Postinflammatory Hyperpigmentation

Aka: Postinflammatory Hyperpigmentation

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II. Definitions

  1. Postinflammatory Hyperpigmentation
    1. Hyperpigmentation response to inflammation on dark skin

III. Pathophysiology

  1. Common complication following Trauma or inflammation in darker skin type (3 to 6)
  2. Local inflammation results in Prostaglandin, Leukotriene and Thromboxane release
  3. Epidermal Melanocytes hypertrophy, synthesizing increased Melanin (reactive hypermelanosis)

IV. Causes: Common precipitating lesions

  1. Inflammation
    1. Acne Vulgaris (more than half of cases)
    2. Psoriasis
    3. Atopic Dermatitis
    4. Contact Dermatitis
    5. Lichen Planus
  2. Trauma
    1. Laser therapy or Light Therapy
    2. Cryotherapy
    3. Chemical Peels
    4. Skin Trauma
    5. Insect Bites

V. Signs

  1. Irregular, dark Macules and patches at sites of injury or inflammation

VI. Management

  1. General
    1. Most important management concept is to treat the underlying inflammatory condition
    2. Sunscreen with SPF 30 prevents darkening of Postinflammatory Hyperpigmentation
      1. See prevention below
    3. Topical specific protocols below are not necessary
      1. Epidermal Postinflammatory Hyperpigmentation fades in 6-12 months without treatment
      2. Deeper Postinflammatory Hyperpigmentation may take years to fade
    4. Topical specific treatments have potential risks
      1. Hydroquinone is carcinogenic in rats (when ingested)
      2. Hydroquinone causes exogenous ochronosis (progressive skin darkening where applied)
      3. Bleaching agents may result in Hypopigmentation
      4. Peels and Keratolytics may worsen Postinflammatory Hyperpigmentation
  2. Medications
    1. Bleaching agents (risk of blotchy Hyperpigmentation)
      1. Hydroquinone (Eldoquin Forte) 4% applied once to twice daily for 3 months
    2. Chemical Peels
      1. Salicylic acid
      2. Glycolic Acid peel
    3. Keratolytics
      1. Azelaic Acid (Azelex) 20% cream applied twice daily
      2. Tretinoin (Retin-A) 0.025-0.050% applied at bedtime
      3. Tazarotene (Tazorac) 0.1% cream applied at bedtime
  3. Medication Adverse Effects
    1. Desquamation
    2. Burning or stinging
    3. Dry Skin
    4. Pruritus
  4. Protocol: Single agent for 3 months
    1. Hydroquinone 4% is preferred first line agent
  5. Protocol: Combination agents for 3 months
    1. Most effective protocol is to use these agents in combination
    2. Compounded products (bleaching agent, Keratolytic, Corticosteroid)
      1. Kligman's Formula (Hydroquinone 2%,Tretinoin 0.025%, Mometasone 0.1%)
      2. Tri-luma (Hydroquinone 2%, Tretinoin 0.05%, Flucinolone 0.01%)
    3. Individual agents used together
      1. Hydroquinone 2% with Glycolic Acid 10% applied twice daily
      2. Tretinoin (Retin A) applied at bedtime
  6. Protocol: Other Management
    1. Laser Therapy
      1. May be used with caution, starting with small treatment areas
      2. Risk of dyspigmentation and scarring

VII. Prevention

  1. Sunscreen Broad Spectrum, SPF 30
    1. Prevents darkening of Postinflammatory Hyperpigmentation
    2. Use water-based, broad spectrum (UVA and UVB protection)
    3. Iron oxide Sunscreens offer optimal protection

VIII. Course

  1. Hyperpigmentation changes can persist for years

IX. References

  1. Burns (1997) Dermatol Surg 23(3): 171-5 [PubMed]
  2. Davis (2010) J Clin Aesthet Dermatol 3(7): 20-31 [PubMed]
  3. Frazier (2023) Am Fam Physician 107(1): 26-34 [PubMed]
  4. Plensdorf (2017) Am Fam Physician 96(12): 797-804 [PubMed]

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