eMedicine Specialties > Dermatology > Diseases of Pigmentation
Postinflammatory Hyperpigmentation: Treatment & Medication
Updated: Jul 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The treatment of postinflammatory hyperpigmentation (PIH) tends to be a difficult and prolonged process that often takes 6-12 months to achieve the desired results of depigmentation. Each of these treatment options potentially improves epidermal hypermelanosis, but none is proven effective for dermal hypermelanosis. Daily use of a broad-spectrum sunscreen (sun protection factor [SPF] 15 or greater) is an essential part of any therapeutic regimen.
- A variety of topical treatments have been used to treat epidermal postinflammatory hyperpigmentation, with varying degrees of success. These agents include hydroquinone, tretinoin cream, corticosteroids, glycolic acid (GA), and azelaic acid.3 Lightening of hyperpigmented areas may be achieved with one of the previously named topical agents; however, a combination of topical creams and gels, chemical peels, and sunscreens may be necessary for significant improvement.4 They are only effective for epidermal hyperpigmentation.
- Topical tretinoin 0.1% has been effective in African Americans. GA peels, in combination with tretinoin and hydroquinone, are an effective treatment of postinflammatory hyperpigmentation in dark-complexioned individuals.5 All-trans retinoic acid aqueous gel 0.1-0.4% may be applied concomitantly with hydroquinone–lactic acid ointment for bleaching.6,7 After sufficient improvement of the hyperpigmentation is achieved, a corticosteroid may be applied topically with hydroquinone to promote healing. This combination of various topical therapeutic agents has been shown to be beneficial, especially on the face.
- Topical azelaic acid, which has been approved for the treatment of acne vulgaris, is useful for postinflammatory hyperpigmentation.8 It may be desirable to use to treat acne itself for patients in whom postinflammatory hyperpigmentation tends to develop. The efficacy of tazarotene 0.1% cream for the treatment of dyschromia associated with photoaging and for acne vulgaris may also be beneficial, particularly in people with dark skin.9
- Other treatment modalities include use of trichloroacetic acid and gentle cryotherapy with liquid nitrogen. Each method must be used with extreme caution to avoid necrosis or blistering of the treated skin. These 2 methods of treatment should be avoided in dark-skinned patients because of the risk of permanent depigmentation and scarring.
- Pigmented makeup creams have also been successfully used to camouflage hyperpigmented skin to a hue similar to that of the surrounding unaffected skin.
- More options will be available in the future. Retinaldehyde (RAL) has shown depigmenting activity, while GA decreases the excess of pigment by a wounding and reepithelization process. A combination of RAL 0.1% and GA 6% RALGA (Diacneal) in the treatment of acne vulgaris and postinflammatory hyperpigmentation was noted as successful.10 The peroxidase inhibitor methimazole, a noncytotoxic inhibitor of melanin production, is a possible agent for topical use in the years ahead.11
- The efficacy and safety of a combined treatment regimen including serial GA peels, topical azelaic acid cream, and adapalene gel in the treatment of recalcitrant melasma was evaluated in 28 patients in a prospective, randomized, controlled trial lasting 20 weeks.12 Those receiving chemical peels underwent serial GA peels in combination with topical azelaic acid 20% cream (twice daily) and adapalene 0.1% gel (4 times daily, applied at night). Combined treatment with serial GA peels, azelaic acid cream, and adapalene gel may be an effective and safe therapy for recalcitrant melasma.
- Choi et al report that Lepidium apetalum is a potential inhibitor of hyperpigmentation caused by UV radiation.13
- Also see Skin Lightening and Depigmenting Agents.
Surgical Care
Fractional photothermolysis may be used to treat postinflammatory hyperpigmentation after carbon dioxide laser resurfacing.14,15 Laser treatment may be able to address dermal pigment deposition.
The guideline from the British Association of Dermatologist, Guidelines for topical photodynamic therapy: update,16 may be of interest, as may Photodynamic Therapy for the Dermatologist.
Medication
Topical treatments include hydroquinone, azelaic acid, corticosteroids, tretinoin cream, GA, and trichloroacetic acid.17 Wide-spectrum sunscreens are an integral part of any treatment regimen. Winhoven et al report successful therapy with oral isotretinoin in an Asian patient.18 Combined therapy using Q-switched ruby laser and cutaneous bleaching with tretinoin and hydroquinone may be used for periorbital skin hyperpigmentation in selected patients.19
Depigmenting agents
These agents are used for gradual bleaching of hyperpigmented skin.
