Advancing the Management of Melasma and Hyperpigmentation in Skin of Color

At the 2025 Fall Clinical Dermatology Conference in Las Vegas, Nevada, Andrew Alexis, MD, MPH, professor of clinical dermatology and vice-chair for diversity and inclusion at Weill Cornell Medicine in New York, New York, gave an in-depth discussion on the evolving management of melasma and hyperpigmentation conditions, with a special focus on their prevalence and impact in patients with skin of color.¹ His insights highlighted new evidence-based approaches—from photoprotection to procedural innovations—while also emphasizing the psychosocial burden these conditions impose on patients.

Global and Clinical Significance of Hyperpigmentation

“Melasma and hyperpigmentation disorders are among the most prevalent dermatologic disorders in the world, especially among patients who have more melanin-rich skin or skin of color, and these can really contribute adversely to quality of life,” Alexis explained.

As he noted, these disorders often coexist with inflammatory skin diseases such as acne, atopic dermatitis, and psoriasis—conditions in which post-inflammatory hyperpigmentation (PIH) may be as distressing to patients as the primary inflammation itself. Addressing hyperpigmentation, he emphasized, is not only a matter of aesthetics but a crucial component of improving overall quality of life and patient satisfaction.

Photoprotection as Step One

Alexis emphasized that photoprotection remains the cornerstone of hyperpigmentation management. “When it comes to photo protection, we are protecting both against UV radiation, but also visible light,” he noted, a key consideration for patients with skin of color, in whom visible light can exacerbate pigmentation.

According to Alexis, effective protection includes tinted sunscreens containing iron oxides, which shield against visible light, as well as formulations rich in antioxidants and free radical quenchers. Adjunctive oral photoprotectants, such as polypodium leucotomos extract, can further reduce oxidative stress and support pigment control.

Beyond Hydroquinone

Topical therapy forms the foundation of active treatment for melasma and PIH. Hydroquinone remains the gold standard for short-term therapy, typically prescribed for 3 to 6 months depending on concentration. However, due to risks such as exogenous ochronosis, long-term continuous use is discouraged.

For extended maintenance, a variety of non-hydroquinone alternatives are now available. Alexis reviewed azelaic acid, cysteamine, thiamidol, and Melasyl, many of which are incorporated into cosmeceutical formulations suitable for chronic use. These newer agents allow for a safer, more sustainable approach to long-term pigment control, according to Alexis.

Oral and Procedural Adjuncts

For patients with suboptimal response to topicals alone, oral and procedural options can enhance outcomes. Oral tranexamic acid, typically at 325 mg twice daily, has shown efficacy in reducing melasma through its antifibrinolytic and vascular-modulating effects. Polypodium leucotomos can be continued as an adjunctive antioxidant therapy.

Procedural options include superficial chemical peels—such as glycolic acid, salicylic acid, or Jessner’s solution—and select laser modalities, including nonablative fractional lasers, picosecond lasers, and Q-switched Nd:YAG 1064 nm systems. Alexis cautioned that procedural therapy in Fitzpatrick skin types IV–VI requires a nuanced technique to minimize the risk of post-inflammatory dyspigmentation. “When we leverage our photo protection, topical therapy, and strategic use of procedural or oral therapy, we can get the best results for our patients,” he said.

Acquired Dermal Macular Hyperpigmentation

Alexis also discussed a spectrum of conditions collectively termed acquired dermal macular hyperpigmentation (ADMH)—which includes lichen planus pigmentosus, erythema dyschromicum perstans (ashy dermatosis), and related disorders. These conditions present with violaceous-to-gray macules affecting the face, neck, or trunk and are particularly challenging to treat, according to Alexis.

Management of ADMH often requires a dual approach combining immunomodulatory therapy with pigment-reducing strategies. “There's growing experience using low-dose oral isotretinoin as part of the management of these patients for 6 months or longer to achieve successful results in terms of improving the hyperpigmentation,” Alexis noted, citing growing clinical experience with this regimen in lichen planus pigmentosus and similar conditions.²

Patient-Centered Approach

Alexis concluded by highlighting the growing recognition of pigmentary disorders in dermatologic research and education. ‘Fortunately, we've seen tremendous progress in terms of awareness and understanding of the impact of pigmentary disorders in patients with skin of color,” he said. “Plus, a growing list of newer approaches that have pushed the level of efficacy that we are able to achieve to drive the best results for our patients.”

References

1. Alexis A. Melasma and other hyperpigmentation disorders. Presented at: 2025 Fall Clinical Dermatology Conference; October 23-26, 2025; Las Vegas, NV.
2. Xu Z, Ding Y, Zhang C, et al. Treatment of acquired dermal macular hyperpigmentation with oral isotretinoin: a multi-institutional retrospective study of 121 cases. Pigment Cell Melanoma Res. 2025;38(5):e70052. doi: 10.1111/pcmr.70052