Post-Inflammatory Hyperpigmentation

Skin pigmentation conditions can be a problem for all women (and men) with brown skin - people of Asian, African, Latin or Native American background. While the natural pigmentation in brown skin provides many advantages—sun protection and slowed signs of aging—it is also more highly susceptible to skin discolorations, which can cause distress in social situations, as well as psychological stress.

Melanin is the chemical that determines the color of skin. The more melanin there is in a person's skin, the darker that person's skin will be. Sometimes the cells that contain melanin are damaged or over stimulated. When this happens, the affected cells may begin to produce too much, or too little melanin. Too much melanin causes darker spots or patches, while too little causes lighter spots or patches. These lighter or darker spots appear on the surface of the skin, and can be unsightly. Unfortunately, these skin color problems are much more visible and common in people with skin of color.

There are many different conditions that can cause discoloration, but the most common are Post-Inflammatory Hyperpigmentation and Melasma.

post inflammatory hyperpigmentation

Post-inflammatory hyperpigmentation (PIH)
Post-inflammatory hyperpigmentation (PIH) causes skin darkening and discoloration that show up as spots, or as large patches on a person's body. This is because cells that normally produce brown pigment evenly across your skin go into overdrive and produce too much melanin. This happens because of an inflammatory reaction in, or to an injury to, the skin. If the excess melanin is produced in the upper layer of skin (epidermis), the pigmentation color is a darker shade of brown. If the excess melanin is produced in the lower layer of skin (the dermis), a gray or blue discoloration becomes visible.

post inflammatory hyperpigmentation
secondary to laser

Although PIH can occur in all skin types, it is more common in people of Africa, Asia, Latin, and indigenous Indian background, and can affect men and women equally. Areas of the skin affected by PIH correspond with areas of previous inflammation or injury. When dark changes in your skin's color remain after the underlying problem has gone away, you have PIH. The most common causes are injuries such as scratches, burns, cuts, or bruises. Rashes of any type can cause PIH (examples of which include eczema, psoriasis, pityriasis rosea, lichen planus, and fungal infections). Ordinary conditions such as acne or pimples are a very common cause of PIH in individuals with brown skin. PIH can also be caused by injury to the skin resulting from sunburns, surgery or cosmetic procedures such as chemical peels, dermabrasion, lasers and cryotherapy (liquid nitrogen treatments).

If you, or your doctor, suspect that you may have PIH, it is important to search for the underlying cause and treat that cause. For example, when the discoloration is caused by a problem such as acne, the acne must first be eliminated or treated before PIH can effectively be treated. Every time a new pimple develops and then resolves, a new area of PIH will develop. Therefore, it is crucial to minimize all new outbreaks with appropriate medications. Only then can the treatment for the PIH be effective.

It is also important to know that PIH will in many cases fade over time on its own. However, there are treatments available that can speed up the process.

For patients with PIH, the most common way to return the skin to its natural glowing complexion is through use of products containing Hydroquinone, a chemical lightening agent that is applied directly to the dark mark. Your dermatologist can determine if hydroquinone is appropriate for your skin. Many dermatologists consider hydroquinone to be the best treatment for PIH. Hydroquinone works by blocking an enzyme that is responsible for the production of the pigment melanin. By blocking the formation of melanin, the dark area will lighten. However, it is important to realize that you may need to use the hydroquinone medication for up to 6 months before clearing of the dark marks is seen.

Hydroquinone products can be purchased over the counter at 1% to 2% concentrations, or by prescription at 3% to 4% concentrations. The prescription products are stronger and hence more effective than the over-the-counter varieties. (see chart below) In either case, the hydroquinone product should be carefully applied to the dark marks—avoiding normal-appearing skin—once or twice a day. One scientific study demonstrated that 80% of individuals who used a 4% hydroquinone product combined with glycolic acid had an improvement in their PIH after 3-months time. Because the lightening agent can sometimes cause other skin conditions, your treatment should not exceed 6 months. There are many varieties of prescription hydroquinone products available for the treatment of PIH. Some of these products are combined with other agents or medications, such as: sunscreen, glycolic acid, retinol, vitamins C and E and tretinoin (Retin A) or cortisone to improve the effects.

