American Journal of Clinical Dermatology

, Volume 12, Issue 2, pp 87–99 | Cite as

Postinflammatory Hyperpigmentation

Etiologic and Therapeutic Considerations
  • Valerie D. Callender
  • Sharleen St. Surin-Lord
  • Erica C. Davis
  • Marissa Maclin
Therapy In Practice Therapies for Postinflammatory Hyperpigmentation

Abstract

Postinflammatory hyperpigmentation (PIH) is a reactive hypermelanosis and sequela of a variety of inflammatory skin conditions. PIH can have a negative impact on a patient’s quality of life, particularly for darker-skinned patients. Studies show that dyschromias, including PIH, are one of the most common presenting complaints of darker-skinned racial ethnic groups when visiting a dermatologist. This is likely due to an increased production or deposition of melanin into the epidermis or dermis by labile melanocytes. A variety of endogenous or exogenous inflammatory conditions can culminate in PIH and typically most epidermal lesions will appear tan, brown, or dark brown while dermal hypermelanosis has a blue-gray discoloration.

Depigmenting agents target different steps in the production of melanin, most commonly inhibiting tyrosinase. These agents include hydroquinone, azelaic acid, kojic acid, arbutin, and certain licorice (glycyrrhiza) extracts. Other agents include retinoids, mequinol, ascorbic acid (vitamin C), niacinamide, N-acetyl glucosamine, and soy, and these products depigment by different mechanisms. Certain procedures can also be effective in the treatment of PIH including chemical peeling and laser therapy. It is important to note that these same therapeutic modalities may also play a role in causing PIH. Lastly, those lesions that are not amenable to medical or surgical therapy may experience some improvement with cosmetic camouflage.

Notes

Acknowledgments

No sources of funding were used in the preparation of this review. Valerie D. Callender, MD, is a consultant and speaker for Allergan, Galderma, Skin Medica, and Proctor & Gamble, a researcher for Intendis, and a consultant and researcher for Medicis. The other authors have no conflicts of interest that are directly relevant to the content of this review.

