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The Pathogenesis and Management of Acne-Induced Post-inflammatory Hyperpigmentation

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Abstract

Acne vulgaris is a common inflammatory disease. Among patients with darker skin phototypes (Fitzpatrick III–VI), the inflammatory processes of acne stimulate excess melanogenesis and abnormal melanin deposition, leading to pigmentary sequelae known as post-inflammatory hyperpigmentation and post-inflammatory erythema in all skin tones, although post-inflammatory hyperpigmentation is more common in darker skin and post-inflammatory erythema in lighter skin. These pigmentary alterations can be long lasting and are often more distressing to patients than the active acne lesions. This article discusses what is known about acne-related pigmentation, much of which is extrapolated from general study of nonspecific pigment deposition. Because dyspigmentation poses both a significant clinical concern to patients and a therapeutic challenge to clinicians, we formed a working group consisting of pigmentary experts with the aim of increasing awareness and education of acne-related pigmentary sequelae.

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References

  1. Alexis AF, Lamb A. Concomitant therapy for acne in patients with skin of color: a case-based approach. Dermatol Nurs. 2009;21:33–6.

    PubMed  Google Scholar 

  2. Halder RM, Brooks HL, Callender VD. Acne in ethnic skin. Dermatol Clin. 2003;21(609–15):vii.

    Google Scholar 

  3. Halder RM, Grimes PE, McLaurin CI, Kress MA, Kenney JA Jr. Incidence of common dermatoses in a predominantly black dermatologic practice. Cutis. 1983;32(388):390.

    Google Scholar 

  4. Taylor SC. Epidemiology of skin diseases in ethnic populations. Dermatol Clin. 2003;21:601–7.

    Article  PubMed  Google Scholar 

  5. Abad-Casintahan F, Chow SK, Goh CL, et al. Frequency and characteristics of acne-related post-inflammatory hyperpigmentation. J Dermatol. 2016;43(7):926–8.

    Article  Google Scholar 

  6. Goh CL, Abad-Casintahan F, Chow SK, et al. Evaluating acne-related post-inflammatory hyperpigmentation is a challenge even amongst experts. J Dermatol. 2014;41:1106–8.

    Article  PubMed  Google Scholar 

  7. Gollnick H, Abanmi AA, Al-Enezi M, et al. Managing acne in the Middle East: consensus recommendations. J Eur Acad Dermatol Venereol. 2017;31(Suppl. 7):4–35.

    Article  PubMed  Google Scholar 

  8. Abanmi AA, Al-Enezi M, Al Hammadi A, Galadari I, Kibbi A-G, Zimmo S. Progress and problems with acne management in the Middle East. Gulf J Dermatol Venereol. 2016;23:1–5.

    Google Scholar 

  9. Callender VD, Barbosa V, Burgess CM, et al. Approach to treatment of medical and cosmetic facial concerns in skin of color patients. Cutis. 2017;100:375–80.

    PubMed  Google Scholar 

  10. Kang SJ, Davis SA, Feldman SR, McMichael AJ. Dyschromia in skin of color. J Drugs Dermatol. 2014;13:401–6.

    PubMed  Google Scholar 

  11. Davis SA, Narahari S, Feldman SR, Huang W, Pichardo-Geisinger RO, McMichael AJ. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466–73.

    PubMed  Google Scholar 

  12. Min S, Park SY, Yoon JY, Kwon HH, Suh DH. Fractional microneedling radiofrequency treatment for acne-related post-inflammatory erythema. Acta Derm Venereol. 2016;96:87–91.

    Article  CAS  PubMed  Google Scholar 

  13. Tan J, Bourdes V, Bissonnette R, et al. Prospective study of pathogenesis of atrophic acne scars and role of macular erythema. J Drugs Dermatol. 2017;16:566–72.

    PubMed  Google Scholar 

  14. Poli F. Acne on pigmented skin. Int J Dermatol. 2007;46(Suppl. 1):39–41.

    Article  PubMed  Google Scholar 

  15. Akinboro AO, Ezejiofor OI, Olanrewaju FO, et al. The impact of acne and facial post-inflammatory hyperpigmentation on quality of life and self-esteem of newly admitted Nigerian undergraduates. Clin Cosmet Investig Dermatol. 2018;11:245–52.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Abanmi A, Al-Enezi M, Al Hammadi A, Galadari I, Kibbi AG, Zimmo S. Survey of acne-related post-inflammatory hyperpigmentation in the Middle East. J Dermatolog Treat. 2019;30:578–81.

    Article  CAS  PubMed  Google Scholar 

  17. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol. 1994;19:303–8.

    Article  CAS  PubMed  Google Scholar 

  18. Kane A, Niang SO, Diagne AC, Ly F, Ndiaye B. Epidemiologic, clinical, and therapeutic features of acne in Dakar. Senegal Int J Dermatol. 2007;46(Suppl. 1):36–8.

    Article  PubMed  Google Scholar 

  19. Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20–31.