4% Hydroquinone Products:

  • Alustra™
  • Claripel™
  • Epiquin Micro
  • Eldoquin Forte™
  • Eldopaque Forte™
  • Glyquin XM™
  • Glyquin®
  • Lustra®
  • Lustra-AF™
  • Solaquin Forte®
  • Tri-Luma®

Possible effects of hydroquinone products include redness, irritation and possible burning of the skin. It is also possible for your normal skin tone to become lighter in a ring around the dark discoloration. Should you notice any of these side effects, the product should be discontinued and you must notify your dermatologist.

For patients with PIH related to acne or pimples, prescription retinoids are another commonly used treatment for both the acne and PIH. Retinoids are derivatives of vitamin A and include Retin-A, Differin, and Tazorac. All retinoids are effective in the treatment of acne. For the treatment of PIH, Retin-A has been studied in individuals with brown skin. For these patients with acne and PIH, the retinoid is applied to the acne and PIH prone areas nightly.

Retinoids are to be used sparingly in brown skin. A small green-pea size amount is enough to cover the entire face. It is important to realize that this treatment can take up to 40 weeks for the dark marks to fade completely. A scientific study reported that 91% of individuals using the retinoid tretinoin (Retin-A) for a 40 week period had clearing of their PIH. Like many of the other treatments for PIH, retinoids can cause irritation, dryness and peeling of the skin. Consequently, it is important to begin treatment only under the direction of your dermatologist and to closely watch your skin’s appearance while using these products. Irritation, redness and burning are reasons to discontinue the treatment and notify the dermatologist who prescribed these medications.

Azelaic acid
Azelaic acid is another prescription treatment for both acne and PIH. It has anti-inflammatory, anti-bacterial, and skin lightening properties. A small amount of this cream is applied to the acne and PIH prone skin once or twice daily. It is particularly useful for individuals who are unable to tolerate the hydroquinone products. Improvement in the dark marks can be seen after 6 months. A scientific study comparing the lightening ability of azelaic acid and hydroquinone for the pigmentation problem, melasma, found both forms of therapy to be effective when used for a total of 24-weeks. Azeleic acid has the potential of producing the side effects of skin irritation, burning, itching and redness. It is important to check with your dermatologists to see if azeleic acid is appropriate for your skin.

Glycolic acid
Glycolic acid products are available over the counter and are also used as a treatment for PIH. These products work by gently exfoliating (removing) the upper-most layer of the skin and the dark marks with it. There are many products that contain glycolic acid. These include cleansers, lotions, gels, toners and creams. The concentration of glycolic acid contained in the products range from 5 to 20 percent. Products with the lower concentrations can be purchased in drugstores, but the products containing the higher concentrations must be acquired from a dermatologist’s office. Glycolic acid products should be considered medications, so it is important to consult with your dermatologist to determine if he or she thinks glycolic acid is appropriate for your skin. You will usually be instructed to wash with a glycolic cleanser and then follow-up with a glycolic acid cream, gel, or lotion. You will probably need to use the glycolic acid containing products for 3-6 month before seeing an improvement in the dark marks. You will see another benefit in your skin after only a few weeks--the glycolic acid treatments will leave your skin smooth and soft! Because glycolic acid can sometimes lead to skin irritation, it is important to keep an eye on your skin’s appearance while using these products.

Chemical Peels
Chemical Peels are a more intensive treatment used in cases of more persistent PIH or to hasten the lightening effects of the topical prescription products. Peels work by exfoliating the upper-most layer of your skin and the dark area with it. There are many different types of peels and they are usually solutions that the dermatologist applies to the skin. The peels that are used most often to treat PIH in brown skin are the alpha-hydroxy acid (glycolic acid) or beta-hydroxy acid (salicylic acid) peels.

Although the technique that your doctor may use to apply the peel may be slightly different, in general, the peel process is a follows. Prior to the peel, all make-up is removed and the skin is fully cleansed and prepared. The peel solution is applied to the skin and left on for anywhere from one to five minutes. During the peel you may experience a tingling, itching or burning sensation which is often minimized by using a fan that blows cool air onto the skin. Following the peel, a cold compress or spray is applied to soothe the skin. Immediately following the peel, the skin may appear red in color and over the next few days, you may see actual peeling of the skin. As with all cosmetic procedures, there are possible side effects. These include irritation of the skin, a rash, blistering, marked peeling, or discolorations of the skin.

Chemical peels are not covered by insurance and the cost varies depending on where in the country the patient is located and who actually performs the procedure (make sure that it is someone knowledgeable about brown skin). In a dermatologist’s office, the cost will range between $100- $200 per peel. Most dermatologists recommend a total of 4-6 peels to observe maximal improvement in PIH. Peels are generally performed once every three to four weeks. Although peels are an investment in time and finances, they offer the benefit of improving PIH and overall skin clarity, and at the same time they uncover your soft, smooth, flawless skin.