Hydroquinone (Ambi Skin Tone, Melanex, Nuquin HP)
A 1,4-benzenediol that suppresses melanocyte metabolic processes, especially enzymatic oxidation of tyrosine to 3,4-dihydroxyphenylamine. Exposure to sun reverses effects and causes repigmentation.
Adult
Apply sparingly and rub in bid
Pediatric
<12 years: Not established
>12 years: Apply as in adults
None reported
Documented hypersensitivity; sunburns
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Application area should not extend beyond face, neck, hands, or arms; avoid sun exposure on treated skin during treatment (patient should wear sun-protective clothing or broad-spectrum sunscreen to prevent increased hyperpigmentation or repigmentation)
Azelaic acid (Azelex, Finevin)
May have bleaching effect on skin. Also, may have an antimicrobial effect.
Adult
Wash area and apply sparingly bid
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Sensitivity or severe irritation (discontinue treatment); avoid contact with eyes
Keratolytic agents
These agents cause cornified epithelium to swell and soften and then become macerated and desquamated.
Trichloroacetic acid (Tri-Chlor)
Cauterizes skin, keratin, and other tissues.
Adult
Paint onto lesions, avoid uninvolved skin; repeat q1-2wk
Pediatric
Not established
None reported
Documented hypersensitivity; not for use on premalignant or malignant lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For external use only; restrict to treatment areas only; use with extreme caution to avoid necrosis of treated skin; avoid in dark-skinned patients (risk of permanent depigmentation and scarring)
Retinoids
Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes and modulate keratinocyte differentiation.
Tretinoin (Avita, Renova, Retin-A)
Inhibits microcomedo formation and eliminates lesions. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Also available as 0.01% and 0.025% gels.
Adult
Apply hs or qod; begin with lowest concentration and increase as tolerated; decrease frequency if irritation develops
Pediatric
<12 years: Not established
>12 years: Apply as in adults
Increased toxicity with coadministration of benzoyl peroxide, salicylic acid, and resorcinol; avoid topical sulfur, resorcinol, salicylic acid, other keratolytics, abrasives, astringents, spices, and lime
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Because of increased susceptibility to burning, patients should minimize exposure to sunlight or sunlamps; local erythema, burning, stinging, or peeling (avoid application to eyes, mouth, angles of the nose, and mucous membranes)
Corticosteroids
These drugs have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Hydrocortisone (Cortaid, Dermacort, Westcort)
An adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Has mineralocorticoid and glucocorticoid effects, resulting in anti-inflammatory activity.
Adult
Apply sparingly to affected areas bid/qid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use, applying over large surface areas, applying potent steroids, and use of occlusive dressings may increase systemic absorption and cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Desonide (DesOwen, Tridesilon)
Stimulates synthesis of enzymes that decrease inflammation. Suppresses mitotic activity and causes vasoconstriction.
Adult
Apply sparingly bid/qid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use, applying over large surface areas, applying potent steroids, and use of occlusive dressings may increase systemic absorption and cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Betamethasone (Alphatrex, Diprolene, Maxivate)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
Apply thin film bid/qid until response occurs
Pediatric
Apply as in adults, with caution
None reported
Documented hypersensitivity; paronychia; cellulitis; impetigo; angular cheilitis; erythrasma; erysipelas; rosacea; perioral dermatitis; acne
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use on skin with decreased circulation; can cause atrophy of groin, face, and axillae; may cause striae distensae or rosacealike eruption; may increase skin fragility; may suppress HPA axis (rare); in infection that is not responsive to antibiotic treatment, discontinue until infection is under control; do not use monotherapy to treat widespread plaque psoriasis
More on Postinflammatory Hyperpigmentation |
| Overview: Postinflammatory Hyperpigmentation |
| Differential Diagnoses & Workup: Postinflammatory Hyperpigmentation |
 Treatment & Medication: Postinflammatory Hyperpigmentation |
| Follow-up: Postinflammatory Hyperpigmentation |
| Multimedia: Postinflammatory Hyperpigmentation |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
postinflammatory hyperpigmentation, postinflammatory hypermelanosis, melanotic hyperpigmentation, PIH, dermal melanosis, epidermal melanosis, skin inflammation, hyperpigmentation