References

  1. 1.
    Grimes PE. Management of hyperpigmentation. Semin Cutan Med Surg 2009; 28: 77–85PubMedCrossRefGoogle Scholar
  2. 2.
    Halder RM, Grimes PE, McLaurin CI, et al. Incidence of common dermatoses in a predominately black dermatologic practice. Cutis 1983; 32: 388–90PubMedGoogle Scholar
  3. 3.
    Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis 2007; 80: 387–94PubMedGoogle Scholar
  4. 4.
    Sanchez MR. Cutaneous diseases in Latinos. Dermatol Clin 2003; 21: 689–97PubMedCrossRefGoogle Scholar
  5. 5.
    Nordlund JJ, Abdel-Malek ZA. Mechanisms for post-inflammatory hyperpigmentation and hypopigmentation. In: Bagnara JT, editor. Advances in pigment cell research: proceedings of symposia and lectures from the Thirteenth International Pigment Cell Conference held in Tucson, AZ, October 5-9, 1986. New York: Liss, 1988: 219–39Google Scholar
  6. 6.
    Tomita Y, Maeda K, Tagami H. Melanocyte-stimulating properties of arachidonic acid metabolites: possible role in postinflammatory pigmentation. Pigment Cell Res 1992; 5: 357–61PubMedCrossRefGoogle Scholar
  7. 7.
    Ortonne J. Retinoic acid and pigment cells: a review of in-vitro and in-vivo studies. Br J Dermatol 1992; 127 Suppl. 41: 43–7PubMedCrossRefGoogle Scholar
  8. 8.
    Taylor SC, Grimes PE, Lim J, et al. Postinflammatory hyperpigmentation. J Cutan Med Surg 2009; 13: 183–91PubMedGoogle Scholar
  9. 9.
    Lacz NL, Vafaie J, Kihiczac NI, et al. Postinflammatory hyperpigmentation: a common but troubling condition. Int J Dermatol 2004; 4: 362–5CrossRefGoogle Scholar
  10. 10.
    Masu S, Seiji M. Pigmentary incontinence in fixed drug eruptions: histologic and electron microscopic findings. J Am Acad Dermatol 1983; 8: 525–32PubMedCrossRefGoogle Scholar
  11. 11.
    Ruiz-Maldonado R, Orozco-Covarrubias ML. Postinflammatory hypopigmentation and hyperpigmentation. Semin Cutan Med Surg 1997; 16: 36–43PubMedCrossRefGoogle Scholar
  12. 12.
    Chang MW. Disorders of hyperpigmentation. In: Jorizzo JL, Rapini RP, Bolognia JL, editors. Dermatology. 2nd ed. New York: Mosby Elsevier, 2009: 333–89Google Scholar
  13. 13.
    Stratigos AJ, Katsambas AD. Optimal managment of recalcitrant disorders of hyperpigmentation in dark-skinned patients. Am J Clin Dermatol 2004; 5: 161–8PubMedCrossRefGoogle Scholar
  14. 14.
    Cook-Bolden F. The efficacy and tolerability of combination cream containing 4% hydroquinone in the treatment of postinflammatory hyperpigmentation in skin types IV-VI. Cosmetic Dermatol 2004; 17: 149–55Google Scholar
  15. 15.
    Cook-Bolden FE, Hamilton SF. An open-label study of the efficacy and tolerability of microencapsulated hydroquinone 4% and retinol 0.15% with antioxidants for the treatment of hyperpigmentation. Cutis 2008; 81: 365–71PubMedGoogle Scholar
  16. 16.
    Grimes PE. A microsponge formulation of hydroquinone 4% and retinol 0.15% in the treatment of melasma and postinflammatory hyperpigmentation. Cutis 2004; 74: 362–8PubMedGoogle Scholar
  17. 17.
    Taylor SC, Callender VD. A multicenter, 12-week, phase 3b trial: a combination solution of mequinol 2%/tretinoin 0.01% vs hydroquinone 4% cream in the treatment of mild to moderate postinflammatory hyperpigmentation [abstract]. J Am Acad Dermatol 2006; 54 Suppl.: AB194Google Scholar
  18. 18.
    Bulengo-Ransby SM, Griffiths C, Kimbrough-Green CK, et al. Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med 1993; 328: 1438–43PubMedCrossRefGoogle Scholar
  19. 19.
    Jacyk AK, Mpofu P. Adapalene gel 0.1%for topical treatment of acne vulgaris in African patients. Cutis 2001; 68: 48–54PubMedGoogle Scholar
  20. 20.
    Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study. Cutis 2006; 77: 45–50PubMedGoogle Scholar
  21. 21.
    Lowe NJ, Rizk D, Grimes P, et al. Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients. Clin Ther 1998; 20: 945–59PubMedCrossRefGoogle Scholar
  22. 22.
    Kakita LS, Lowe NJ. Azelaic acid and glycolic acid combination therapy for facial hyperpigmentation in darker-skinned patients: a clinical comparison with hydroquinone. Clin Ther 1998; 20: 960–70PubMedCrossRefGoogle Scholar
  23. 23.
