thanks for doing the research for me, John. Based on what you said, I think it is best for me to visit a dermatologist and seek professional help. I am just too lazy sometimes..haha…and I HATE the wait at doctor’s office.

    Thanks for sharing your experience with the RESIS Pure Radiance serum. I think I’ll order the antioxidant serum first since it is on sale and then try the pure radiance one later. I use the CeraVe PM, so I get my dose of niacinamide from there. I’m glad to hear that the antioxidant serum won’t ball up when topped with sunscreen and foundation. I hate when that happens.

    Thanks again!

  • @Sarah

    You are too kind! So I did a bit more research and apparently your blue/gray spots are actual dermal, rather than epidermal, clumps of melanin. And since hydroquinone doesn’t adequately penetrate past the dermal-epidermal junction, it wouldn’t do much. 🙁

    And as with most topicals, they aren’t very effective for that deep of a cluster.

    As for the Tranexamic Acid, there is very, VERY little research demonstrating its potential to be beneficial for the skin. One study suggests that when applied right after UV exposure, it can inhibit the sebsequent tanning by interfering with prostaglandin synthesis. However, even if that were true, it still won’t do anything for already present pigmentation, especially ones so deep in the skin.

    Again, I’d recommend speaking with a dermatologist. I’m guessing that manual minimally-invasive surgery, laser surgery, ultrasound, and/or deep chemical peels would be suitable options.

    As for the RESIST Pure Radiance, I do love it for the ingredients it contains. However, I don’t really have any hypigmentation on my face, so I wouldn’t be a good candidate in terms of demonstrating its sking-lightening efficacy. I just use it because of the inclusion of high concentrations of niacinamide (and other documented beneficial ingredients).

    Finally, while I no longer use it, the RESIST Serum is still a very good product. If I layer products at nighttime, that serum would go on last. During the day, I would use it before sunscreen and makeup. And no, I have never experienced it balling up under foundation. It’s not a “dry” silicone texture; it’s a bit more “wet,” which prevents noticeable clumping.

    Does that all make sense?

  • Sarah

    Hi John. From your reply, you begun with “Thank you again for reading”….err…you remember me from my previous comments? That can’t be! Does that mean you actually remember your readers’ names and their posts? No way!! You are incredible!

    I’ve used hydroquinone a long time ago, but I don’t remember having stellar results and that’s why I never continued using it.

    I love my L-asorbic acid, but I find it brighten my overall complextion more than lighten any scars. I will, of course, continue to use it, but I really am itching to try something with Tranexamic Acid, especially one with 3% concentration. I know a few Taiwanese skincare brands that has this ingredient and at this optimal concentraion, but I have yet to find one in North America. Do you know any?

    What are some of your personal favourite skin lightening ingredients?

    I can be wrong, but I think you mentioned recently that you started using Paula’s new product, the “RESIST Pure Radiance Skin Brightening Treatment”. How is that working out? You must give us a review!

    Lastly, this is slightly off topic, but Paula’s Resist antioxidant serum is now at 20% off. I know that you said the downside of this is that it can get quite greasy feeling. But if I can tolerate that, do you still think it is one of the better antioxidant serums out there? And does the silicone slip agents make layering products on top difficult? Or balls up when applying foundation on top?

    Again…many MANY thanks for your help and patience!! I always look forward to your replies.

  • @coraline

    Sure, sure. You’re welcome. I’m still researching the hydroquinone issue. 🙂

  • coraline

    Thanks for answering my question, John. And I’d certainly enjoy reading a post about hydroquinone, if you decide to write one!

  • @janine

    You know, it’s good that you brought this up. I’ve been asked this question many times and I’ve always said that it’s better to take breaks when using hydroquinone. However, that was only Dr. Leslie Baumann recommended doing so. Interestingly, I’ve actually never seen any study why this must be so. I mean, I can rationalize why this concept makes sense, but I haven’t seen documentation proving it. I’ve just been taking her word for it. So, I’m going to do some research and perhaps write an entire post dedicated to this.

    Thanks for asking this question!

  • @Sarah

    Thank you again for reading! Yes I currently and have in the past, used lightening products in the past. However, because I’m quite pale, I’m not really prone to postinflammatory hyperpigmenation. I therefore don’t have many dark spots. However, I have used a product with 2% hydroquinone in the past and I didn’t notice much effect. However, that could only mean that the specific formulation was defected, since hydroquinone is very sensitive to degradation.

    Also, you may want to check with a dermatologist to see if your spots really are just post-acne scars. I’ve never seen blue/ed spots, but then again I’m no doctor. 🙁

    Finally, L-ascorbic acid can be useful, but combining it with other documented skin-lightening ingredients in your routine can certainly be helpful. And of course, you need to be very diligent with the use an excellent (not good) UVA and UVB sunscreen!

