eMedicine Specialties > Dermatology > Diseases of Pigmentation
Postinflammatory Hyperpigmentation
Updated: Jul 27, 2009
Introduction
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; these processes include infections, allergic reactions, mechanical injuries, reactions to medications, phototoxic eruptions, trauma (eg, burns), and inflammatory diseases (eg, lichen planus, lupus erythematosus, atopic dermatitis). Typically, postinflammatory hyperpigmentation is most severe in patients with lichenoid dermatoses in which the basal cell layer of the epidermis is disrupted.
Pathophysiology
Postinflammatory hyperpigmentation is caused by 1 of 2 mechanisms that result in either epidermal melanosis 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.
Frequency
United States
Postinflammatory hyperpigmentation is a universal response of the skin, but it is more common in pigmented, darker skin. 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.
Mortality/Morbidity
- Morbidity associated with postinflammatory hyperpigmentation is related to the underlying inflammatory process that causes postinflammatory hyperpigmentation.
- To the author's knowledge, no cases of mortality have been associated with postinflammatory hyperpigmentation.
Race
Although postinflammatory hyperpigmentation occurs in whites, it is more common in dark-skinned individuals (eg, African Americans).
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.
Clinical
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 appearance if lesions contain dermal melanin (ie, dermal melanosis).
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 excoriée.
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.1,2
- Common inflammatory diseases that result in postinflammatory hyperpigmentation include acne excoriée, 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.
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References
Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: experience with 961 treatments. Dermatol Surg. Mar 2008;34(3):301-5; discussion 305-7. [Medline].
Harari Z, Sommer I, Knobel B. Multifocal contact dermatitis to nitroderm TTS 5 with extensive postinflammatory hypermelanosis. Dermatologica. 1987;174(5):249-52. [Medline].
Breathnach AS. Melanin hyperpigmentation of skin: melasma, topical treatment with azelaic acid, and other therapies. Cutis. Jan 1996;57(1 Suppl):36-45. [Medline].
Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin. Jan 2000;18(1):91-8, ix. [Medline].
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. Mar 1997;23(3):171-4; discussion 175. [Medline].
Yoshimura K, Harii K, Aoyama T, Shibuya F, Iga T. A new bleaching protocol for hyperpigmented skin lesions with a high concentration of all-trans retinoic acid aqueous gel. Aesthetic Plast Surg. Jul-Aug 1999;23(4):285-91. [Medline].
Yoshimura K, Harii K, Aoyama T, Iga T. Experience with a strong bleaching treatment for skin hyperpigmentation in Orientals. Plast Reconstr Surg. Mar 2000;105(3):1097-108; discussion 1109-10. [Medline].
Del Rosso JQ. The use of topical azelaic acid for common skin disorders other than inflammatory rosacea. Cutis. Feb 2006;77(2 Suppl):22-4. [Medline].
Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study. Cutis. Jan 2006;77(1):45-50. [Medline].
Katsambas AD. RALGA (Diacneal), a retinaldehyde and glycolic acid association and postinflammatory hyperpigmentation in acne--a review. Dermatology. 2005;210 Suppl 1:39-45. [Medline].
Kasraee B, Handjani F, Parhizgar A, et al. Topical methimazole as a new treatment for postinflammatory hyperpigmentation: report of the first case. Dermatology. 2005;211(4):360-2. [Medline].
Erbil H, Sezer E, Tastan B, Arca E, Kurumlu Z. Efficacy and safety of serial glycolic acid peels and a topical regimen in the treatment of recalcitrant melasma. J Dermatol. Jan 2007;34(1):25-30. [Medline].
Choi H, Ahn S, Lee BG, Chang I, Hwang JS. Inhibition of skin pigmentation by an extract of Lepidium apetalum and its possible implication in IL-6 mediated signaling. Pigment Cell Res. Dec 2005;18(6):439-46. [Medline].
Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: a pilot study. Dermatol Surg. Dec 2005;31(12):1645-50. [Medline].
Rokhsar CK, Ciocon DH. Fractional photothermolysis for the treatment of postinflammatory hyperpigmentation after carbon dioxide laser resurfacing. Dermatol Surg. Mar 2009;35(3):535-7. [Medline].
[Guideline] Morton CA, McKenna KE, Rhodes LE. Guidelines for topical photodynamic therapy: update. Br J Dermatol. Dec 2008;159(6):1245-66. [Medline].
Perez-Bernal A, Munoz-Perez MA, Camacho F. Management of facial hyperpigmentation. Am J Clin Dermatol. Sep-Oct 2000;1(5):261-8. [Medline].
Winhoven SM, Ahmed I, Owen CM, Lear JT. Postinflammatory hyperpigmentation in an Asian patient: a dramatic response to oral isotretinoin (13-cis-retinoic acid). Br J Dermatol. Feb 2005;152(2):368-9. [Medline].
Momosawa A, Kurita M, Ozaki M, et al. Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for periorbital skin hyperpigmentation in Asians. Plast Reconstr Surg. Jan 2008;121(1):282-8. [Medline].
Epstein JH. Postinflammatory hyperpigmentation. Clin Dermatol. Apr-Jun 1989;7(2):55-65. [Medline].
Lacz NL, Vafaie J, Kihiczak NI, Schwartz RA. Postinflammatory hyperpigmentation: a common but troubling condition. Int J Dermatol. May 2004;43(5):362-5. [Medline].
Nordlund JJ. Postinflammatory hyperpigmentation. Dermatol Clin. Apr 1988;6(2):185-92. [Medline].
Ruiz-Maldonado R, Orozco-Covarrubias ML. Postinflammatory hypopigmentation and hyperpigmentation. Semin Cutan Med Surg. Mar 1997;16(1):36-43. [Medline].
Tomita Y, Maeda K, Tagami H. Mechanisms for hyperpigmentation in postinflammatory pigmentation, urticaria pigmentosa and sunburn. Dermatologica. 1989;179 Suppl 1:49-53. [Medline].
Further Reading
Keywords
postinflammatory hyperpigmentation, postinflammatory hypermelanosis, melanotic hyperpigmentation, PIH, dermal melanosis, epidermal melanosis, skin inflammation, hyperpigmentation


Overview: Postinflammatory Hyperpigmentation