    Finkey MB, Herndon J, Stephens T, et al. Soy moisturizer SPF 15 improves dyschromia [poster]. J Am Acad Dermatol 2005; 52 Suppl.: P170Google Scholar
  24. 24.
    Sah A, Stephens TJ, Kurtz ES. Topical acne treatment improves postacne postinflammatory hyperpigmentation (PIH) in skin of color [poster]. J Am Acad Dermatol 2005; 52 Suppl.: P25Google Scholar
  25. 25.
    Halder RM, Nandekar MA, Neal KW. Pigmentary disorders in pigmented skins. In: Halder RM, editor. Dermatology and dermatological therapy of pigmented skins. Boca Raton (FL): CRC/Taylor & Francis, 2006: 91–114Google Scholar
  26. 26.
    Jimbow K, Minamitsuji Y. Topical therapies for melasma and disorders of hyperpigmentation. Dermatol Ther 2001; 14: 35–45CrossRefGoogle Scholar
  27. 27.
    Yoshimura K, Harii K, Aoyama T, et al. A new bleaching protocol for hyperpigmentated skin lesions with a high concentration of all-trans retinoic acid aqueous gel. Aesthetic Plast Surg 1999; 23: 285–91PubMedCrossRefGoogle Scholar
  28. 28.
    Yoshimura K, Harii K, Aoyama T, et al. Experience with a strong bleaching treatment for skin hyperpigmentation in Orientals. Plast Reconstr Surg 2000; 105: 1097–108PubMedCrossRefGoogle Scholar
  29. 29.
    Ortonne JP, Passeron T. Melanin pigmentary disorders: treatment update. Dermatol Clin 2005; 23: 209–26PubMedCrossRefGoogle Scholar
  30. 30.
    Taylor SC, Torok H, Jones T, et al. Efficacy and safety of a new triplecombination agent for the treatment of facial melasma. Cutis 2003; 72: 67–72PubMedGoogle Scholar
  31. 31.
    Chan R, Park KC, Lim MH, et al. A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma. Br J Dermatol 2008; 159: 697–703PubMedGoogle Scholar
  32. 32.
    Torok HM, Jones T, Rich P, et al. Hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%: a safe and efficacious 12-month treatment for melasma. Cutis 2005; 75: 57–62PubMedGoogle Scholar
  33. 33.
    Grimes P, Kelly AP, Torok H, et al. Community-based trial of a triplecombination agent for the treatment of facial melasma. Cutis 2006; 77: 177–84PubMedGoogle Scholar
  34. 34.
    Katsambas AD. RALGA (Diacneal), a retinaldehyde and glycolic acid association and postinflammatory hyperpigmentation in acne: a review. Dermatology 2005; 210 Suppl. 1: 39–45PubMedCrossRefGoogle Scholar
  35. 35.
    Levin CY, Maibach H. Exogenous ochronosis: an update on clinical features, causative agents and treatment options. Am J Clin Dermatol 2001; 2: 213–7PubMedCrossRefGoogle Scholar
  36. 36.
    Levitt J. The safety of hydroquinone: a dermatologist’s response to the 2006 Federal Register. J Am Acad Dermatol 2007; 57: 854–72CrossRefGoogle Scholar
  37. 37.
    Fleischer AB, Schwartzel EH, Colby SI, et al. The combination of 2% 4-hydroxyanisole (mequinol) and 0.01% tretinoin is effective in improving the appearance of solar lentigines and related hyperpigmented lesions in two double-blind multicenter clinical studies. J Am Acad Dermatol 2000; 42: 459–67PubMedCrossRefGoogle Scholar
  38. 38.
    Draelos ZD. The combination of 2% 4-hydroxyanisole (mequinol) and 0.01% tretinoin effectively improves the appearance of solar lentigines in ethnic groups. J Cosmet Dermatol 2006; 5: 239–44PubMedCrossRefGoogle Scholar
  39. 39.
    Ortonne JP, Camacho F, Wainwright N, et al. Safety and efficacy of combined use of 4-hydroxyanisole (mequinol) 2%/tretinoin 0.01% solution and sunscreen in solar lentigines. Cutis 2004; 74: 261–4PubMedGoogle Scholar
  40. 40.
    Callender VD. A small open-label study of a 2% 4-hydroxyanisole and 0.01% tretinoin solution for the treatment of postinflammatory hyperpigmentation [poster]. J Am Acad Dermatol 2004; 50 Suppl.: P175CrossRefGoogle Scholar
  41. 41.
    Piacquadio D, Farris P, Downie J, et al. Mequinol 2%/tretinoin 0.01% solution monotherapy and combination treatment of solar lentigines and postinflammatory hyperpigmentation [poster]. J Am Acad Dermatol 2004; 52 Suppl.: P145Google Scholar
  42. 42.
    Winhoven SM, Ahmed I, Owen CM, et al. Postinflammatory hyperpigmentation in an Asian patient: a dramatic response to oral isotretinoin (13-cis-retinoic acid). Br J Dermatol 2005; 152: 368–9PubMedCrossRefGoogle Scholar
  43. 43.