  • @coraline

    Other AHAs have shown efficacy, but less research than glycolic acid. However, using them are still better than nothing. As for salicylic acid, it doesn’t reduce hypepigmentation much. However, because it is anti-inflammatory it can reduce the chances of irritation-induced (postinflammatory) hyperpigmentation.

  • Is it true that one should only use hydroquinone for a few months at a time and then take a few months off before returning to it for another few months? If so, why and what is the longest/shortest period of time one should do either for maximum efficacy?

  • Sarah

    Hi John, thanks for another great post. Do you use any lightening products yourself, now or in the past? What are your experience with them? My many acne scars have always bother me, but unfortunately, I have yet to find a topical treatment that works. It has been a year since I’ve incorporated L-ascorbic into my routine, and while I do see results on my light sunspots (freckles?), I don’t see much result on my acne scars. Is it because my scars are more of a blue-ish/dark red brown rather than light brown? Thanks in advanc!

  • coraline

    My skin is highly intolerant of glycolic acid. Even Paula’s Choice 5% was too irritating and seemed to cause broken capillaries. What do you think of other AHAs, such as lactic or mandelic? (Currently I’m using PC’s 1% BHA lotion, as the 2% was also too irritating. It hasn’t helped fade any brown spots yet, though my skin is more smooth.)

  • @Tres

    No they can certainly help because sometimes hyperpigmentation is ongoing, meaning that melanocytes are constantly producing melanin in response to some previous damage. As I noted in the article, these ingredients can certainly help diminish hyperpigentation, but they don’t have much effect on the melanin that’s already been delivered by the melanosomes to the lower epidermis.

    As I’ve also noted in the post, the more ingredients, the better, since these ingredients work via different mechanisms to lighten the skin. So you’re absolutely right; that idea IS a takeaway message. 🙂

    Finally, IPL works better for things like melasma and sunspots. But for things like postinflammatory hyperpigmenation, which comes from inflammatory conditions like acne, topicals are still the weapon of choice.

    In this post, I tried to focus on topicals because that’s what most people have access to. Furthermore, my goal was to help answer the question of the titl; something that many people are frustrated with.

    Does that make sense?

  • Tres

    The only notable topical ingredient that can diminish existing hyperpigmentation is glycolic acid. So that means that TXC, resorcinol. kojic acid, hydroquinone, lumixyl, vivite, niacinimide, etc., don’t help reduce existing hyperpigmentation (i.e. diminish it) AT ALL?? Those those topicals do diminish it but that glycolic acid helps to more permanently remove it because it exfoliates rather than just fades/prevents, right? So the takeaway is that combination therapy with glycolic acid for exfoliation and turnover PLUS another topical treatment that inhibits or interferes with tyrosinase and/or reduces prostaglandins and arachidonic acid is what works best to diminish hyperpigmentation. Right?

    Topicals are great but in my experience IPL dramatically helps reduce brown spots so I do both. I’m a big fan of lactic acid, glycolic acid, or retin-a, plus the usual hyperpigmentation topicals. What’s your take on IPL?

  • @maria

    I’ve never actually heard this concept before, so I did some digging and came up with some interesting information. I’ll do a full post on this in the coming weeks either on here or my blog, so stay tuned!

    But from the research I’ve seen, it does NOT cause undereye circle and collagen degradation when used topically.

  • maria

    hi John — have you heard anything about Rogaine and its effect on skin?? I’ve read that it causes undereye circles and degrades collagen. Thanks.

  • @erika

    I LOVE the 5% AHA. It definitely isn’t the most potent treatment out there, but it’s so nice to apply. 🙂

    Good luck with any hyperpigmentation and you’re welcome!

  • @fairytalesandcoffee

    Great job for saying that you’ll be more consistent! Initiative is good.

  • @Peach

    Isn’t it annoying?! Well recommendations would be a huge other post lol! Is there a specific ingredient that you’re looking for? That’ll help narrow our search.

  • erika

    whew! just bought paula’s choice 5% glycolic to use in the morning every other day. i’ve been using hydroquinone at night for a couple of months and i’m in a last few months of using it before i stop so i’m adding the glycolic for that extra push! thanks for thie post….it was so helpful!!

  • fairytalesandcoffee

    This was so helpful. Even though I am familiar with most of this, there were a few things I didn’t know. it is really helpful to be reminded! Gotta up my glycolic acid use! I’ve gotten a tad lazy.

  • Peach

    So happy to see this article!! Thanks John!! And honestly…that face totally describes how I am when my hyperpigmentation won’t go away!! lol. Darn acne!! Great article, though I would have liked to see a section for recommendations. Ya got any? 🙂

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