Melasma and Post Inflammatory Hyperpigmentation: Management Update and Expert Opinion

Dyschromia is a leading cause for cosmetic consultation, especially in those with diverse skin types (mixture of ethnicities) and with the rise of non-core and untrained physicians performing cosmetic procedures. Melasma and post-inflammatory hyperpigmentation (PIH) account for the majority of cases and are characterized by pigmented macules and patches distributed symmetrically in sun-exposed areas of the forehead, cheeks, and chin in melasma, and irregularly in areas of inflammation or an inciting traumatic event with PIH. Treatment is challenging and focused on a variety of mechanisms to stop, hinder, and/or prevent steps in the pigment production (melanocytic hyperactivity) process, breaking down deposited pigment for internal removal or external release, exfoliating cells to enhance turnover, and decreasing inflammation. Topical lightening therapy in combination with sun protection is essential for potential improvement. The most commonly prescribed and researched topical lightening agents are hydroquinone (HQ), azelaic acid (AzA), and retinoids - although only HQ and a triple combination cream (Tri-Luma®; fluocinolone acetonide 0.01%, HQ 4%, tretinoin 0.05%) are US FDA-approved for "bleaching of hyperpigmented skin" (HQ) and "melasma" (Tri-Luma®). Numerous non-HQ brightening/lightening agents, including antioxidant and botanical cosmeceuticals, have recently flooded the market with improvements that claim less irritant potential, as well as avoiding the stigmata associated with HQ agents such as carcinogenesis and cutaneous ochronosis. Combining topical therapy with procedures such as chemical peels, intense pulsed light (IPL), fractional non-ablative lasers or radiofrequency, pigment lasers (microsecond, picosecond, Q-switched), and microneedling, enhances results. With proper treatment, melasma can be controlled, improved, and maintained; alternatively, PIH can be cured in most cases. Herein, we review treatments for both conditions and provide an opinion on proper management for enhanced results.