Skin of Color Dermatology: Managing Hyperpigmentation and Keloids

Why Hyperpigmentation Hits Harder in Skin of Color

When you have darker skin, a pimple, cut, or even a scratch doesn’t just heal-it often leaves behind a dark mark that lingers for months, sometimes years. This isn’t just a cosmetic issue. For many people with skin of color, these dark spots become a source of stress, self-consciousness, and even social withdrawal. The reason? Higher melanin levels. While melanin protects the skin from UV damage, it also makes the skin more reactive to inflammation. When the skin gets irritated-whether from acne, eczema, tight hairstyles, or even harsh skincare products-it overproduces pigment, creating patches that range from light brown to grayish-black.

This is called post-inflammatory hyperpigmentation, or PIH. It’s not an infection or an allergy. It’s the skin’s natural healing process gone too far. Unlike lighter skin tones, where redness fades quickly, darker skin turns darker. And unlike sunspots, which appear on exposed areas, PIH can show up anywhere the skin was injured-even under clothing or behind the ears.

What Makes Melasma Different-and More Tricky

If you’re seeing brown or gray patches mostly on your face-cheeks, forehead, upper lip-it’s likely melasma. This isn’t caused by trauma. It’s driven by hormones. Pregnancy, birth control pills, hormone replacement therapy, and even stress can trigger it. Melasma is far more common in women, especially those with Fitzpatrick skin types IV to VI. And unlike PIH, it doesn’t always fade after the trigger is removed. Many women find melasma returns every summer, even with sunscreen.

What makes melasma stubborn is that it doesn’t just sit on the surface. It digs deep into the dermis, the lower layer of skin. That’s why over-the-counter brighteners often don’t work. Prescription treatments like hydroquinone, tretinoin, and azelaic acid are needed. And even then, results take time. A 2022 study in the Journal of Clinical and Aesthetic Dermatology showed that combining topical tranexamic acid with sunscreen improved melasma in 78% of patients after 12 weeks-but only if they used it daily without skipping.

The One Thing You Can’t Skip: Sunscreen

There’s no treatment for hyperpigmentation that works if you’re not wearing sunscreen every single day. Not just when it’s sunny. Not just at the beach. Every day. Rain or shine, indoors or out.

Why? Because UV light-even through windows-triggers melanocytes to keep making pigment. And blue light from phones and screens? It can darken pigmentation too, especially in darker skin tones. That’s why dermatologists now recommend tinted sunscreens with iron oxides. These block not just UVA and UVB, but also visible light. And they blend better with brown skin, so you don’t get that ghostly white cast.

Look for SPF 30 or higher, broad-spectrum, and water-resistant. Apply it like you’re painting your face-two fingers’ worth for your entire face and neck. Reapply every two hours if you’re outside. And don’t forget your ears, neck, hands, and scalp if you have thinning hair. Skipping sunscreen won’t just make your dark spots worse-it can undo months of treatment.

Topical Treatments That Actually Work

Not all brightening products are created equal. Some over-the-counter serums promise results but deliver nothing but irritation. Here’s what dermatologists actually prescribe for skin of color:

• Hydroquinone (2-4%): The gold standard for fading dark spots. It blocks the enzyme that makes melanin. Used for short cycles (3-6 months), then paused to avoid side effects.
• Tretinoin (0.025-0.1%): A retinoid that speeds up skin turnover and helps other ingredients penetrate. Often paired with hydroquinone for better results.
• Azelaic acid (15-20%): Gentle enough for sensitive skin. Reduces pigment and calms inflammation. Great for acne-prone skin.
• Vitamin C (10-20%): An antioxidant that blocks pigment production and brightens overall tone. Best used in the morning under sunscreen.
• Kojic acid and cysteamine cream (5%): Newer options with fewer side effects than hydroquinone. Cysteamine, in particular, has shown strong results in clinical trials for melasma.

Don’t stack five brightening products at once. That’s how you get irritation-and more PIH. Start with one, use it every other night, and build up slowly. If your skin stings, turns red, or flakes, stop. Talk to a dermatologist. Over-treating is a common mistake.

Keloids: When Scars Grow Beyond the Wound

If you’ve ever had an ear piercing, surgery, or even a minor cut that turned into a raised, rubbery lump that kept growing-chances are you have a keloid. These aren’t just big scars. They’re abnormal healing responses where the body makes too much collagen, and it doesn’t stop. Keloids are more common in people with skin of color-up to 15-20% of Black, Hispanic, and Asian populations develop them. They’re rare in lighter skin tones.

Keloids can form after anything that breaks the skin: acne, chickenpox, tattoos, vaccinations, or even insect bites. They’re not dangerous, but they can be painful, itchy, and restrict movement if they form near joints. And emotionally? They can feel like a permanent scar of trauma.

Treatment is harder than for hyperpigmentation. Creams and lasers alone won’t fix them. The most effective approach combines injections of corticosteroids (to shrink the tissue), silicone gel sheets (to flatten and soften), and sometimes pressure earrings (for ear keloids). In stubborn cases, surgery followed by radiation therapy may be used-but only by specialists who know how to prevent recurrence. Left untreated, keloids often come back bigger than before.

What Not to Do

There are so many TikTok trends and Instagram ads promising quick fixes for dark spots. But some of the most popular methods can make things worse:

• Scrubbing or exfoliating aggressively: This causes micro-tears, which trigger more PIH.
• Using lemon juice or vinegar: These are acidic and can burn darker skin, leading to more discoloration.
• Skipping sunscreen because you’re "already dark": Melanin isn’t enough protection. UV damage still happens.
• Trying chemical peels at home: Even mild peels can cause burns in skin of color. Always see a dermatologist trained in pigmented skin.
• Ignoring acne: The longer acne lasts, the more PIH you’ll get. Treat the acne first.

When to See a Dermatologist

You don’t need to wait until dark spots are unbearable. If you’ve had the same patch for more than three months, or if new spots keep appearing, it’s time to get help. A dermatologist who specializes in skin of color can:

• Confirm whether it’s PIH, melasma, or something else like lichen planus or discoid lupus.
• Prescribe the right combination of medications.
• Recommend safe in-office procedures like low-dose lasers or microneedling with growth factors.
• Help you manage keloids before they become large or painful.

Don’t settle for a dermatologist who says, "Just use sunscreen and wait." That’s not enough. You deserve a plan. Look for providers who list "skin of color" or "pigmented skin" as a specialty. The American Academy of Dermatology has a directory you can search by location and expertise.

Realistic Expectations

There’s no magic cure. Even the best treatments take 3-6 months to show noticeable results. And some dark spots never fully disappear. That’s okay. The goal isn’t perfection-it’s improvement. Many patients go from dark, obvious patches to faint, barely noticeable marks. That’s a win.

Also, relapse is normal. Stress, sun exposure, or hormonal shifts can bring back hyperpigmentation. That’s why maintenance is part of the plan. Keep using sunscreen. Keep using your prescribed cream, even after the spots fade. Think of it like brushing your teeth-you don’t stop once your cavity is filled.

Final Thoughts

Hyperpigmentation and keloids aren’t just skin deep. They affect confidence, relationships, and daily life. But they’re treatable-with the right knowledge and consistent care. You don’t have to live with dark spots that make you feel unseen. Start with sun protection. See a specialist who understands your skin. And be patient. Healing takes time, but it’s possible.