    PubMed  PubMed Central  Google Scholar 

  20. Tanghetti EA. The role of inflammation in the pathology of acne. J Clin Aesthet Dermatol. 2013;6:27–35.

    PubMed  PubMed Central  Google Scholar 

  21. Jeremy AH, Holland DB, Roberts SG, Thomson KF, Cunliffe WJ. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol. 2003;121:20–7.

    Article  CAS  PubMed  Google Scholar 

  22. Norris JF, Cunliffe WJ. A histological and immunocytochemical study of early acne lesions. Br J Dermatol. 1988;118:651–9.

    Article  CAS  PubMed  Google Scholar 

  23. Silpa-Archa N, Kohli I, Chaowattanapanit S, Lim HW, Hamzavi I. Postinflammatory hyperpigmentation: a comprehensive overview: epidemiology, pathogenesis, clinical presentation, and noninvasive assessment technique. J Am Acad Dermatol. 2017;77:591–605.

    Article  PubMed  Google Scholar 

  24. Adalatkhah H, Sadeghi BH. The association between melasma and postinflammatory hyperpigmentation in acne patients. Iran Red Crescent Med J. 2013;15:400–3.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Nordlund JJB, Hearing VJ, King RA, Oetting W, Ortonne JP. The pigmentary system: physiology and pathophysiology. Malden: Blackwell Publishing; 2006.

    Book  Google Scholar 

  26. Cayce KA, McMichael AJ, Feldman SR. Hyperpigmentation: an overview of the common afflictions. Dermatol Nurs. 2004;16:401–6.

    PubMed  Google Scholar 

  27. Isedeh P, Kohli I, Al-Jamal M, et al. An in vivo model for postinflammatory hyperpigmentation: an analysis of histological, spectroscopic, colorimetric and clinical traits. Br J Dermatol. 2016;174:862–8.

    Article  CAS  PubMed  Google Scholar 

  28. Nordlund JJA-M, Abdel-Malek ZA. Mechanisms for post-inflammatory hyperpigmentation and hypopigmentation. In: Bagnara JT, editor. Thirteenth international pigment. Tucson: Liss; 1986. p. 219–39.

    Google Scholar 

  29. Ebanks JP, Wickett RR, Boissy RE. Mechanisms regulating skin pigmentation: the rise and fall of complexion coloration. Int J Mol Sci. 2009;10:4066–87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Del Bino S, Duval C, Bernerd F. Clinical and biological characterization of skin pigmentation diversity and its consequences on UV impact. Int J Mol Sci. 2018;19:2668.

    Article  PubMed Central  CAS  Google Scholar 

  31. Shin JWP, Park KC. Current clinical use of depigmenting agents. Dermatol Sin. 2014;32:205–10.

    Article  Google Scholar 

  32. D’Mello SA, Finlay GJ, Baguley BC, Askarian-Amiri ME. Signaling pathways in melanogenesis. Int J Mol Sci. 2016;17(7):1144.

    Article  PubMed Central  CAS  Google Scholar 

  33. Shah SK, Alexis AF. Acne in skin of color: practical approaches to treatment. J Dermatol Treat. 2010;21:206–11.

    Article  Google Scholar 

  34. Chaowattanapanit S, Silpa-Archa N, Kohli I, Lim HW, Hamzavi I. Postinflammatory hyperpigmentation: a comprehensive overview: treatment options and prevention. J Am Acad Dermatol. 2017;77:607–21.

    Article  PubMed  Google Scholar 

  35. Palumbo A, d’Ischia M, Misuraca G, Prota G. Mechanism of inhibition of melanogenesis by hydroquinone. Biochim Biophys Acta. 1991;1073:85–90.

    Article  CAS  PubMed  Google Scholar 

  36. Kircik LH. Efficacy and safety of azelaic acid (AzA) gel 15% in the treatment of post-inflammatory hyperpigmentation and acne: a 16-week, baseline-controlled study. J Drugs Dermatol. 2011;10:586–90.

    CAS  PubMed  Google Scholar 

  37. Sarkar R, Ghunawat S, Garg VK. Comparative study of 35% glycolic acid, 20% salicylic-10% mandelic acid, and phytic acid combination peels in the treatment of active acne and postacne pigmentation. J Cutan Aesthet Surg. 2019;12:158–63.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Chan HH, Manstein D, Yu CS, Shek S, Kono T, Wei WI. The prevalence and risk factors of post-inflammatory hyperpigmentation after fractional resurfacing in Asians. Lasers Surg Med. 2007;39:381–5.

    Article  PubMed  Google Scholar 

  39. Alexis AF. Lasers and light-based therapies in ethnic skin: treatment options and recommendations for Fitzpatrick skin types V and VI. Br J Dermatol. 2013;169(Suppl. 3):91–7.

    Article  PubMed  Google Scholar 

  40. Bae YC, Rettig S, Weiss E, Bernstein L, Geronemus R. Treatment of post-inflammatory hyperpigmentation in patients with darker skin types using a low energy 1,927 nm non-ablative fractional laser: a retrospective photographic review analysis. Lasers Surg Med. 2020;52:7–12.

