- Nazanin Saedi, MD
Nazanin Saedi, MD
- Associate Professor - Department of Dermatology and Cutaneous Biology
- Thomas Jefferson University
Postinflammatory hyperpigmentation (PIH), also known as postinflammatory melanosis, is a reactive hypermelanosis of the skin that occurs as a sequela of cutaneous inflammation (picture 1A-I) . Common causes of PIH include acne vulgaris, eczematous dermatoses, and burn injury. PIH is a frustrating problem that can have a strong psychological toll on affected patients.
The pathogenesis, diagnosis, and treatment of PIH will be reviewed here. Other causes of cutaneous hyperpigmentation are reviewed separately. (See "Approach to the patient with hyperpigmentation disorders".)
PIH is a common disorder that can occur at any age and has an equivalent incidence in males and females. Although PIH may occur regardless of skin color, risk for clinically significant PIH increases with darkening skin pigmentation.
Skin phototype, a measure defined by the self-reported tendency to sunburn or tan after sun exposure (table 1), correlates with skin pigmentation and is useful for stratifying risk for PIH. Compared with individuals with skin phototype I or II, individuals with skin phototypes III to VI are more likely to develop PIH .
ETIOLOGY AND PATHOGENESIS
The provoking inflammatory process that leads to PIH can be endogenous or exogenous . Common endogenous causes of PIH include acne vulgaris, atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, psoriasis, and lichen planus. Accidental burns, non-ionizing radiation therapy, phototoxicity, chemical peels, and laser procedures are examples of exogenous causes [1,3,4].
- Epstein JH. Postinflammatory hyperpigmentation. Clin Dermatol 1989; 7:55.
- Rossi AM, Perez MI. Treatment of hyperpigmentation. Facial Plast Surg Clin North Am 2011; 19:313.
- Callender VD, St Surin-Lord S, Davis EC, Maclin M. Postinflammatory hyperpigmentation: etiologic and therapeutic considerations. Am J Clin Dermatol 2011; 12:87.
- Hasan AT, Eaglstein W, Pardo RJ. Solar-induced postinflammatory hyperpigmentation after laser hair removal. Dermatol Surg 1999; 25:113.
- Tomita Y, Maeda K, Tagami H. Mechanisms for hyperpigmentation in postinflammatory pigmentation, urticaria pigmentosa and sunburn. Dermatologica 1989; 179 Suppl 1:49.
- Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol 2010; 3:20.
- Vashi NA, Kundu RV. Facial hyperpigmentation: causes and treatment. Br J Dermatol 2013; 169 Suppl 3:41.
- Masu S, Seiji M. Pigmentary incontinence in fixed drug eruptions. Histologic and electron microscopic findings. J Am Acad Dermatol 1983; 8:525.
- Ruiz-Maldonado R, Orozco-Covarrubias ML. Postinflammatory hypopigmentation and hyperpigmentation. Semin Cutan Med Surg 1997; 16:36.
- Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin 2000; 18:91.
- Weedon D. Disorders of pigmentation. In: Weedon's Skin Pathology, 3rd ed, Elsevier Limited, 2010. p.255.
- Jimbow K, Obata H, Pathak MA, Fitzpatrick TB. Mechanism of depigmentation by hydroquinone. J Invest Dermatol 1974; 62:436.
- Katsambas AD, Stratigos AJ. Depigmenting and bleaching agents: coping with hyperpigmentation. Clin Dermatol 2001; 19:483.
- Ennes SBP, Paschoalick RC, Mota de Avelar. A double-blind, comparative, placebo-controlled study of the efficacy and tolerability of 4% hydroquinone as a depigmenting agent in melasma. J Dermatolog Treat 2000; 11:173.
- Cook-Bolden FE, Hamilton SF. An open-label study of the efficacy and tolerability of microencapsulated hydroquinone 4% and retinol 0.15% with antioxidants for the treatment of hyperpigmentation. Cutis 2008; 81:365.
- Grimes PE. A microsponge formulation of hydroquinone 4% and retinol 0.15% in the treatment of melasma and postinflammatory hyperpigmentation. Cutis 2004; 74:362.
- Saxena S, Andersen RM, Maibach HI. Pitfalls in clinical trials reveal need for well tolerated, more effective depigmenting agents. J Dermatolog Treat 2015; 26:440.
- Ortonne JP, Passeron T. Melanin pigmentary disorders: treatment update. Dermatol Clin 2005; 23:209.
