Andrew Alexis, MD, MPH, provides an overview of hyperpigmentation and available treatments for patients. Melasma is subcategorized into centrofacial, malar, and mandibular based on primary facial location as well as into dermal, epidermal, or mixed presentations based on depth of hyperpigmentation. Other types of hyperpigmentation are frequently mistaken for melasma, particularly in individuals with skin of color, as it may also be indicative of conditions such as lichen planus pigmentosus or drug-associated photodistributed hyperpigmentation. 

The presentation emphasized prevention of hyperpigmentation through reducing visible light exposure and early treatment of acne in skin of color. A study presented showed that darker skin exposed to visible light was more hyperpigemented compared to UVA exposure. Therefore, prevention of visible light penetration using iron oxide rather than titanium or zinc oxide becomes increasingly important with increasing darkness of skin. 

There are several treatments that affect various steps in the pigment production pathway, including retinoids, glucosamine, azelaic acid, ellagic acid, and nicotinamide. Despite the numerous available treatments, there are several challenges to treating hyperpigmentation, including limitations and side effects from known treatments. Hydroquinone, often a first-line treatment for hyperpigmentation, can have adverse effects such as halo hypopigmentation and ochronosis. There are several treatments that are currently being explored as alternatives to hydroquinone, which include topical cysteamine, 2-mercaptonicotinoyl, oral tranexamic acid, chemical peels, lasers, and microneedling. 

Dr Alexis concludes by recommending a treatment progression that begins with hydroquinone 4% triple combination therapy, followed by the addition of procedural treatments and oral agents with a transition to or incorporation of nonhydroquinone therapies. Visible light photoprotection should be incorporated into all regimens as preventive protection.