    Article  PubMed  Google Scholar 

  41. Haimovic A, Brauer JA, Cindy Bae YS, Geronemus RG. Safety of a picosecond laser with diffractive lens array (DLA) in the treatment of Fitzpatrick skin types IV to VI: a retrospective review. J Am Acad Dermatol. 2016;74:931–6.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors acknowledge the editorial assistance provided by Valerie Sanders, Sanders Medical Writing, and by Galderma Laboratories, LP.

Author information

Authors and Affiliations

  1. Department of Dermatology, Keck School of Medicine, University of Southern California, 830 S Flower Street, Suite 100, Los Angeles, CA, 90017, USA

    Nada Elbuluk

  2. Department of Dermatology, David Geffen School of Medicine, University of California - Los Angeles, CA, Los Angeles, USA

    Pearl Grimes

  3. Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Anna Chien & Sewon Kang

  4. Department of Dermatology, Henry Ford Hospital, Detroit, MI, USA

    Iltefat Hamzavi

  5. Department of Dermatology, Weill Cornell Medicine, New York, NY, USA

    Andrew Alexis

  6. Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Susan Taylor

  7. Department of Dermatology, Mount Sinai, New York, NY, USA

    Noelani Gonzalez

  8. Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA

    Jonathan Weiss

  9. Georgia Dermatology Partners and Gwinnett Clinical Research Center, Snellville, GA, USA

    Jonathan Weiss

  10. Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Seemal R. Desai

  11. Innovative Dermatology, Plano, TX, USA

    Seemal R. Desai

Authors
  1. Nada Elbuluk
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  2. Pearl Grimes
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  3. Anna Chien
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  4. Iltefat Hamzavi
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  5. Andrew Alexis
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  6. Susan Taylor
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  7. Noelani Gonzalez
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  8. Jonathan Weiss
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  9. Seemal R. Desai
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  10. Sewon Kang
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Corresponding author

Correspondence to Nada Elbuluk.

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Conflict of interest

Dr Elbuluk has served as a paid consultant and/or advisory board member for VisualDx, Scientis, Galderma Laboratories LP, Zosana, and Avita; and has received fees for being a Unilever partner. Dr Grimes has served as a consultant for Galderma Laboratories LP, Up-to-Date, and Proctor & Gamble, received grants from Incyte, VT Technologies, Pfizer, Sun, and Arcutis, and has lectures for Scientis (Cyspera). Dr Chien has served as a consultant and/or advisory board member for Galderma Laboratories LP. Dr Hamzavi has served as a consultant and/or advisory board member for Galderma Laboratories LP, AbbVie, Incyte, Pfizer, UCB, Boehringer Ingelheim, and Clarify Medical; he has served as an investigator for Pfizer Inc, Bayer, Lenicura, Incyte, Estee Lauder, Ferndale Laboratories, Inc, Galderma Laboratories LP, L’Oreal, Unigen, Arcutis, and Avita; and is Co-Chair of the Global Vitiligo Foundation. Dr Alexis has served as a consultant and/or advisory board member for Leo, Novartis, Galderma Laboratories LP, Sanofi Regeneron, Dermavent, Unilever, Beiersdorf, Valeant, L’Oreal, Bristol Meyers Squibb, Scientis, Bausch Health, UCB, Arcutis, Janssen, Allergan, Almirall, AbbVie, and Sol-Gel; has served as a speaker for Astra Zeneca; and has received royalties from Springer Verlag, Wiley Blackwell, and Wolters Kluwer. Dr Taylor has served as a consultant, advisory board member, speaker and investigator for Galderma Laboratories LP. Dr Gonzalez has served as a consultant and/or advisory board member for Galderma Laboratories LP, Neostrata, Exuviance, and Bioderma. Dr Weiss has served as a speaker for Abbvie, Almirall, Galderma Laboratories LP, Ortho Dermatologics, Regeneron and Sanofi; as a consultant and/or advisory board member for Cassiopia, Cutera Inc, Dr Reddy, EPI Health, Foamix, Galderma Laboratories LP, Incyte, Leo Pharma, Novartis, Ortho Dermatologics, and UCB; and as investigator for AbbVie, Aclaris, Bausch Health, Celgene/Amgen, Cutera, Endo, Foamix, Galderma Laboratories LP, Leo Pharma, Moberg, and Novartis. Dr Kang has served as a consultant and investigator for Almirall and Galderma Laboratories LP.

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Galderma LLP provided funding for editorial services associated with this manuscript.

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All authors made substantial contributions to the draft work, revised the content critically, and approved the version to be published.

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Elbuluk, N., Grimes, P., Chien, A. et al. The Pathogenesis and Management of Acne-Induced Post-inflammatory Hyperpigmentation. Am J Clin Dermatol 22, 829–836 (2021). https://doi.org/10.1007/s40257-021-00633-4

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  • DOI: https://doi.org/10.1007/s40257-021-00633-4

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