Pigment

Postinflammatory Hyperpigmentation

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Postinflammatory Hyperpigmentation

  • Definition
  1. Hyperpigmentation response to inflammation on dark skin
  • 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 Melanin
  • Signs
  1. Irregular, dark Macules and patches at sites of injury or inflammation
  • Management
  1. General
    1. Most important management concept is to treat the underlying inflammatory condition
    2. Sunscreen with SPF 30 is required to prevent darkening of Postinflammatory Hyperpigmentation
    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. Single agents
    1. Hydroquinone 4% is preferred first line agent
  3. Combination agents
    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
  4. Bleaching agents (risk of blotchy Hyperpigmentation)
    1. Hydroquinone (Eldoquin Forte) 2-4% applied twice daily
  5. Chemical Peels
    1. Salicylic acid
    2. Glycolic Acid peel
  6. 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
  • Course
  1. Changes can persist for years