    Halder RM, Richards GM. Topical agents used in the management of hyperpigmentation. Skin Therapy Lett 2004; 9: 1–3PubMedGoogle Scholar
  44. 44.
    Nguyen QH, Bui TP. Azelaic acid: pharmacokinetic and pharmacodynamic properties and its therapeutic role in hyperpigmentary disorders and acne. Int J Dermatol 1995; 34: 75–84PubMedCrossRefGoogle Scholar
  45. 45.
    Lim JT. Treatment of melasma using kojic acid in a gel containing hydroquinone and glycolic acid. Dermatol Surg 1999; 25: 282–4PubMedCrossRefGoogle Scholar
  46. 46.
    Garcia A, Fulton JE. The combination of glycolic acid and hydroquinone or kojic acid for the treatment ofmelasma and related conditions. Dermatol Surg 1996; 22: 443–7PubMedCrossRefGoogle Scholar
  47. 47.
    Grimes PE. Management of hyperpigmentation in darker racial ethnic groups. Semin Cutan Med Surg 2009; 28: 77–85PubMedCrossRefGoogle Scholar
  48. 48.
    Serra-Baldrich E, Tribo MJ, Camarasa JG. Allergic contact dermatitis from kojic acid. Contact Dermatitis 1998; 39: 86–7PubMedCrossRefGoogle Scholar
  49. 49.
    Nakagawa M, Kawai K, Kawai K. Contact allergy to kojic acid in skin care products. Contact Dermatitis 1995; 32: 9–13PubMedCrossRefGoogle Scholar
  50. 50.
    Petit L, Pierard GE. Skin-lightening products revisited. Int J Cosmet Sci 2003; 25: 169–81PubMedCrossRefGoogle Scholar
  51. 51.
    Zhu W, Gao J. The use of botanical extracts as topical skin-lightening agents for the improvement of skin pigmentation disorders. J Inv Dermatol Symp Proc 2008; 13: 20–4CrossRefGoogle Scholar
  52. 52.
    Draelos ZD. Skin lightening preparations and the hydroquinone controversy. Dermatol Ther 2007; 20: 308–13PubMedCrossRefGoogle Scholar
  53. 53.
    Maeda K, Fukuda M. Arbutin: mechanism of its depigmenting action in human melanocyte culture. J Pharmacol Exp Ther 1996; 276: 765–9PubMedGoogle Scholar
  54. 54.
    Funayama M, Arakawa H, Yamamoto R, et al. Effects of alpha- and betaarbutin on activity of tyrosinases from mushroom and mouse melanoma. Biosci Biotechnol Biochem 1995; 59: 143–4PubMedCrossRefGoogle Scholar
  55. 55.
    Boissy RE, Visscher M, de Long MA. Deoxyarbutin: a novel reversible tyrosinase inhibitorwith effective in vivo skin lightening potency. Exp Dermatol 2005; 14: 601–8PubMedCrossRefGoogle Scholar
  56. 56.
    Hakozaki T, Minwalla L, Zhuang J, et al. The effect of niacinamide on reducing cutaneous pigmentation and suppression ofmelanosome transfer. Br J Dermatol 2002; 147: 20–31PubMedCrossRefGoogle Scholar
  57. 57.
    Kimball AB, Kaczvinsky JR, Li J, et al. Reduction in the appearance of facial hyperpigmentation after use of moisturizers with a combination of topical niacinamide and N-acetyl glucosamine: results of a randomized, doubleblind, vehicle-controlled trial. Br J Dermatol 2010; 162: 435–41PubMedCrossRefGoogle Scholar
  58. 58.
    Bissett DL, Miyamoto K, Sun P, et al. Topical niacinamide produces yellowing, wrinkling, red blotchiness, and hyperpigmented spots in aging facial skin. Int J Cosmet Sci 2004; 26: 231–8PubMedCrossRefGoogle Scholar
  59. 59.
    Bissett DL, Robinson LR, Raleigh PS, et al. Reduction in the appearance of facial hyperpigmentation by topical N-acetyl glucosamine. J Cosmet Dermatol 2007; 6: 20–6PubMedCrossRefGoogle Scholar
  60. 60.
    Espinal-Perez LE, Moncada B, Castanedo-Cazares JP. A double-blind randomized trial of 5% ascorbic acid vs. 4% hydroquinone in melasma. Int J Dermatol 2004; 43: 604–7PubMedCrossRefGoogle Scholar
  61. 61.
    Farris PK. Topical vitamin C: a useful agent for treating photoaging and other dermatologic conditions. Dermatol Surg 2005; 31: 814–8PubMedCrossRefGoogle Scholar
  62. 62.
    Fu B, Li H, Wang X, et al. Isolation and identification of flavonoids in licorice and a study of their inhibitory effects on tyrosinase. J Agric Food Chem 2005; 53: 7408–14PubMedCrossRefGoogle Scholar
  63. 63.
    Yokota T, Nishio H, Kubota Y, et al. The inhibitory effect of glabridin from licorice extracts on melanogenesis and inflammation. Pigment Cell Res 1998; 11: 355–61PubMedCrossRefGoogle Scholar
  64. 64.
    Amer M, Metwalli M. Topical liquiritin improves melasma. Int J Dermatol 2000; 39: 299–301PubMedCrossRefGoogle Scholar
