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Chapter 69: Post-Inflammatory Hyperpigmentation

Orlando Martinez Luna; Amit G. Pandya

POST-INFLAMMATORY HYPERPIGMENTATION

Therapeutic Approach

Postinflammatory hyperpigmentation (PIH) is a relatively common, acquired pigmentary disorder caused by acute skin injury or inflammation. PIH can be categorized as epidermal or dermal, based on the depth of involvement. Initial treatment should focus on controlling the primary cause of skin inflammation. Subsequent therapy should be based on the depth of involvement and severity. See Table 69-1.

Table 69-1Post-Inflammatory Hyperpigmentation Treatment Table
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Table 69-1 Post-Inflammatory Hyperpigmentation Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Broad-spectrum sunscreens/tinted sunscreens All PIH patients Ultraviolet light blocker + visible light blocker SPF = 50; applied daily Skin irritation None III1
Triple combination cream (TCC)a First-line: EP, MX Tyrosinase inhibition, anti-inflammatory, ECM repair properties HQ 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%; apply QD Contraindicated in pregnancy; skin irritation, skin atrophy None IB2
Retinoids First-line: EP, MX, acne-related PIH Tyrosinase inhibition, melanosome transfer inhibition, increased epidermal turnover Adapalene 0.1% gel, tretinoin 0.1% cream, tazarotene 0.1% cream; applied QD Erythema, burning, peeling None IB3,4
Azelaic acid First-line: EP, MX, acne-related PIH Tyrosinase inhibition 15%-20% gel; applied BID Erythema, burning, dryness None IB5,6
Hydroquinone (HQ) First-line: EP, MX, acne-related PIH Tyrosinase inhibition 2%-4% cream BID, consider adding SA 20%-30% if acne-related Contraindicated in pregnancy; skin irritation, contact dermatitis, worsening PIH None IIB7,8
Soy-based moisturizer First-line (alternative): EP, MX Melanosome transfer inhibition (PAR-2) Cream applied BID Erythema, burning, dryness None IB9,10
Niacinamide First-line (alternative): EP, MX Melanosome transfer inhibition 4% cream QD Skin irritation None IB11,12
N-acetyl glucosamine (NAG) First-line (alternative): EP, MX Tyrosinase inhibition 2% cream BID ± niacinamide 4%  BID Skin irritation None IB13,14
Kojic acid plus emblica and GA First-line (alternative): EP, MX Tyrosinase inhibition, keratolytic Cream applied QD Allergic contact dermatitis, erythema None IB15
Mequinol First-line (alternative): EP, MX Tyrosinase inhibition 2% cream + 0.01% tretinoin cream; applied BID PIH, erythema None IB16
Thiamidol First-line (alternative): EP, MX Tyrosinase inhibition 0.2% cream; applied BID Skin irritation, erythema None IB17
Ascorbic acid First-line (alternative): EP, MX Tyrosinase inhibition 10% cream; applied BID Skin irritation None IB18
Licorice root extracts First-line (alternative): EP, MX Tyrosinase inhibition 2%-4% cream; applied QD Skin irritation None IIB19
Chemical peels Second-line: EP, MX, DE Keratolytic Glycolic acid 50% q3wk, salicylic acid 20%-30% q2wk, Jessner’s solution PIH, erythema, skin irritation None IB20-23
Systemic Therapy
Tranexamic acid Prevention of PIH after acute skin injury Plasmin inhibitor 250 mg BID Contraindicated in patients with hx of thromboembolic disease; menstrual changes, headache, arthralgias None IV24
Procedural Therapy
1064-nm QSNd:YAG laser DE Targets melanin 6 mm spot, 3.0-3.8 J/cm2, 5 sessions (laser toning procedure) PIH, erythema, stinging None III25
Fractional 1550-nm erbium-doped ...

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