- Levin CY, Maibach H. Exogenous ochronosis. An update on clinical features, causative agents and treatment options. Am J Clin Dermatol 2001; 2:213.
- Touart DM, Sau P. Cutaneous deposition diseases. Part II. J Am Acad Dermatol 1998; 39:527.
- Kang HY, Valerio L, Bahadoran P, Ortonne JP. The role of topical retinoids in the treatment of pigmentary disorders: an evidence-based review. Am J Clin Dermatol 2009; 10:251.
- Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol 1975; 111:40.
- Bulengo-Ransby SM, Griffiths CE, Kimbrough-Green CK, et al. Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med 1993; 328:1438.
- Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study. Cutis 2006; 77:45.
- Jacyk WK. Adapalene in the treatment of African patients. J Eur Acad Dermatol Venereol 2001; 15 Suppl 3:37.
- Tanghetti E, Dhawan S, Green L, et al. Randomized comparison of the safety and efficacy of tazarotene 0.1% cream and adapalene 0.3% gel in the treatment of patients with at least moderate facial acne vulgaris. J Drugs Dermatol 2010; 9:549.
- Nighland M, Yusuf M, Wisniewski S, et al. The effect of simulated solar UV irradiation on tretinoin in tretinoin gel microsphere 0.1% and tretinoin gel 0.025%. Cutis 2006; 77:313.
- Jutley GS, Rajaratnam R, Halpern J, et al. Systematic review of randomized controlled trials on interventions for melasma: an abridged Cochrane review. J Am Acad Dermatol 2014; 70:369.
- Bhawan J, Grimes P, Pandya AG, et al. A histological examination for skin atrophy after 6 months of treatment with fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05% cream. Am J Dermatopathol 2009; 31:794.
- Grimes PE, Bhawan J, Guevara IL, et al. Continuous therapy followed by a maintenance therapy regimen with a triple combination cream for melasma. J Am Acad Dermatol 2010; 62:962.
- Nguyen QH, Bui TP. Azelaic acid: pharmacokinetic and pharmacodynamic properties and its therapeutic role in hyperpigmentary disorders and acne. Int J Dermatol 1995; 34:75.
- Lowe NJ, Rizk D, Grimes P, et al. Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients. Clin Ther 1998; 20:945.
- Kakita LS, Lowe NJ. Azelaic acid and glycolic acid combination therapy for facial hyperpigmentation in darker-skinned patients: a clinical comparison with hydroquinone. Clin Ther 1998; 20:960.
- Grimes PE. Management of hyperpigmentation in darker racial ethnic groups. Semin Cutan Med Surg 2009; 28:77.
- Burns RL, Prevost-Blank PL, Lawry MA, et al. Glycolic acid peels for postinflammatory hyperpigmentation in black patients. A comparative study. Dermatol Surg 1997; 23:171.
- Grimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups. Dermatol Surg 1999; 25:18.
- Ahn HH, Kim IH. Whitening effect of salicylic acid peels in Asian patients. Dermatol Surg 2006; 32:372.
- Kim S, Cho KH. Treatment of procedure-related postinflammatory hyperpigmentation using 1064-nm Q-switched Nd:YAG laser with low fluence in Asian patients: report of five cases. J Cosmet Dermatol 2010; 9:302.
- Cho SB, Park SJ, Kim JS, et al. 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.
- Katz TM, Goldberg LH, Firoz BF, Friedman PM. Fractional photothermolysis for the treatment of postinflammatory hyperpigmentation. Dermatol Surg 2009; 35:1844.
- Oram Y, Akkaya AD. Refractory Postinflammatory Hyperpigmentation Treated Fractional CO2 Laser. J Clin Aesthet Dermatol 2014; 7:42.
- 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.
- Draelos ZD. A split-face evaluation of a novel pigment-lightening agent compared with no treatment and hydroquinone. J Am Acad Dermatol 2015; 72:105.
- McMichael L. Skin camouflage. BMJ 2012; 344:d7921.
- ETIOLOGY AND PATHOGENESIS
- CLINICAL MANIFESTATIONS
- Patient history
- Physical examination
- Wood's lamp examination
- DIFFERENTIAL DIAGNOSIS
- Essential measures
- - Photoprotection
- - Elimination of exacerbating factors
- Medical treatment
- - Patient selection
- - First-line therapy
- Topical hydroquinone
- - Second-line therapy
- Topical retinoids
- Triple-agent therapy
- Azelaic acid
- Chemical peels
- Other therapies
- SUMMARY AND RECOMMENDATIONS