Skin of Color Dermatology: Managing Hyperpigmentation and Keloids

Why Hyperpigmentation Hits Harder in Skin of Color

When you have darker skin, a pimple doesn’t just fade away. It leaves behind a dark spot that can stick around for months-even years. This isn’t just a cosmetic issue. For many people with skin of color, these dark patches become a source of stress, embarrassment, and even anxiety. The reason? Higher melanin levels. Melanin is your skin’s natural shield against UV rays, but when it overproduces after injury or inflammation, it creates stubborn dark spots called post-inflammatory hyperpigmentation (PIH). Unlike lighter skin tones, where redness fades quickly, darker skin turns brown or gray instead. It’s not a rash or an infection. It’s your skin’s overprotective response.

PIH doesn’t care if you’re 16 or 60. It shows up after acne, eczema, razor bumps, burns, or even aggressive scrubs. But here’s what most people don’t realize: the same trauma that leaves a faint mark on fair skin can leave a deep, lasting stain on darker skin. A study from the American Society for Dermatologic Surgery found that up to 65% of people with skin of color report visible PIH after minor skin injuries. And it’s not just acne. Hair removal, tight braids, and even scratching an itch can trigger it.

Melasma: More Than Just Sunspots

If you’re a woman with darker skin and you’ve noticed brown or gray patches on your cheeks, forehead, or upper lip, you might be dealing with melasma. This isn’t just sun damage-it’s hormonal. Melasma flares up during pregnancy (often called the “mask of pregnancy”), while taking birth control pills, or during hormone replacement therapy. Unlike PIH, which follows a wound, melasma appears without any injury. It’s symmetrical, stubborn, and often returns even after treatment.

What makes melasma worse? Sunlight. Even a few minutes of exposure can darken it. Blue light from phones and computer screens can also contribute. That’s why tinted sunscreens with iron oxides are now a must-have. Regular chemical sunscreens block UV rays, but iron oxides block the visible light that triggers pigment in darker skin. A 2023 review in the Journal of Clinical and Aesthetic Dermatology confirmed that daily use of tinted sunscreen reduced melasma recurrence by nearly 40% compared to untinted options.

The Sun Is the Biggest Enemy

No treatment works if you’re not protecting your skin from the sun. Every dermatologist will tell you this-but most people still skip sunscreen on cloudy days or when they’re indoors. That’s a mistake. UVA rays penetrate clouds and glass. And in skin of color, even low levels of UV exposure can trigger or worsen hyperpigmentation.

Here’s what actually works:

1. Use a broad-spectrum sunscreen with SPF 30 or higher every single morning-rain or shine.
2. Choose a formula with iron oxides. They block blue light and blend better on deeper skin tones.
3. Reapply every two hours if you’re outside.
4. Wear wide-brimmed hats, UV-blocking sunglasses, and long sleeves when possible.
5. Avoid being outside between 10 a.m. and 4 p.m., when UV rays are strongest.

One patient I worked with thought she was doing fine because she wore a hat. But she still got dark patches under her chin-because she didn’t apply sunscreen there. Sun protection isn’t optional. It’s the foundation of every successful treatment plan.

Treatment Options That Actually Work

There’s no magic cream that erases hyperpigmentation overnight. But with the right combination of products and patience, most cases improve significantly.

The most effective first-line treatments include:

• Hydroquinone (2-4%): The gold standard for lightening dark spots. It blocks the enzyme that makes melanin. Use it for 3-6 months, then take a break to avoid irritation.
• Tretinoin (retinoid): Speeds up skin cell turnover, helping fade spots over time. Often combined with hydroquinone for better results.
• Azelaic acid (15-20%): Reduces pigment and inflammation. Great for sensitive skin and safe during pregnancy.
• Vitamin C: An antioxidant that brightens skin and blocks UV damage. Look for L-ascorbic acid at 10-20% concentration.
• Kojic acid and glycolic acid: Gentle exfoliants that help peel away dark layers. Use cautiously-overuse can irritate and worsen PIH.

