Sections

Sections Postinflammatory Hyperpigmentation
Overview
DDx
Treatment
Medication
References

Medication

Medication Summary

Topical treatments include hydroquinone, azelaic acid, corticosteroids, tretinoin cream, GA, and trichloroacetic acid.^[38]Skin whitening products are used for clinical treatment of postinflammatory hyperpigmentation.^[39]They act at various levels of melanin production in the skin, some being competitive inhibitors of tyrosinase, while others inhibit the maturation of this enzyme or the transport of melanosomes from melanocytes to surrounding keratinocytes. Soy products containing serine protease inhibitors appear to have potential as a therapeutic option for the treatment of hyperpigmentation.^[40]Postinflammatory hyperpigmentation has also been treated using vitamin C with a full-face iontophoresis mask and a mandelic/malic acid skin care regimen.^[41]Extracts of the tropical fern Polypodium leucotomos given orally may be beneficial as an adjunctive approach.^[42]Wide-spectrum sunscreens are an integral part of any treatment regimen.

Some prefer topical retinoids unless contraindicated, recognizing that novel formulations or application of commonly recommended moisturizers may help reduce irritation, and that retinoids can be combined with other topical agents and procedures such as superficial chemical peels to improve hyperpigmentation.^[43]

Winhoven et al reported successful therapy with oral isotretinoin in an Asian patient.^[44]Combined therapy using Q-switched ruby laser and cutaneous bleaching with tretinoin and hydroquinone may be used for periorbital skin hyperpigmentation in selected patients.^[45]The efficacy and safety retinoids and azelaic acid in individuals with a dark complexion has been demonstrated.^[46] Topical cysteamine 5% cream is also another option.^[47]

The combination of treatment with a low-fluence Q-switched 1064-nm Nd:YAG laser and a topical mixture of tranexamic acid, niacinamide, and kojic acid would seem beneficial for melasma.^[48] Kojic acid has become a popular option for hyperpigmentation and melasma, available in over-the-counter skincare products.^[49] Other common cosmeceuticals similarly employed as primary, adjunctive, or maintenance treatment for pigmentary disorders include licorice extract, niacinamide, azelaic acid, and hydroxyacids such as lactic, glycolic, and salicylic acid.^[50]

Class Summary

These agents are used for gradual bleaching of hyperpigmented skin.

Hydroquinone (Alphaquin HP, Eldopaque Forte, Nuquin HP)

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Hydroquinone is a 1,4-benzenediol that suppresses melanocyte metabolic processes, especially enzymatic oxidation of tyrosine to 3,4-dihydroxyphenylamine. Exposure to the sun reverses the effects and causes repigmentation.

Class Summary

Acne products are used for their antibacterial and comedolytic properties and some may have bleaching effects.

Azelaic acid (Azelex, Finacea)

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Azelaic acid may have bleaching effects on the skin. Also, it may have an antimicrobial effect.

Class Summary

These agents cause cornified epithelium to swell and soften and then become macerated and desquamated.

Trichloroacetic acid topical (Tri-Chlor)

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Trichloroacetic acid cauterizes skin, keratin, and other tissues. Trichloroacetic acid is a highly corrosive desiccating agent that cauterizes skin, keratin, and other tissues and is used to burn lesions. Although it is caustic, it causes less local irritation and systemic toxicity than other agents in the same class.

Class Summary

Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes and modulate keratinocyte differentiation.

Tretinoin topical (Avita, Renova, Retin-A)

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Tretinoin inhibits microcomedo formation and eliminates lesions. It makes keratinocytes in sebaceous follicles less adherent and easier to remove. Tretinoin topical is available as 0.025%, 0.05%, and 0.1% creams and 0.01% and 0.025% gels.

Class Summary

These drugs have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Hydrocortisone topical (Cortaid, Cortizone, Westcort)

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Hydrocortisone topical is an adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. It has mineralocorticoid and glucocorticoid effects, resulting in anti-inflammatory activity.

Desonide (DesOwen, LoKara)

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Desonide stimulates the synthesis of enzymes that decrease inflammation. It suppresses mitotic activity and causes vasoconstriction.

