Decoding Your Dark Spots: A Beginner’s Guide to Hyperpigmentation
Dark spots can come into our lives seemingly overnight, but getting rid of them never seems to happen as fast (unfortunately). Whether your dark spots are from a pimple you knew better than to pop, or the aftermath of an eczema flare-up, or the result of another type of skin trauma, most of us have experienced hyperpigmentation at one point or another—you know, those dark marks that get left behind and stick around for weeks at a time?
There are several different types of hyperpigmentation, which are mainly classified into two buckets: PIH (post-inflammatory hyperpigmentation) and PIE (post-inflammatory erythema). PIH is when your skin overproduces melanin due to trauma (think: squeezing your acne), while PIE is usually caused by injury to the capillaries. Essentially, both are caused by trauma, but PIH typically presents as brown spots, while PIE presents as red, pink, or purple spots, depending on your skin tone.
Though there’s nothing inherently “wrong” or medically concerning about this type of discoloration, there’s also nothing wrong with wanting to get rid of it, either, if you’re not a fan of yours. However, before we get into the specifics, there’s one thing to note about hyperpigmentation: Treating it often requires a lot of patience, so you need to manage your expectations here (slow and steady vs. overnight miracles).
To help, we chatted with board-certified internal medicine physician Glenicia Nosworthy, MD, and board-certified dermatologist Mona Gohara, MD, to explain everything there is to know about hyperpigmentation, how to spot it, and what to do about it.
What is hyperpigmentation?
Hyperpigmentation is the skin’s natural response to trauma, and is typically broken into two categories: post-inflammatory erythema (PIE)—which happens when capillaries in the skin are damaged—and post-inflammatory hyperpigmentation (PIH), which is when damage or trauma causes your skin to produce more melanin.
“Hyperpigmentation occurs as a result of skin injury or inflammation, such as acne, eczema, or psoriasis,” Dr. Nosworthy says. “Once the skin has healed, it may leave darkened areas or spots behind.” These spots can look pink to red (more common in lighter skin tones) or purple to brown (more common in deeper, melanin-rich skin tones). While all skin tones and types can experience hyperpigmentation, “people with darker skin tones are more prone to hyperpigmentation than people with lighter skin tones,” says Dr. Gohara, “since more melanin is present in the skin.”
What causes hyperpigmentation?
While specific triggers for hyperpigmentation can vary—from acne to sun damage—they all have one thing in common: physical trauma. When there’s “trauma” to the skin (like scrapes, burns, cuts, or zits), your skin goes into repair mode, triggering an inflammatory response that causes an increased release of melanin, says Dr. Gohara. The result? A dark patch on your skin.
“Acne itself is an inflammatory disorder, so it goes hand in hand with hyperpigmentation, especially for more severe or cystic acne,” explains Dr. Gohara. If you pop or squeeze a pimple, a reddish spot (on fairer skin tones) or a browner spot (on brown or deeper complexions) might replace your bump once the pimple is gone.
But bumps and scrapes aren’t the only causes of hyperpigmentation. In reality, hyperpigmentation can also be caused by:
Sun damage
“Hormonal changes
Aging
Genetic predisposition
PIE vs PIH
If you’ve seen a dermatologist (or gotten sucked into Reddit threads while researching hyperpigmentation), you’ve likely seen or heard the terms PIH and PIE being tossed around; understanding both can help you better identify your spots.
When it comes to PIE vs. PIH, the main differences are in color and cause. “PIE appears as red- or purple-colored spots on the skin, while PIH appears as darker patches on the skin,” Dr. Gohara shares. Still, if you’re unsure of which type of discoloration you’re experiencing, Dr. Nosworthy suggests applying pressure to the affected area. “If the mark fades or turns white upon pressure, it is likely PIE,” she shares. On the other hand, if the color remains unchanged, the mark is more likely to be PIH.”
Need a further breakdown on specifics? See below for the differences between PIE and PIH, including the best ways to treat them both:
PIE
“PIE occurs as a vascular reaction triggered by inflammation or irritation,” explains Dr. Nosworthy. “Capillaries beneath the skin’s surface respond to inflammation by increasing blood flow to the affected area as part of the healing process.” PIE commonly occurs as a result of acne, which triggers the inflammatory response.
However, PIE can also be caused by other factors, like exposure to UV radiation, injuries, or skin irritation. People with lighter skin are more prone to developing PIE, while people with deeper skin tones are more prone to developing PIH.
How to treat PIE
There are many ways to treat PIE, whether you use over-the-counter topical creams, opt for in-office procedures, or commit to a mix of both. According to Dr. Gohara, a series of laser treatments, including IPL (intense pulsed light) and PDL (pulsed dye laser), can greatly reduce the appearance of PIE by targeting the blood vessels in your skin contributing to the hyperpigmentation.