Microdermabrasion is a cosmetic procedure, performed in the dermatologist’s office, in which fine crystals are sprayed onto the skin’s surface to gently sand away the upper-most layers of the skin. As with chemical peels, microdermabrasion works by exfoliating the upper-most layer of your skin and the dark area with it. This procedure is particularly well suited for individuals who have sensitive skin (many individuals with brown skin) or those who have had a previous reaction to a chemical peeling agent. The procedure is performed with a machine that gently sprays the tiny crystals onto the skin’s surface and uses gentle suction to remove the dead superficial skin. The entire procedure takes about 20-30 minutes. You are then able to resume you normal activities.

Even though microdermabrasion is generally well tolerated in brown skin, side effects are possible. These include irritation of the skin, redness, marked peeling, swelling or discolorations. Before having a microdermabrasion done, make sure that the person who performs the procedure is knowledgeable about brown skin.

The microdermabrasion procedure is usually performed every 2 to 4 weeks for a total of six to eight treatments. To maintain results, it is often advisable to periodically repeat the treamtent after the original sessions are completed. As it is a cosmetic procedure, microdermabrasion is not covered by insurance. The cost of microdermabrasion may range from $75 to $150, depending on the area in which you live. As with chemical peels, these treatments are an investment in time and finances. However, microdermabrasion offers the benefit of improving PIH and overall skin clarity, as well as uncovering soft, smooth and flawless skin that feels polished.

Other treatments
Home microdermabrasion kits and chemical peeling kits are readily available and for some individuals may help PIH. These at-home kits offer a milder version of the in-office procedures. The primary advantages of these kits are their low relative cost and easy accessibility. However, it is very important to ask your dermatologist if these at-home procedures are appropriate for your skin. This is especially important if you are using any type of topical medication. Another word of caution: it is crucial that you follow the directions on the box exactly and that you do not perform the procedure more often than indicated on the box. Failure to follow the directions can result in serious side effects.

There are many home remedies for the treatment of dark marks. Some of these may result in serious harm to the skin. Others have not been scientifically proven to be effective in the treatment of PIH. It is very important to check with your doctor before using any treatment for PIH. If you take matters in your own hands, it may lead to more harm than you could ever imagine.

Cocoa butter is a commonly used home remedy for PIH, especially in the African-American community. The cocoa butter preparation is applied to the skin once or twice daily for weeks or months. It provides moisturization to the skin. However, there is no scientific data available that supports the efficacy of cocoa butter in the treatment of PIH.

Aloe vera is another home remedy used for healing wounds, burns and skin discolorations. The gel from the aloe vera plant or a commercially available cream or lotion is applied directly to the skin. However, there is no scientific evidence that aloe vera effectively treats PIH.

Topical corticosteroid (cortisone) creams, both over-the-counter and prescription varieties, are used for a variety of skin disorders. Unfortunately, some individuals with brown skin have used these creams for the treatment of PIH. The creams are inappropriately applied to the skin and in many instances are applied for a prolonged period of time. This leads to damaging side effects. The side effects include permanent thinning of the skin, permanent redness of the skin from overgrowth of blood vessels, the appearance of rashes on the skin and uncontrollable outbreaks of pimples. Topical cortisones should not be used for the treatment of PIH unless under the direct supervision of a dermatologist.

Examples of corticosteroid creams obtained in beauty supply stores that should NEVER be used for PIH.

Chlorine bleach is a dangerous home remedy for the treatment of PIH and should never be used on the skin for any reason. As you would anticipate, there is no scientific data to support its efficacy in treating PIH.

Sunscreen is another effective and simple way to fight PIH. By regularly using a sunscreen containing an SPF of 15 or 30, even in winter, you can prevent the further darkening of areas of existing PIH. The best products to use are considered “broad spectrum” because they block both UVA and UVB rays. Patients concerned about oily skin should look for sunscreen sprays and gels in order to avoid further skin surface oil.

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What is Brown Skin? is an educational site for individuals with skin of color. Whether your ethnicity and skin care needs are related to your Asian skin care, Latina skin care, African American skin care, Black skin care, or Indian skin care, this site is meant for you. covers topics related to skin care conditions from Acne to Hair Loss to Skin Cancer. The site contains skin care tips and advice designed to help individuals with skin of color understand their skin type.


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