Postinflammatory Hyperpigmentation Follow-up

Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD more...

Background
Postinflammatory hyperpigmentation (PIH) is a frequently encountered problem and represents the sequelae of various cutaneous
disorders as well as therapeutic interventions. This acquired excess of pigment can be attributed to various preceding disease
processes that affect the skin such as infections, allergic reactions, mechanical injuries, reactions to medications, phototoxic
eruptions, trauma (eg, burns), and inflammatory diseases (eg, lichen planus, lupus erythematosus, atopic dermatitis).
PIH can also be seen following treatment with a number of electromagnetic devices such as ultrasound, radiofrequency, lasers,
light-emitting diodes, and visible light, as well as secondary to microdermabrasion. Typically, postinflammatory hyperpigmentation is
most severe in patients whose basal cell layer of the epidermis is disrupted such as lichenoid dermatoses or lupus erythematosus.

Pathophysiology
Postinflammatory hyperpigmentation is caused by 1 of 2 mechanisms that result in either epidermal or dermal melanosis. The
epidermal inflammatory response (ie, dermatitis) results in the release and subsequent oxidation of arachidonic acid to
prostaglandins, leukotrienes, and other products. These products of inflammation alter the activity of both immune cells and
melanocytes.
Specifically, these inflammatory products stimulate epidermal melanocytes, causing them to increase the synthesis of melanin and
subsequently to increase the transfer of pigment to surrounding keratinocytes. Such increased stimulation and transfer of melanin
granules results in epidermal hypermelanosis.
On the contrary, dermal melanosis occurs when inflammation disrupts the basal cell layer, causing melanin pigment to be released
and subsequently trapped by macrophages in the papillary dermis, also known as pigmentary incontinence.
Fibroblast-derived melanogenic growth factors may be salient in mesenchymal-epithelial interactions modulating melanocyte
function.[1]

Epidemiology
Frequency
United States
Postinflammatory hyperpigmentation is a universal response of the skin, but it is more common in individuals with darker skin
(Fitzpatrick skin types III to VI). Postinflammatory hyperpigmentation can be caused by any inflammatory process of the skin;
however, it is more apparent in photo-induced dermatoses and more severe in lichenoid dermatoses.
International
Internationally, postinflammatory hyperpigmentation is a common inflammatory response of the skin, developing more commonly in
darker skin. Despite their lighter skin color, certain Asians (from Pacific rim countries such as Japan, Taiwan, China) are more
susceptible to developing PIH following one of the inciting factors listed above.

Mortality/Morbidity
Morbidity associated with postinflammatory hyperpigmentation is related to the underlying inflammatory process that causes
postinflammatory hyperpigmentation. If the hyperpigmentation is located in cosmetically sensitive regions, a significant amount of
emotional distress may result.

Race
Although postinflammatory hyperpigmentation occurs in whites, it is more common in darker pigmented individuals including African
Americans or Asians.

Sex
Postinflammatory hyperpigmentation occurs with equal incidence in males and females; it has no sexual predilection.

Age
Postinflammatory hyperpigmentation can occur in persons of any age.

History
A diagnosis of postinflammatory hyperpigmentation should be considered if a history of a preceding pathologic process or injury to
the affected area of hyperpigmentation is present.

Physical
The distribution of the hypermelanotic lesions depends on the location of the original inflammatory dermatosis. The color of the
lesions ranges from light brown to black, with a lighter brown appearance if the pigment is within the epidermis (ie, epidermal
melanosis) and a darker gray to bluish appearance if lesions contain dermal melanin (ie, dermal melanosis). Note the image below.

Photo of a 42-year-old African American woman with macules of postinflammatory hyperpigmentation on

the left side of her face as a result of acne excorie.

Causes
Postinflammatory hyperpigmentation can occur with various disease processes that affect the skin. These processes include
allergic reactions, infections, trauma, and phototoxic eruptions. Fractional laser photothermolysis occasionally induces
postinflammatory hyperpigmentation.[2, 3]
Common inflammatory diseases that result in postinflammatory hyperpigmentation include acne excorie, lichen planus, systemic
lupus erythematosus, chronic dermatitis, and cutaneous T-cell lymphoma, especially erythrodermic variants.
Furthermore, lesions of postinflammatory hyperpigmentation can darken with exposure to UV light and various chemicals and
medications, such as tetracycline, bleomycin, doxorubicin, 5-fluorouracil, busulfan, arsenicals, silver, gold, antimalarial drugs,
hormones, and clofazimine.

Differential Diagnoses

Acanthosis Nigricans
Addison Disease
Amyloidosis, Lichen
Amyloidosis, Macular
Ephelides
Erythema Dyschromicum Perstans
Hemochromatosis
Lentingines
Lichen Planus
Melasma
Riehl Melanosis
Tinea Versicolor

Laboratory Studies
A Wood lamp examination enables distinction of epidermal postinflammatory hyperpigmentation (PIH) from dermal
postinflammatory hyperpigmentation. Epidermal lesions tend to have accentuated borders under a Wood lamp examination,
whereas those of dermal lesions appear poorly circumscribed and are not accentuated with a Wood lamp examination.