Betamethasone topical (Celestone Diprolene, Luxiq)

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Betamethasone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Kaufman BP, Aman T, Alexis AF. Postinflammatory Hyperpigmentation: Epidemiology, Clinical Presentation, Pathogenesis and Treatment. Am J Clin Dermatol. 2017 Dec 8. [QxMD MEDLINE Link].
Wong ITY, Richer V. Prophylaxis of Post-Inflammatory Hyperpigmentation From Energy-Based Device Treatments: A Review [Formula: see text]. J Cutan Med Surg. 2021 Jan-Feb. 25 (1):77-86. [QxMD MEDLINE Link].
Breathnach AS. Melanin hyperpigmentation of skin: melasma, topical treatment with azelaic acid, and other therapies. Cutis. 1996 Jan. 57(1 Suppl):36-45. [QxMD MEDLINE Link].
Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin. 2000 Jan. 18(1):91-8, ix. [QxMD MEDLINE Link].
Mohamed Ali BM, Gheida SF, El Mahdy NA, Sadek SN. Evaluation of salicylic acid peeling in comparison with topical tretinoin in the treatment of postinflammatory hyperpigmentation. J Cosmet Dermatol. 2017 Mar. 16 (1):52-60. [QxMD MEDLINE Link].
Sarkar R, Parmar NV, Kapoor S. Treatment of Postinflammatory Hyperpigmentation With a Combination of Glycolic Acid Peels and a Topical Regimen in Dark-Skinned Patients: A Comparative Study. Dermatol Surg. 2017 Apr. 43 (4):566-573. [QxMD MEDLINE Link].
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. 1997 Mar. 23(3):171-4; discussion 175. [QxMD MEDLINE Link].
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. 1999 Jul-Aug. 23(4):285-91. [QxMD MEDLINE Link].
Yoshimura K, Harii K, Aoyama T, Iga T. Experience with a strong bleaching treatment for skin hyperpigmentation in Orientals. Plast Reconstr Surg. 2000 Mar. 105(3):1097-108; discussion 1109-10. [QxMD MEDLINE Link].
Del Rosso JQ. The use of topical azelaic acid for common skin disorders other than inflammatory rosacea. Cutis. 2006 Feb. 77(2 Suppl):22-4. [QxMD MEDLINE Link].
Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study. Cutis. 2006 Jan. 77(1):45-50. [QxMD MEDLINE Link].
Shah SK, Alexis AF. Acne in skin of color: practical approaches to treatment. J Dermatolog Treat. 2010 May. 21(3):206-11. [QxMD MEDLINE Link].
Katsambas AD. RALGA (Diacneal), a retinaldehyde and glycolic acid association and postinflammatory hyperpigmentation in acne--a review. Dermatology. 2005. 210 Suppl 1:39-45. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. 2007 Jan. 34(1):25-30. [QxMD MEDLINE Link].
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. 2005 Dec. 18(6):439-46. [QxMD MEDLINE Link].
Abu Ubeid A, Zhao L, Wang Y, Hantash BM. Short-sequence oligopeptides with inhibitory activity against mushroom and human tyrosinase. J Invest Dermatol. 2009 Sep. 129(9):2242-9. [QxMD MEDLINE Link].
Kassim AT, Hussain M, Goldberg DJ. Open-label evaluation of the skin-brightening efficacy of a skin-brightening system using decapeptide-12. J Cosmet Laser Ther. 2012 Apr. 14(2):117-21. [QxMD MEDLINE Link].
Hantash BM, Jimenez F. A split-face, double-blind, randomized and placebo-controlled pilot evaluation of a novel oligopeptide for the treatment of recalcitrant melasma. J Drugs Dermatol. 2009 Aug. 8(8):732-5. [QxMD MEDLINE Link].
Sadick NS, Palmisano D. Novel synthetic oligopeptide formulation offers nonirritating cosmetic alternative for the treatment of melasma. Cosmet Dermatol. Apr 2010. 23:175-9.
Ali SA, Galgut JM, Choudhary RK. On The Novel Action of Melanolysis by a Leaf Extract of Aloe vera and Its Active Ingredient Aloin, Potent Skin Depigmenting Agents. Planta Med. 2012 May. 78(8):767-71. [QxMD MEDLINE Link].
Park GH, Rhee do Y, Moon HR, Won CH, Lee MW, Choi JH, et al. Effect of an epidermal growth factor-containing cream on postinflammatory hyperpigmentation after Q-switched 532-nm neodymium-doped yttrium aluminum garnet laser treatment. Dermatol Surg. 2015 Jan. 41 (1):131-5. [QxMD MEDLINE Link].
Fatima S, Braunberger T, Mohammad TF, Kohli I, Hamzavi IH. The Role of Sunscreen in Melasma and Postinflammatory Hyperpigmentation. Indian J Dermatol. 2020 Jan-Feb. 65 (1):5-10. [QxMD MEDLINE Link].
Isedeh P, Kohli I, Al-Jamal M, Agbai ON, Chaffins M, Devpura S, et al. An in vivo model for postinflammatory hyperpigmentation: an analysis of histological, spectroscopic, colorimetric and clinical traits. Br J Dermatol. 2016 Apr. 174 (4):862-8. [QxMD MEDLINE Link].
Cardinali G, Kovacs D, Picardo M. Mechanisms underlying post-inflammatory hyperpigmentation: lessons from solar lentigo. Ann Dermatol Venereol. 2012 Dec. 139 Suppl 4:S148-52. [QxMD MEDLINE Link].
Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: experience with 961 treatments. Dermatol Surg. 2008 Mar. 34(3):301-5; discussion 305-7. [QxMD MEDLINE Link].
Harari Z, Sommer I, Knobel B. Multifocal contact dermatitis to nitroderm TTS 5 with extensive postinflammatory hypermelanosis. Dermatologica. 1987. 174(5):249-52. [QxMD MEDLINE Link].
