Nothing seems to be working for post accutane PIH hyperpigmentation - suggestions? (Photos)

Question

I have done accutane course and now I rarely get new acne. The issue is the remaining PIH on back and chest which is making me anxious almost everyday. I am having hard time accepting myself with these flaws. I have visited many dermats. Done 12 sitting of TCA peel for 12 months. 3 sittings of Full q switch nanoseconds lasr treatment on back and chest. Applied ga-6 glycolic acid for months. I feel nothing is working and nothing gonna work. If there is anyone who treated this PIH fully here. Please help. 30M

Behnoush Zarrini, MD · Answer

The stubborn nature of trunk hyperpigmentation after accutane is often due to the pigment being trapped in the deeper dermal layers where standard chemical peels and older nanosecond lasers cannot effectively reach it. Since your skin has not responded to multiple rounds of TCA and Q switched treatments it is likely that the thermal energy from those procedures was either too superficial or triggered a protective inflammatory response that maintained the dark spots. You should consider transitioning to a picosecond laser which uses photoacoustic pressure rather than heat to shatter pigment into smaller particles that your immune system can clear more easily.
In addition to advanced laser technology you may benefit from a more aggressive medical grade topical regimen that includes tranexamic acid or cysteamine to block the chemical pathways that produce melanin. These ingredients work differently than glycolic acid and can be much more effective for persistent discoloration that has resisted traditional exfoliants. It is also worth discussing oral tranexamic acid with a specialist as a systemic approach can sometimes clear body pigment that refuses to budge with local treatments alone. Be patient with the process as the skin on the back regenerates much more slowly than the face and often requires a combination of internal and external interventions to see a full resolution.

Anna Chacon, MD, FAAD · Answer

I hear your frustration—and I want to be very direct: this type of pigmentation is one of the most stubborn we treat.

You’ve already done:

TCA peels
Q-switched laser
Glycolic acid

That tells me this is likely:

deep dermal pigmentation, or
chronic post-inflammatory hyperpigmentation with ongoing triggers
Why it’s not improving:
The back/chest heal slower than the face
Friction, sweat, and inflammation keep re-triggering pigment
Some lasers (especially nanosecond) are not strong enough for deeper pigment
What I would consider next:
Different laser class (e.g., picosecond or fractional resurfacing—not the same as what you had)
Strict maintenance to prevent new inflammation
Patience—this can take months to years, not weeks
Important:

“Fully removing” PIH on the body is often unrealistic—but significant fading is achievable with the right approach.

Yong-Heon Ha, MD · Answer

It is understandable how frustrating PIH can be, especially after you’ve already gone through so many treatments. Post-inflammatory hyperpigmentation is unfortunately one of the more stubborn types of pigmentation because the skin in these areas tends to be thicker, slower to heal, and more prone to recurring inflammation.
That said, PIH is generally not untreatable, but it tends to respond slowly and requires very targeted, consistent approaches over time.
Q-switched lasers are quite versatile, but in cases like yours, results can sometimes be limited or inconsistent. You may benefit more from a more focused and controlled approach such as pico-toning (picosecond laser treatments), which targets pigment more precisely with less thermal damage to surrounding tissue.
However, as mentioned before it typically requires multiple sessions spaced appropriately apart to allow the skin to heal in-between. Progress is usually gradual, but many patients do see clearer improvement over time when the protocol is consistent and properly tailored.
It may also be worth reassessing inflammation triggers and ensuring strict pigment prevention (sun exposure, friction, secondary irritation), since PIH often persists when there is ongoing low-grade irritation.
It’s understandable to feel discouraged, but there are still reasonable options to explore.

Nothing seems to be working for post accutane PIH hyperpigmentation - suggestions? (Photos)

Answers (3)

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