Procedures
If a history of preceding inflammatory dermatosis is unclear or absent, skin biopsy is warranted to exclude other underlying causes
of hyperpigmentation. Staining of the biopsy specimen with Fontana-Masson silver stain for melanin enables localization of the
melanin in the epidermis and/or the dermis.

Histologic Findings
Epidermal postinflammatory hyperpigmentation involves increased melanin pigment in the basal cell layer of the epidermis.
Occasionally, giant melanosomes are evident in the epidermis.
Dermal postinflammatory hyperpigmentation involves melanin pigment in the upper dermis, with pigment incontinence due to
increased numbers of melanophages in the papillary dermis.

Medical Care
The treatment of postinflammatory hyperpigmentation (PIH) tends to be a difficult and prolonged process that often takes 6-12
months to achieve the desired results of depigmentation. Each of these treatment options potentially improves epidermal
hypermelanosis, but none is proven effective for dermal hypermelanosis. Daily use of a broad-spectrum sunscreen (sun protection
factor [SPF] 15 or greater) is an essential part of any therapeutic regimen.

A variety of topical treatments have been used to treat epidermal postinflammatory hyperpigmentation, with varying degrees of
success. These agents include hydroquinone, tretinoin cream, corticosteroids, glycolic acid (GA), and azelaic acid.[4] Lightening of
hyperpigmented areas may be achieved with one of the previously named topical agents; however, a combination of topical creams
and gels, chemical peels, and sunscreens may be necessary for significant improvement.[5] They are only effective for epidermal
hyperpigmentation.
Topical tretinoin 0.1% has been effective in treating postinflammatory hyperpigmentation. GA peels, in combination with tretinoin
and hydroquinone, are an effective treatment of postinflammatory hyperpigmentation in dark-complexioned individuals.[6] Alltrans retinoic acid aqueous gel 0.1-0.4% may be applied concomitantly with hydroquinonelactic acid ointment for bleaching.[7,
8]
After sufficient improvement of the hyperpigmentation is achieved, a corticosteroid may be applied topically with hydroquinone to
promote healing. This combination of various topical therapeutic agents has been shown to be beneficial, especially on the face.
Topical azelaic acid, which has been approved for the treatment of acne vulgaris, is useful for postinflammatory hyperpigmentation
as well.[9] In acne patients who are prone to postinflammatory hyperpigmentation, azelaic acid may be a good treatment option. The
efficacy of tazarotene 0.1% cream for the treatment of dyschromia associated with photoaging and for acne vulgaris may also be
beneficial, particularly in people with dark skin tone.[10]
Early and efficacious treatment of acne in patients with dark-toned skin helps minimize pigmentary abnormalities.[11]
Other treatment modalities include use of trichloroacetic acid and gentle cryotherapy with liquid nitrogen. Each method must be
used with extreme caution to avoid necrosis or blistering of the treated skin. These 2 methods of treatment should be avoided in
dark-skinned patients because of the risk of permanent depigmentation and scarring.
Pigmented makeup creams have also been successfully used to camouflage hyperpigmented skin to a hue similar to that of the
surrounding unaffected skin.
More options will be available in the future. Retinaldehyde (RAL) has shown depigmenting activity, while GA decreases the excess
of pigment by a wounding and reepithelization process. A combination of RAL 0.1% and GA 6% (Diacneal) in the treatment of acne
vulgaris and postinflammatory hyperpigmentation has been reported.[12] The peroxidase inhibitor methimazole, a noncytotoxic
inhibitor of melanin production, is a possible agent for topical use in the years ahead.[13]
The efficacy and safety of a combined treatment regimen including serial GA peels, topical azelaic acid cream, and adapalene gel
in the treatment of recalcitrant melasma was evaluated in 28 patients in a prospective, randomized, controlled trial lasting 20
weeks.[14] Those receiving chemical peels underwent serial GA peels in combination with topical azelaic acid 20% cream (twice
daily) and adapalene 0.1% gel (4 times daily, applied at night). Combined treatment with serial GA peels, azelaic acid cream, and
adapalene gel may be an effective and safe therapy for recalcitrant melasma. Choi et al report that Lepidium apetalum is a
potential inhibitor of hyperpigmentation caused by UV radiation.[15]
Other studies suggest that decapeptide-12 was 17-fold more potent than hydroquinone at inhibiting tyrosinase in vitro. .[16,
17]
Decapeptide-12 was shown not to be cytotoxic to melanocytes, making it a safer alternative to hydroquinone. A pilot study by
Hantash and Jimenez showed that twice a day treatment for 4 months with decapeptide-12 formulated in a topical emulsion also
resulted in a 50% improvement in melasma in patients who had failed 6 months of Tri-Luma therapy.[17] The potential of
decapeptide-12 as a therapeutic option for melasma was recently reviewed.[18]
Depigmenting agents abound in a variety of formations. Aloe vera leaf extract and its active ingredient aloin are considered potent
skin depigmenting agents.[19]Delivery too can be important. Glabridin microsponge-loaded gel may be beneficial in treating
hyperpigmentation.[20]
Also see Skin Lightening and Depigmenting Agents.

