This patient has postinflammatory hyperpigmentation (PIH) resulting from her inflammatory acne papules, and she should be treated with a topical retinoid. The first step in management is to treat her acne, which is the source of the discoloration, rather than initially treating the discoloration with a bleaching cream such as hydroquinone. After any injury to the skin such as inflammation or trauma, dark skin may become hypo- or hyperpigmented. For this reason it is important to advise patients not to pick at their acne, as this can contribute to postinflammatory discoloration. Patients often report “scarring,” when in fact there are only postinflammatory changes. The duration of postinflammatory pigmentary changes varies, depending on the location and degree of inflammation. Hyperpigmentation on the lower legs can take several years to fade. Some postinflammatory pigment changes are permanent. Treatment of postinflammatory pigment changes includes treatment of any underlying skin inflammation, sun avoidance or sun protection, and consideration of a bleaching cream, such as hydroquinone. Topical retinoids are the standard of care for acne therapy, as they can prevent acne. They should be applied to the entire area affected by acne, not used as a “spot treatment.”

This patient has moderate acne with more than a dozen inflammatory papules distributed over her face. A topical antimicrobial agent would not be the first choice in acne management since it has no preventive properties and there are no clinical signs of infection, such as impetiginization of the acne lesions. Topical glucocorticoids would not be a treatment for this patient because they can exacerbate acne.