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| EDITORIAL |
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| Year : 2019 | Volume
: 6
| Issue : 2 | Page : 57-58 |
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Postinflammatory hyperpigmentation: what we should know
Rashmi Sarkar1, Anupam Das2
1 Department of Dermatology, Maulana Azad Medical College, New Delhi, India
2 Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
| Date of Web Publication | 19-Dec-2019 |
Correspondence Address:
Anupam Das
“Prerana” 19, Phoolbagan, Kolkata 700086, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/Pigmentinternational.Pigmentinternational_
How to cite this article:
Sarkar R, Das A. Postinflammatory hyperpigmentation: what we should know. Pigment Int 2019;6:57-8 |
Postinflammatory hyperpigmentation (PIH) is an acquired hypermelanosis that develops following cutaneous inflammation or injury, which can arise in all skin types, but more frequently affects skin-of-color patients. The most common precipitating factors include: infections such as dermatophytoses or viral exanthems, allergic reactions due to insect bites or contact dermatitis, dermatoses like acne vulgaris, atopic dermatitis, impetigo; papulo-squamous diseases like psoriasis or lichen planus, drug-induced PIH, or injury from irritants, burns, or cosmetic procedures. Authors of the review article (published in this issue) have comprehensively summarized the dermatological conditions that can lead to post inflammatory hyperpigmentation.
It develops due to increased synthesis of melanin or an irregular dispersion of pigment, following cutaneous inflammation. When PIH is restricted to the epidermis, there is an increase in the production and transfer of melanin to surrounding keratinocytes, by apocopation. When PIH involves the dermis, it is due to inflammation-induced damage to basal keratinocytes, leading to release of large amounts of melanin, which is phagocytosed by macrophages, producing a bluish-gray cutaneous discoloration.[1]
The course and outcome of PIH are unpredictable and post-treatment relapse is very common. The underlying condition should be addressed aggressively. The mainstay of therapy is photoprotection to prevent the worsening of PIH. Patients should be thoroughly educated regarding the use of broad-spectrum sunscreens with a sun protection factor (SPF) of 30 or above, apart from adopting general measures like avoidance of sunlight, wearing covered clothes, hats etc. Specific therapeutic options include topical depigmenting agents, such as hydroquinone, low potency corticosteroids, azelaic acid, kojic acid, licorice extract, and retinoids, and procedures such as chemical peeling and laser therapy. Topical agents constitute the first line of management followed by aesthetic procedures, if there is inadequate response even after 8–12 weeks of conventional management.[2]
In refractory cases, superficial and medium depth peels may be used. Superficial peels are preferred because they offer greater flexibility when it comes to Indian skin, apart from maintaining a smooth skin texture. Additionally, the chances of worsening of PIH are minimal. Superficial peels include 15–20% trichloroacetic acid (TCA), 50–70% glycolic acid (GA), four to ten coats of Jessner’s solution, 20–30% salicylic acid (SA) etc.
SA peels (with or without 4% hydroquinone) have shown good results in the treatment of PIH in darker skin patients.[3],[4] In total, 20–30% SA peel may also be combined with 0.1% topical tretinoin solution, for better results.[5] GA peels give excellent results in post-acne pigmentation. We would like to mention that it is important to treat acne simultaneously with doxycycline or isotretinoin along with depigmenting agents, for better results. Even when the pigmentation is following some other dermatological condition, GA peels are known to produce satisfactory improvement. A total of 70% GA followed by 35% TCA peels give good results in PIH due to any condition including post-acne pigmentation and melasma.[6] Burns et al.[7] showed improvement in PIH with six serial high-concentration (maximum 68%) GA peels applied in combination with 2% HQ + 10% GA gel twice daily and 0.05% tretinoin cream at night. The control group applied the topical therapy only. All patients were Fitzpatrick skin type IV or above. Besides, in a study by Sarkar et al.[8], serial GA peels in combination with a modified Kligman formula (MKF) containing hydroquinone 2%, tretinoin 0.05%, and hydrocortisone 1% were found to be efficacious and safe in the treatment of facial PIH in dark-skinned patients.
Lasers may be used in combination with chemical peels and other topical modalities. The 1064 nm quality-switched (QS) neodymium-doped yttrium aluminum garnet (Nd: YAG), Q-switched ruby laser, and 1550 nm Erbium fiber fractional thermolysis lasers provide good results.[9],[10],[11] Authors of the review article have discussed the medical and aesthetic management in detail.[12] Polypodium leucotomos have been proposed as one of the emerging therapies in the management of PIH, but there are no clinical trials in support of this venture.[2] Therefore, postinflammatory hyperpigmentation is a notorious dermatosis, resulting from a multitude of factors and therapy is extremely challenging, to say the least. Photoprotection alongside topical agents form the backbone of treatment, followed by chemical peels and lasers as the next line of options.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
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| 2. | Patel AB. Postinflammatory hyperpigmentation: review of pathogenesis, prevention, and treatment. Pigment Int 2014;1:59-69. [Full text] |
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| 4. | Bari AU, Iqbal Z, Rahman SB. Tolerance and safety of superficial chemical peeling with salicyclic acid in various facial dermatoses. Indian J Dermatol Venereol Leprol 2005;71:87-90. [ PUBMED] [Full text] |
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| 6. | Coleman WP 3rd, Futrell JM. The glycolic acid trichloroacetic acid peel. J Dermatol Surg Oncol 1994;20:76-80 |
| 7. | Burns RL, Prevost-Blank PL, Lawry MA, Lawry TB, Faria DT, Fivenson DP. Glycolic acid peels for postinflammatory hyperpigmentation in black patients. A comparative study. Dermatol Surg 1997;23:171-4. |
| 8. | Sarkar R, Parmar NV, Kapoor S. Treatment of postinflammatory hyperpigmentation with a combination of glycolic acid peels and a topical regimen in dark-skinned patients: a comparative study. Dermatol Surg 2017;43:566-73. |
| 9. | Tse Y, Levine VJ, McClain SA, Ashinoff R. The removal of cutaneous pigmented lesions with the Q-switched ruby laser and the Q-switched neodymium: yttrium-aluminum-garnet laser. A comparative study. J Dermatol Surg Oncol 1994;20:795-800. |
| 10. | Tafazzoli A, Rostan EF, Goldman MP. Q-switched ruby laser treatment for postsclerotherapy hyperpigmentation. Dermatol Surg 2000;26:653-6. |
| 11. | Cho SB, Park SJ, Kim JS, Kim MJ, Bu TS. Treatment of post-inflammatory hyperpigmentation using 1064-nm Q-switched Nd: YAG laser with low fluence: report of three cases. J Eur Acad Dermatol Venereol 2009;23:1206-7. |
| 12. | Dayal S, Sahu P, Sangal B, Sharma S. Role of chemical peels in postinflammatory hyperpigmentation: a comprehensive review. Pigment Int 2019;6:59-66. [Full text] |
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