Surgical Care
Fractional photothermolysis may be used to treat postinflammatory hyperpigmentation after or in conjunction with ablative carbon
dioxide laser resurfacing.[21, 22, 23] Paradoxically, successful treatment of postinflammatory hyperpigmentation after two sessions of
fractional carbon dioxide laser has been described.[24] Laser treatment may be able to address dermal pigment deposition. The
1064-nm Q-switched Nd:YAG laser with low-fluence treatment may be considered in the treatment of postinflammatory
hyperpigmentation caused by procedures such as laser surgery and chemical peeling in Asian patients.[25]
The guideline from the British Association of Dermatologist, Guidelines for topical photodynamic therapy: update,[23] may be of
interest, as may Photodynamic Therapy for the Dermatologist.

Medication Summary
Topical treatments include hydroquinone, azelaic acid, corticosteroids, tretinoin cream, GA, and trichloroacetic acid.[26] Skin
whitening products are used for clinical treatment of postinflammatory hyperpigmentation.[27] They act at various levels of melanin
production in the skin, some being competitive inhibitors of tyrosinase, while others inhibit the maturation of this enzyme or the
transport of melanosomes from melanocytes to surrounding keratinocytes. Soy products containing serine protease inhibitors
appear to have potential as a therapeutic option for the treatment of hyperpigmentation.[28] Postinflammatory hyperpigmentation has
also been treated using vitamin C with a full-face iontophoresis mask and a mandelic/malic acid skin care regimen.[29] Extracts of the
tropical fern Polypodium leucotomos given orally may be beneficial as an adjunctive approach.[30] Wide-spectrum sunscreens are an
integral part of any treatment regimen.
Winhoven et al reported successful therapy with oral isotretinoin in an Asian patient.[31] Combined therapy using Q-switched ruby
laser and cutaneous bleaching with tretinoin and hydroquinone may be used for periorbital skin hyperpigmentation in selected
patients.[32] The efficacy and safety retinoids and azelaic acid in individuals with a dark complexion has been demonstrated.[33]

Depigmenting Agents
Class Summary
These agents are used for gradual bleaching of hyperpigmented skin.
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Hydroquinone (Alphaquin HP, Eldopaque Forte, Nuquin HP)

A 1,4-benzenediol that suppresses melanocyte metabolic processes, especially enzymatic oxidation of tyrosine to 3,4dihydroxyphenylamine. Exposure to sun reverses effects and causes repigmentation.

Acne Agents, Topical

Class Summary
Acne products are used for their antibacterial and comedolytic properties and some may have bleaching effects.
View full drug information

Azelaic acid (Azelex, Finacea)

May have bleaching effect on skin. Also, may have an antimicrobial effect.

Keratolytic Agents
Class Summary
These agents cause cornified epithelium to swell and soften and then become macerated and desquamated.
View full drug information

Trichloroacetic acid topical (Tri-Chlor)

Cauterizes skin, keratin, and other tissues. Trichloroacetic acid (TCA) is a highly corrosive desiccating agent that cauterizes skin,
keratin, and other tissues and is used to burn lesions. Although it is caustic, it causes less local irritation and systemic toxicity than
other agents in the same class.

Retinoid-Like Agents
Class Summary
Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes and modulate keratinocyte differentiation.
View full drug information

Tretinoin topical (Avita, Renova, Retin-A)

Inhibits microcomedo formation and eliminates lesions. Makes keratinocytes in sebaceous follicles less adherent and easier to
remove. Available as 0.025%, 0.05%, and 0.1% creams. Also available as 0.01% and 0.025% gels.

Corticosteroids
Class Summary
These drugs have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's
immune response to diverse stimuli.
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Hydrocortisone topical (Cortaid, Cortizone, Westcort)

An adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Has mineralocorticoid and
glucocorticoid effects, resulting in anti-inflammatory activity.
View full drug information

Desonide (DesOwen, LoKara)

Stimulates synthesis of enzymes that decrease inflammation. Suppresses mitotic activity and causes vasoconstriction.

View full drug information

Betamethasone topical (Celestone Diprolene, Luxiq)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Deterrence/Prevention
Patients with postinflammatory hyperpigmentation (PIH) should use sunscreen on a daily basis to prevent any further darkening of
lesions.

Prognosis
Postinflammatory hyperpigmentation tends to fade with time and therapy, as previously discussed. Remnants of epidermal
hyperpigmentation may persist for indefinite periods, typically 6-12 months, after the initial inflammatory process resolves. Dermal
postinflammatory hyperpigmentation may even persist for years.

Patient Education
Educate patients about the cause of postinflammatory hyperpigmentation, prolonged therapy, and persistence of hyperpigmented
lesions.