Newer options like tranexamic acid (topical or oral) and 5% cysteamine cream are showing promise in clinical trials. Tranexamic acid, originally used to reduce bleeding, has been found to block pigment-triggering signals in the skin. Cysteamine works by neutralizing the molecules that cause darkening. Both are less likely to cause irritation than hydroquinone, making them ideal for long-term use.

Keloids: When Scars Grow Beyond the Wound

While hyperpigmentation fades slowly, keloids are a different beast. They’re raised, thick, rubbery scars that grow beyond the original cut, burn, or piercing. They don’t hurt, but they itch, ache, and can restrict movement. And they’re far more common in people with skin of color-especially those of African, Asian, or Hispanic descent.

Why does this happen? In darker skin, the healing process goes into overdrive. Fibroblasts-the cells that make collagen-don’t know when to stop. The result? A scar that keeps growing, sometimes for years. Keloids often appear on the chest, shoulders, earlobes, and jawline. They’re not contagious. They’re not cancer. But they can be emotionally devastating.

Treating keloids is harder than treating hyperpigmentation. Topical creams won’t flatten them. The most effective treatments include:

• Corticosteroid injections: The first-line treatment. Injected every 4-6 weeks, they shrink the scar and reduce itching.
• Silicone sheets or gel: Applied daily for months, they help flatten and soften keloids. Works best when started early.
• Cryotherapy: Freezing the keloid with liquid nitrogen. Can lighten the color but may cause hypopigmentation in darker skin.
• Laser therapy: Pulsed dye or Nd:YAG lasers reduce redness and flatten the scar. Must be done by someone experienced with skin of color.
• Surgery: Only if combined with other treatments. Cutting out a keloid alone has a 50-100% chance of coming back worse.

One patient came in with a keloid from an ear piercing that had grown to the size of a grape. After six months of steroid injections and silicone gel, it shrank by 70%. She said it felt like she got her identity back.

What Doesn’t Work (and Can Make Things Worse)

Not all treatments are created equal. Some can actually make hyperpigmentation or keloids worse.

Here’s what to avoid:

• At-home chemical peels: Especially those with high concentrations of glycolic or salicylic acid. They can burn darker skin and trigger more PIH.
• Intense pulsed light (IPL): Often marketed as a “brightening” treatment, but it can burn melanin-rich skin and cause permanent dark spots.
• Harsh scrubs or exfoliants: Rubbing your skin raw won’t fade spots-it’ll create new ones.
• Unregulated skin-lightening creams: Some contain mercury, steroids, or hydroquinone in unsafe doses. These can cause skin thinning, infections, or even kidney damage.

Always see a dermatologist before trying anything new. What works for someone with fair skin might destroy yours.

When to See a Dermatologist

You don’t need to wait until your dark spots are unbearable. If you notice:

• Dark patches that don’t fade after 3-4 months
• Scars that keep growing after healing
• Itching, pain, or redness around a scar
• Dark spots spreading or changing shape

It’s time to get professional help. A dermatologist who understands skin of color can create a personalized plan. They’ll check for underlying causes-like hormonal imbalances, untreated acne, or medication side effects-and adjust your routine accordingly.

Regular follow-ups matter. Hyperpigmentation and keloids are chronic conditions. You’re not failing if they come back. You’re just managing a biological response that’s deeply rooted in your skin’s biology.

Living With It: Mindset Matters

Dealing with skin changes can feel isolating. You might avoid mirrors, skip social events, or feel judged. But you’re not alone. Studies show that over 70% of people with skin of color experience emotional distress because of hyperpigmentation or keloids.

Healing isn’t just about creams and lasers. It’s about self-acceptance. Talk to others. Join online communities. Find a dermatologist who listens. Progress takes time. A spot that took six months to form won’t vanish in two weeks. But with consistency, the right tools, and patience, most people see major improvement.

Your skin doesn’t need to be perfect. It just needs to be cared for-with knowledge, respect, and the right support.