Milbar HC, Jeon H, Ward MA, Mitchell SE, Weiss CR, Cohen BA. Hyperpigmentation after Foamed Bleomycin Sclerotherapy for Vascular Malformations. J Vasc Interv Radiol. 2019 Apr 5. [QxMD MEDLINE Link].
Deshmukh K, Poddar SS. Tyrosinase inhibitor-loaded microsponge drug delivery system: new approach for hyperpigmentation disorders. J Microencapsul. 2012 Apr 3. [QxMD MEDLINE Link].
Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: a pilot study. Dermatol Surg. 2005 Dec. 31(12):1645-50. [QxMD MEDLINE Link].
Huang L. A new modality for fractional CO2 laster resurfacing for acne scars in Asians. Lasers Med Sci. May 2012.
Oram Y, Akkaya AD. Refractory Postinflammatory Hyperpigmentation Treated Fractional CO2 Laser. J Clin Aesthet Dermatol. 2014 Mar. 7(3):42-4. [QxMD MEDLINE Link]. [Full Text].
Rokhsar CK, Ciocon DH. Fractional photothermolysis for the treatment of postinflammatory hyperpigmentation after carbon dioxide laser resurfacing. Dermatol Surg. 2009 Mar. 35(3):535-7. [QxMD MEDLINE Link].
Park JH, Kim JI, Kim WS. Treatment of Persistent Facial Postinflammatory Hyperpigmentation With Novel Pulse-in-Pulse Mode Intense Pulsed Light. Dermatol Surg. 2016 Feb. 42 (2):218-24. [QxMD MEDLINE Link].
Lee YJ, Shin HJ, Noh TK, Choi KH, Chang SE. Treatment of Melasma and Post-Inflammatory Hyperpigmentation by a Picosecond 755-nm Alexandrite Laser in Asian Patients. Ann Dermatol. 2017 Dec. 29 (6):779-781. [QxMD MEDLINE Link].
Kim HY, Lee SK, Lee JH, Suh JH, Kim MS, Lee UH. A case of latanoprost-induced diffuse facial skin hyperpigmentation. J Cosmet Dermatol. 2019 Mar 28. [QxMD MEDLINE Link].
Liu Z, Jiang M, Zhao J, Wang Q, Zhang C, Gao M, et al. Efficacy of a wound-dressing biomaterial on prevention of postinflammatory hyperpigmentation after suction blister epidermal grafting in stable vitiligo patients: a controlled assessor-blinded clinical study with in vitro bioactivity investigation. Arch Dermatol Res. 2020 Feb 27. [QxMD MEDLINE Link].
Kim S, Cho KH. Treatment of procedure-related postinflammatory hyperpigmentation using 1064-nm Q-switched Nd:YAG laser with low fluence in Asian patients: report of five cases. J Cosmet Dermatol. 2010 Dec. 9(4):302-6. [QxMD MEDLINE Link].
[Guideline] Morton CA, McKenna KE, Rhodes LE. Guidelines for topical photodynamic therapy: update. Br J Dermatol. 2008 Dec. 159(6):1245-66. [QxMD MEDLINE Link].
Pérez-Bernal A, Muñoz-Pérez MA, Camacho F. Management of facial hyperpigmentation. Am J Clin Dermatol. 2000 Sep-Oct. 1(5):261-8. [QxMD MEDLINE Link].
Taylor MB, Yanaki JS, Draper DO, Shurtz JC, Coglianese M. Successful short-term and long-term treatment of melasma and postinflammatory hyperpigmentation using vitamin C with a full-face iontophoresis mask and a mandelic/malic acid skin care regimen. J Drugs Dermatol. 2013 Jan. 12(1):45-50. [QxMD MEDLINE Link].
Nestor M, Bucay V, Callender V, Cohen JL, Sadick N, Waldorf H. Polypodium leucotomos as an Adjunct Treatment of Pigmentary Disorders. J Clin Aesthet Dermatol. 2014 Mar. 7(3):13-17. [QxMD MEDLINE Link]. [Full Text].
Callender VD, Baldwin H, Cook-Bolden FE, et al. Effects of Topical Retinoids on Acne and Post-inflammatory Hyperpigmentation in Patients with Skin of Color: A Clinical Review and Implications for Practice. Am J Clin Dermatol. 2022 Jan. 23 (1):69-81. [QxMD MEDLINE Link]. [Full Text].
Smit N, Vicanova J, Pavel S. The hunt for natural skin whitening agents. Int J Mol Sci. 2009 Dec 10. 10(12):5326-49. [QxMD MEDLINE Link]. [Full Text].
Leyden J, Wallo W. The mechanism of action and clinical benefits of soy for the treatment of hyperpigmentation. Int J Dermatol. 2011 Apr. 50(4):470-7. [QxMD MEDLINE Link].
Woolery-Lloyd HC, Keri J, Doig S. Retinoids and azelaic acid to treat acne and hyperpigmentation in skin of color. J Drugs Dermatol. 2013 Apr. 12(4):434-7. [QxMD MEDLINE Link].
Mathe N, Balogun M, Yoo J. A case report on the use of topical cysteamine 5% cream in the management of refractory postinflammatory hyperpigmentation (PIH) resistant to triple combination cream (hydroquinone, topical corticosteroids, and retinoids). J Cosmet Dermatol. 2021 Jan. 20 (1):204-206. [QxMD MEDLINE Link].
Park SJ, Park JW, Seo SJ, Park KY. Evaluating the tolerance and efficacy of laser-assisted delivery of tranexamic acid, niacinamide, and kojic acid for melasma: A single center, prospective, split-face trial. Dermatol Ther. 2022 Mar. 35 (3):e15287. [QxMD MEDLINE Link].
Zachary CM, Wang JV, Saedi N. Kojic Acid for Melasma: Popular Ingredient in Skincare Products. Skinmed. 2020. 18 (5):271-273. [QxMD MEDLINE Link].
Quiñonez RL, Agbai ON, Burgess CM, Taylor SC. An update on cosmetic procedures in people of color. Part 1: Scientific background, assessment, preprocedure preparation. J Am Acad Dermatol. 2022 Apr. 86 (4):715-725. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