Dr. Nosworthy adds that products with brightening ingredients like niacinamide, azelaic acid, or licorice root can also help to reduce redness while also gently exfoliating at the same time. Another good option? Chemical peels—both at home or in-office—can exfoliate and resurface the top layer of skin, helping to even out your skin over time.
Does PIE go away?
PIE can be treated to improve but it may not ever fully go away. If you’re struggling with fading your pigmentation with intentional skin-care products, Dr. Gohara says that visiting a dermatologist is the next best step. In general, she suggests a mix of in-office treatments paired with prescription topicals, over-the-counter skin-care products, and, in some cases, oral medical to get the best results.
PIH
“PIH is post-inflammatory hyperpigmentation, which is hyperpigmentation caused by trauma or injury to the skin,” says Dr. Gohara. “It is a form of hyperpigmentation that often shows up as darker patches of skin and can occur anywhere on the body.”
Dr. Nosworthy notes that PIH is most likely to occur when a pimple’s inflammation is exacerbated by picking or squeezing or as part of the skin’s natural healing process when recovering from scratches, UV exposure, or chemical burns. While PIH can surface on all skin tones and types, it’s more commonly seen among people of color.
How to treat PIH
Much like PIE, the severity of your PIH will determine the best course of action for treatment. So, always speak with a dermatologist beforehand to develop an effective plan. The good news, however, is that most forms of PIH are fully treatable (hormonal hyperpigmentation like melasma is much harder to permanently get rid of), although you’ll have to practice some patience.
“Most forms of PIH can fully go away and be treated over time,” Dr. Nosworthy says. “However, the time it takes for PIH to fade completely varies from person to person and depends on factors like the underlying cause, skin type, treatment used, and how well the skin responds to treatment.”
In general, the best treatments for PIH include:
Brightening ingredients
Let’s face it: Not all of us have time or energy for a million-step skincare routine. Some of us just want an easy solution that will help diminish our dark spots over time. If that rings true for you, experts say investing in skincare with powerful spot-fading ingredients like kojic acid, tranexamic acid, and vitamin C (which all work to brighten the skin and slow the production of melanin) are your best bet. And, of course, consistency is key. One dab of a dark-spot serum every now and again won’t do the same work as a regular application; hate to break it to ya.
Chemical peels
In-office chemical peels are a great option if you’re looking for fast results. “Peels can help to fade PIH and stimulate collagen production, which can help improve skin texture and tone over time,” Dr. Nosworthy explains. Depending on the intensity of your chemical peel, your skin may be visibly flaky for a week or two, so plan accordingly.
Also, for those with melanated skin, be sure to see a dermatologist with extensive experience working with skin of color to avoid potential chemical burns, which can lead to more severe hyperpigmentation. For a gentler approach, you can also look for an at-home peel with ingredients like glycolic and lactic acids to help resurface the skin with less risk of irritation.
Retinols
Retinol is one of the gold-standard ingredients in skincare thanks to its ability to target several concerns—from smoothing out fine lines to evening out skin tone. “It accelerates the skin’s natural exfoliation process, promoting the shedding of old, pigmented skin cells and stimulating the growth of new skin cells,” Dr. Nosworthy says. “This increased cell turnover can help fade dark spots and even skin tone over time.”
But every rose has its thorn, right? While retinol can be extremely effective, it’s also known to cause redness, irritation, and dryness. Thankfully, there are a few standout retinol and retinol alternatives on the market designed to help. Prescription formulas (like retinoic acid and trifarotene) are also more potent than what you’ll find at the stores, but are designed to help increase cell turnover, which helps fade dark spots over time.
In-office laser treatments
While many cases of PIH can be treated at home, laser treatments may be a good idea for persistent discoloration. Dr. Gohara says that Fractional CO2 laser treatments target deeper layers of the skin with light to help increase collagen production. As always, for those with melanated skin, it’s essential to look for a dermatologist who has extensive experience using lasers on skin of color to potential burning or scarring.
Final takeaway
While hyperpigmentation—whether PIE or PIH—can seem permanent, it can usually be fully resolved with lots of consistency and professional help (depending on severity). Just be sure to speak with a dermatologist before testing out a new at-home treatment to avoid making your dark spots worse. Or, if you have the means, head to your dermatologist first for a targeted approach instead of DIYing at home.
Just remember, as with most good things, less is more when treating hyperpigmentation. Instead of slathering on three peels and a retinoid (a guaranteed nightmare for your face), try curating a simple, targeted routine of basics to help fade dark spots while keeping your skin healthy for the long haul.
Hero Illustration by Janet Mac