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 |
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References
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Further Reading
Keywords
postinflammatory hyperpigmentation, postinflammatory hypermelanosis, melanotic hyperpigmentation, PIH, dermal melanosis, epidermal melanosis, skin inflammation, hyperpigmentation
