Hyperpigmentation: An Overview of the Common Afflictions

Kimberly A. Cayce; Amy J. McMichael; Steven R. Feldman


Dermatology Nursing. 2004;16(5) 

In This Article

Abstract and Introduction


Hyperpigmentation disorders of the skin are common. Three of the more common forms include melasma, lentigines, and post-inflammatory hyperpigmentation. Significant negative psychological consequences can result. Many therapeutic options exist, though treatment is often difficult, requiring lengthy therapy.


Hyperpigmentation disorders of the skin occur commonly and manifest in a variety of different forms. Two separate mechanisms account for the increased pigmentation and each may arise in the epidermis, dermis, or mixed (dermis and epidermis). Typically, patients endure the same consequences. Because of the visible nature of dermatologic diseases, they have a considerable psychological effect on affected patients (Halioua, Beumont, & Lunel, 2000). Disfiguring facial lesions can significantly affect a person's overall emotional well-being and can contribute to decreases in social functioning, productivity at work or school, and self-esteem (Anderson & Rajagopalan, 1997; Chren, Lasek, Sahay, & Sands, 2001; Finlay, 1997). Some of the most common disfiguring facial disorders include the hyperpigmentation disorders. Non-vitiligo pigmentation disorders were the third most common presentation among African-American patients in an urban, private-practice dermatology setting (Halder, Grimes, McLaurin, Kress, & Kenney, Jr., 1983). In general, patients with skin diseases -- including acne, psoriasis, and atopic dermatitis -- have a reduced quality of life. Similarly, women with melasma have decreased health-related quality of life (HRQoL) (Balkrishnan et al., 2003). Three of the more common hyperpigmentation disorders include melasma, lentigines, and postinflammatory hyperpigmentation. Characteristic features and treatment options of these disorders will be discussed.

It is important to understand the underlying mechanisms responsible for these pigmentary disorders to appreciate the clinical differences among the diseases. Hyperpigmentation typically results from increased melanin, which may occur in the epidermis, dermis, or both. Typically, this happens either by increased melanin production by existing melanocytes (melanotic hyperpigmentation) or from proliferation of active melanocytes (melanocytotic hyperpigmentation) (see Figures 1-3). Normally, the melanocytes are located in the basal layer of the epidermis and an increase in number or activity will cause epidermal hyperpigmentation. However, formed melanin may be transferred to the dermis or, in some cases, dermal melanocytes are present. A heightened activity or number of melanocytes in these instances will lead to dermal hyperpigmentation (see Figure 4). Also, a combination of the above may take place, triggering mixed hyperpigmentation. Epidermal involvement appears as brown discoloration, dermal as blue-gray, and mixed epidermal and dermal as brown-gray. Examples of epidermal melanocytotic hyperpigmentation include simple lentigines and solar UV tanning. Mongolian spots and Nevus of Ota demonstrate increased numbers of active melanocytes in the dermis.

Figure 1.

Normal skin.

Figure 2.

Melanotic hyperpigmentation (increased melanocyte number).

Figure 3.

Melanocytotic hyperpigmentation (normal melanocyte number but increased melanin production).

Figure 4.

Dermal hyperpigmentation with increased melanin within the dermis.

The majority of hypermelanoses transpire as a result of increased melanin production with normal numbers of melanocytes. The pattern may be localized, circumscribed lesions or diffuse. Epidermal lesions include ephelides, café-au-lait macules, Becker's nevus, and nevus spilus. Incontinentia pigmenti, hemochromatosis, and fixed-drug eruptions are examples of dermal melanotic changes. Melasma and postinflammatory hyperpigmentation may exhibit epidermal, dermal, or mixed melanotic involvement (Ortonne, Bahadoran, Fitzpatrick, Mosher, & Hori, 2003). In every case, these abnormalities are cosmetically displeasing to most patients and may even cause a significant amount of embarrassment or emotional distress.