The Impact of Medications on the Development of Hyperpigmentation
A Guide for the Skin Care Professional
Certain medications taken by our patients may contribute to the development of hyperpigmentation. It is estimated that approximately 10 to 20 percent of pigmentation cases in the general population are medication related.
Why does this occur?
In some cases, the mechanism is photosensitivity. The medication increases the skin’s sensitivity to ultraviolet radiation, thereby indirectly triggering pigmentation. In other cases, the drug directly induces pigmentary changes through various biological pathways, even without sun exposure. Some medications promote the deposition of metal complexes in the skin or around blood vessels. In certain instances, medication induced pigmentation is dermal in origin, where pigment particles or metallic deposits penetrate into the dermis and are phagocytosed by macrophages.
Dermal pigmentation is particularly challenging to treat. It does not respond to cosmetic depigmenting products. Clinically, dermal pigmentation is characterized by a greyish blue or slate colored tone with indistinct, blurred borders, reflecting the deeper localization of pigment.
Some medications belong to both categories: they are photosensitizing and also directly induce pigmentation.
When dealing with photosensitizing medications, the patient must be instructed to minimize sun exposure and apply broad spectrum photoprotection consistently. Reapplication can be facilitated with powdered sunscreens, which allow convenient renewal throughout the day without disrupting makeup.
It is important to remember that photosensitizing drugs do not only increase pigmentation or worsen existing pigmentary conditions. Upon sun exposure, they may also provoke rashes and other cutaneous reactions. Inflammatory eruptions themselves are a well recognized trigger of post inflammatory hyperpigmentation.
Finally, certain medications increase overall skin sensitivity. This has direct implications for clinical treatment planning. Many of the procedures we perform, whether for pigmentation or other skin concerns, can be irritating to the skin. These include significant chemical peels and invasive technologies such as fractional radiofrequency or microneedling.
If a patient is taking a medication known to increase skin sensitivity, this must be factored into the therapeutic strategy. The goal is to design a treatment plan that is sufficiently gentle to avoid inducing cutaneous stress. Skin stress itself can aggravate hyperpigmentation.
The list below includes only some of the medications associated with photosensitivity or increased skin sensitivity. The complete list is significantly longer. For this reason, the medical history form must include all medications taken by the patient. Each drug should be evaluated for its potential to increase photosensitivity, provoke rashes, or induce cutaneous reactions unrelated to the aesthetic treatment but inherent to the medication’s known side effect profile.
Photosensitizing Medications
- Antibiotics
Tetracyclines such as doxycycline and minocycline
Quinolones such as ciprofloxacin and levofloxacin
Sulfonamides - Nonsteroidal Anti Inflammatory Drugs (NSAIDs)
Ibuprofen
Naproxen
Diclofenac - Antifungal Medications
Griseofulvin
Ketoconazole - Psychiatric Medications
Amitriptyline
Chlorpromazine
Tricyclic antidepressants, which may increase sun sensitivity
Selective serotonin reuptake inhibitors such as fluoxetine and sertraline, which may cause cutaneous rashes or allergic reactions - Diuretics
Thiazides such as hydrochlorothiazide
Furosemide - Acne Treatments
Isotretinoin - Oncology Treatments
5 Fluorouracil
Doxorubicin
Mitomycin
Cyclophosphamide
Methotrexate
Altretamine
Medications That Directly Contribute to Pigmentation
and Medications Associated With Increased Skin Sensitivity
In some cases, medications directly induce pigmentation independent of sun exposure. Below are representative examples. This section also includes medications that primarily increase skin sensitivity rather than directly causing pigmentation. In patients receiving such treatments, caution is required when planning aggressive or intensive procedures that may irritate the skin.
- Antibiotics
Sulfonamides, which may cause rashes, Stevens Johnson syndrome, and photosensitivity
Penicillins and cephalosporins, which may trigger allergic reactions presenting as rashes, pruritus, and in severe cases anaphylaxis
Minocycline, which may cause dark discoloration of the skin, particularly in sun exposed areas such as the face and hands, and may also alter pigmentation of mucosal tissues and teeth
Tetracyclines, which may increase sun sensitivity and provoke cutaneous reactions - Antimalarial Drugs
Hydroxychloroquine and chloroquine, which may induce pigmentary changes, particularly in sun exposed areas - Nonsteroidal Anti Inflammatory Drugs
Naproxen, which with prolonged use may lead to dark macules, mainly in sun exposed areas
Ibuprofen, naproxen, and diclofenac, which may cause photosensitivity, rashes, and in rare cases severe cutaneous reactions such as toxic epidermal necrolysis - Antipsychotic Medications
Chlorpromazine, which may cause hyperpigmentation and photosensitivity
Thioridazine, which may induce hyperpigmentation, particularly in sun exposed and friction prone areas - Acne Treatment
Isotretinoin, which may lead to pigmentary alterations, especially when sun exposure occurs during treatment - Antifungal Medications
Griseofulvin and ketoconazole, which may cause photosensitivity and hyperpigmentation, particularly with sun exposure - Chemotherapy and Anticancer Agents
Bleomycin and doxorubicin, which may induce pigmentary changes
It should be noted that 5 fluorouracil and doxorubicin may also cause severe cutaneous adverse effects including rashes, xerosis, and burns - Cardiovascular Medications
Amiodarone, used for cardiac arrhythmias, which may cause blue grey discoloration of the skin, particularly in sun exposed areas - Diuretics
Thiazides such as hydrochlorothiazide, which may increase sun sensitivity and provoke rashes - Antidiabetic Medications
Sulfonylureas such as glyburide, which may cause photosensitivity and rashes
Dear colleagues,
The medications listed above represent the most common examples. However, additional drugs may also influence pigmentation or increase skin sensitivity. In many cases, this information does not appear in the consumer leaflet but is documented in the scientific literature.
If uncertainty arises regarding a specific medication, consult reliable medical sources and incorporate this assessment into your treatment planning.