Hyperpigmentation has many different etiologies and can be a diagnostic and therapeutic challenge for dermatologists. In this session, Susan C. Taylor, MD, discussed tips for differentiating between the different types of hyperpigmentation and best strategies for treatment. Melasma and postinflammatory hyperpigmentation (PIH) are 2 common causes of facial hyperpigmentation. Melasma is usually found in sun-exposed areas on women of reproductive age, while patients with PIH should have a history of acne or another inflammatory facial dermatosis. Dr Taylor reviewed mimickers of melasma and PIH on the face, including exogenous ochronosis, lichen planus pigmentosus, maturational hyperpigmentation, drug-induced hyperpigmentation, and adrenal insufficiency. Nasal hyperpigmentation can be seen in a postviral state and has been reported following Chikungunya infection and COVID-19 infection. 

Moving on, Dr Taylor discussed strategies for preventing hyperpigmentation, which starts with sun protection. Multiple studies have shown improved resolution of both PIH and melasma with the use of sunscreen. Visible light is now understood to contribute to the pathogenesis of hyperpigmentation and is not blocked by traditional UV filters. Tinted sunscreens containing iron oxides as well as a new formulation of sunscreen containing 5 antioxidants have all been shown to reduce hyperpigmentation from visible light. 

Wrapping up with a review of treatment, Dr Taylor reviewed efficacy data for tretinoin for acne and acne-induced PIH as well as topical cysteamine 5% for PIH. Traditional triple therapy with combination tretinoin, fluocinolone, and hydroquinone has well-known efficacy for the treatment of melasma, although long-term use is limited by the risk of exogenous ochronosis. Dr Taylor introduced a novel triple-combination therapy for melasma containing isobutylamido thiazolyl resorcinol, tretinoin, and a corticosteroid. A 24-week randomized, double-blind, prospective clinical trial comparing the novel triple therapy with traditional triple therapy found a 63% reduction in melasma severity score for the novel combination versus 39% reduction with the traditional combination. Both oral and topical tranexamic acid as well as use of polypodium leucotomos extract has also shown benefit in the treatment of melasma.