Practical Therapeutic Strategies for Acne-Induced Hyperpigmentation Across all Skin Types

Post-inflammatory hyperpigmentation and post-inflammatory erythema are common sequelae of acne, particularly affecting individuals with skin of color. Up to 85% of patients with Fitzpatrick phototypes IV-VI develop post-inflammatory hyperpigmentation following inflammatory acne lesions. Acne-induced hyperpigmentation (AIH) results from increased melanin production and deposition triggered by inflammatory mediators, while acne-induced macular erythema reflects vascular alterations. Both AIH and acne-induced macular erythema can persist for months or even years, significantly contributing to the psychosocial burden of acne and negatively impacting patients' quality of life - sometimes to a greater extent than active acne itself. Female individuals, darker skin color, severe acne, facial sites, excessive sunlight exposure, and traumatized lesions are important risk factors for AIH. Diagnosis relies on visual inspection, acne history, and skin phototype assessment. Treatment options include topical agents such as azelaic acid, retinoids, antioxidants, and hydroquinone, as well as systemic therapies such as isotretinoin, oral antibiotics, and oral tranexamic acid. Chemical peeling and energy-based devices, including lasers and microneedling, offer additional therapeutic avenues. Photoprotection is crucial in managing AIH, particularly in skin of color patients. Despite the high prevalence of AIH, there is a lack of validated patient-reported outcome measures specific to AIH/acne-induced macular erythema, highlighting the need for further research and standardized assessment tools. This article provides a practical approach, highlighting therapeutic strategies and recommendations for AIH across all skin types.