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.

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Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Coauthor(s)

Basil M Hantash, MD, PhD, MBA Medical Director, Advanced Skin Institute

Basil M Hantash, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, Sigma Xi, The Scientific Research Honor Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: Biogen US (Adjudicator for study entry cutaneous lupus erythematosus); Priovant (Adjudicator for entry into a dermatomyositis study); IQVIA (Serono - adjudicator for a study of cutaneous LE) <br/>Received honoraria from UpToDate for author/editor; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for these trust accounts for: Stocks held in various trust accounts: Allergen; Amgen; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble;; Celgene; Gilead; CVS; Walgreens; Bristol-Myers Squibb.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Andrea Leigh Zaenglein, MD Professor of Dermatology and Pediatrics, Department of Dermatology, Hershey Medical Center, Pennsylvania State University College of Medicine

Andrea Leigh Zaenglein, MD is a member of the following medical societies: American Academy of Dermatology, Society for Pediatric Dermatology

Disclosure: Received consulting fee from Galderma for consulting; Received consulting fee from Valeant for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Anacor for consulting; Received grant/research funds from Stiefel for investigator; Received grant/research funds from Astellas for investigator; Received grant/research funds from Ranbaxy for other; Received consulting fee from Ranbaxy for consulting.

Acknowledgements

Nadia I Kihiczak, MD Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey Medical School

Nadia I Kihiczak, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Sections Postinflammatory Hyperpigmentation
Overview
DDx
Treatment
Medication
References

Postinflammatory Hyperpigmentation Medication

Medication Summary

Depigmenting Agents

Class Summary

Hydroquinone (Alphaquin HP, Eldopaque Forte, Nuquin HP)

Hydroquinone (Alphaquin HP, Eldopaque Forte, Nuquin HP)

Acne Agents, Topical