  65. 65.
    Paine C, Sharlow E, Liebel F, et al. An alternative approach to depigmentation by soybean extracts via inhibition of the PAR-2 pathway. J Invest Dermatol 2001; 116: 587–95PubMedCrossRefGoogle Scholar
  66. 66.
    Grimes PE, Rendon MI, Pellerano J. Superficial chemical peels. In: Grimes PE, editor. Aesthetics and cosmetic surgery for darker skin types. Philadelphia (PA): Lippincott Williams & Wilkins, 2008: 154–69Google Scholar
  67. 67.
    Song JY, Kang HA, Kim MY, et al. Damage and recovery of skin barrier function after glycolic acid chemical peeling and crystal microdermabrasion. Dermatol Surg 2004; 30: 390–4PubMedCrossRefGoogle Scholar
  68. 68.
    Burns RL, Prevost-Blank PL, Lawry MA, et al. Glycolic acid peels for postinflammatory hyperpigmentation in black patients: a comparative study. Dermatol Surg 1997; 23: 171–4PubMedCrossRefGoogle Scholar
  69. 69.
    Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther 2004; 17: 196–205PubMedCrossRefGoogle Scholar
  70. 70.
    Ahn HH, Kim IH. Whitening effect of salicyclic acid peels in Asian patients. Dermatol Surg 2006; 32: 372–5PubMedCrossRefGoogle Scholar
  71. 71.
    Tanzi EL, Alster TS. Cutaneous laser surgery in darker skin phototypes. Cutis 2004; 73: 27–30Google Scholar
  72. 72.
    Alster TS, Tanzi EL. Laser surgery in dark skin. Skinmed 2003; 2: 80–5PubMedCrossRefGoogle Scholar
  73. 73.
    Macedo O, Alster TS. Laser treatment of darker skin tones: a practical approach. Dermatol Ther 2000; 13: 114–26CrossRefGoogle Scholar
  74. 74.
    Halder RM, Nootheti PK. Ethnic skin disorders overview. J Am Acad Dermatol 2003; 48: 143–8CrossRefGoogle Scholar
  75. 75.
    Terrel S, Aires D, Schweiger ES. Treatment of acne vulgaris using blue light photodynamic therapy in an African-American patient. J Drugs Dermatol 2009; 8: 669–71Google Scholar
  76. 76.
    Rokhsar CK, Ciocon DH. Fractional photothermolysis for the treatment of postinflammatory hyperpigmentation after carbon dioxide laser resurfacing. Dermatol Surg 2009; 35: 535–7PubMedCrossRefGoogle Scholar
  77. 77.
    Katz TM, Goldberg LH, Firoz BF, et al. Fractional photothermolysis for the treatment of postinflammatory hyperpigmentation. Dermatol Surg 2009; 35: 1844–8PubMedCrossRefGoogle Scholar
  78. 78.
    Holme SA, Beattie PE, Fleming CJ. Cosmetic camouflage advice improves quality of life. Br J Dermatol 2002; 147: 946–9PubMedCrossRefGoogle Scholar
  79. 79.
    Kent G. Testing a model of disfigurement: effects of a skin camouflage service on well-being and appearance anxiety. Psychol Health 2002; 17: 377–86CrossRefGoogle Scholar
  80. 80.
    Antoniou C, Stefanaki C. Cosmetic camouflage. J Cosmet Dermatol 2006; 5: 297–301PubMedCrossRefGoogle Scholar
  81. 81.
    Roberts NG, Nordlund JJ, Wright C. The corrective cover or camouflage clinic. Ear Nose Throat J 1989; 68: 480–2PubMedGoogle Scholar
  82. 82.
    Rayner VL. Camouflage therapy. Dermatol Clin 1995; 13: 467–72PubMedGoogle Scholar
  83. 83.
    Katoulis AC, Alevizou A, Bozi E, et al. A randomized, double-blind, vehiclecontrolled study of a preparation containing undecylenoyl phenylalanine 2% in the treatment of solar lentigines. Clin Exp Dermatol 2010; 35: 473–6PubMedCrossRefGoogle Scholar
  84. 84.
    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: 360–2PubMedCrossRefGoogle Scholar
  85. 85.
    Tirado-Sanchez A, Santamaria-Roman A, Ponce-Olivera RM. Efficacy of dioic acid compared with hydroquinone in the treatment of melasma. Int J Dermatol 2009; 48: 893–5PubMedCrossRefGoogle Scholar
  86. 86.
    Choi S, Park YI, Lee SK, et al. Aloesin inhibits hyperpigmentation induced by UV radiation. Clin Exp Dermatol 2002; 27: 513–5PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2011

Authors and Affiliations

  • Valerie D. Callender
    • 1
    • 2
  • Sharleen St. Surin-Lord
    • 1
    • 2
  • Erica C. Davis
    • 1
  • Marissa Maclin
    • 3
  1. 1.Callender Skin and Laser CenterGlenn DaleUSA
  2. 2.Department of DermatologyHoward University College of MedicineWashington, DCUSA
  3. 3.Stony Brook University School of MedicineStony BrookUSA

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