Beruflich Dokumente
Kultur Dokumente
REVIEW]
Postinflammatory Hyperpigmentation
A Review of the Epidemiology, Clinical Features,
and Treatment Options in Skin of Color
a
a
Callender Skin & Laser Center, Glenn Dale, Maryland;
Department of Dermatology, Howard University College of Medicine, Washington, DC
a,b
ABSTRACT
Postinflammatory hyperpigmentation is a common sequelae of inflammatory dermatoses that tends to affect darker
skinned patients with greater frequency and severity. Epidemiological studies show that dyschromias, including
postinflammatory hyperpigmentation, are among the most common reasons darker racial/ethnic groups seek the care of
a dermatologist. The treatment of postinflammatory hyperpigmentation should be started early to help hasten its
resolution and begins with management of the initial inflammatory condition. First-line therapy typically consists of
topical depigmenting agents in addition to photoprotection including a sunscreen. Topical tyrosinase inhibitors, such as
hydroquinone, azelaic acid, kojic acid, arbutin, and certain licorice extracts, can effectively lighten areas of
hypermelanosis. Other depigmenting agents include retinoids, mequinol, ascorbic acid, niacinamide, N-acetyl
glucosamine, and soy with a number of emerging therapies on the horizon. Topical therapy is typically effective for
epidermal postinflammatory hyperpigmentation; however, certain procedures, such as chemical peeling and laser
therapy, may help treat recalcitrant hyperpigmentation. It is also important to use caution with all of the above treatments
to prevent irritation and worsening of postinflammatory hyperpigmentation.
(J Clin Aesthetic Dermatol. 2010;3(7):2031.)
EPIDEMIOLOGY
Table 1 shows the worldwide prevalence of pigmentary
disorders, excluding vitiligo, in various ethnic
populations.
These
figures
typically
include
postinflammatory hyper- or hypopigmentation although
melasma and solar lentigines may also be included.
Multiple epidemiological studies have shown that PIH
tends to occur more commonly among skin-of-color
patients compared to Caucasian patients.2,3 In 1983,
Halder et al2 published a study comparing the most
common dermatoses seen in African American and
Caucasian patients. Pigmentary disorders, other than
vitiligo, were the third most common dermatoses among
African-American patients (9%), but were the seventh
most common among Caucasian patients (1.7%). A more
recent study in 20073 confirmed these findings showing
DISCLOSURE: Dr. Davis reports no relevant conflicts of interests. Dr. Callender is a consultant and speaker for Allergan, Coria, Medicis, Galderma,
Sanofi-Aventis, and Stiefel. She is also a researcher for Indendis, Medicis, and Merz.
ADDRESS CORRESPONDENCE TO: Valerie D. Callender, MD, Callender Skin & Laser Center, 12200 Annapolis Road, Suite 315, Glenn Dale, MD
20769; E-mail: drcallender@CallenderSkin.com
20
AUTHOR
YEAR
STUDY POPULATION
PREVALENCE
LOCATION
3/13 black,
7/10 white
Washington, DC
10/10
Singapore
0.42%
33/74
Kuwait
8/14 children,
London, England
7/29 adults
Halder2
19801983
Chua-Ty4
19891990
Nanda116
19921996
Child117
1996
Hartshorne118 1999
RANK
22/91 overall
Dunwell119
2001
3/18
Kingston, Jamaica
Sanchez120
Published
2003
6% private practice,
7.5% hospital-based clinic
7/12 private,
6/12 hospital
Arsouze121
2004
6/16 children,
Paris, France
2/20 adults
Alexis3
19.9% of diagnoses in
blacks#, not in whites
2/14
El-Essawi122
Published
2007
Top 2 skin
concerns out
of 10
Detroit, Michigan
ETIOLOGY
Many types of inflammatory dermatoses or cutaneous
injuries can cause pigmentary changes; however, there are
some diseases that show a proclivity to develop PIH rather
than hypopigmentation. A wide range of etiologies for PIH
exists including infections such as dermatophytoses or
viral exanthems, allergic reactions such as those from
insect bites or a contact dermatitis, papulosquamous
diseases like psoriasis or lichen planus, medication-induced
PIH from hypersensitivity reactions, or cutaneous injury
21
PATHOGENESIS
PIH results from the overproduction of melanin or an
irregular dispersion of pigment after cutaneous
inflammation.10 When PIH is confined to the epidermis,
there is an increase in the production and transfer of
melanin to surrounding keratinocytes. Although the exact
mechanism is unknown, this rise in melanocyte activity
has been shown to be stimulated by prostanoids,
cytokines, chemokines, and other inflammatory
mediators as well as reactive oxygen species that are
released during the inflammatory process. Multiple
studies have demonstrated the melanocyte-stimulating
properties of leukotrienes (LT), such as LT-C4 and LT-D4,
prostaglandins E2 and D2, thromboxane-2, interleukin
(IL)-1, IL-6, tumor necrosis factor (TNF)-, epidermal
growth factor, and reactive oxygen species such as nitric
oxide.1,5,11,12
PIH within the dermis results from inflammationinduced damage to basal keratinocytes, which release large
amounts of melanin. The free pigment is then phagocytosed
22
CLINICAL MANIFESTATIONS
PIH typically manifests as macules or patches in the
same distribution as the initial inflammatory process. The
location of the excess pigment within the layers of the skin
will determine its coloration. Epidermal hypermelanosis
will appear tan, brown, or dark brown and may take
months to years to resolve without treatment.1
Hyperpigmentation within the dermis has a blue-gray
appearance and may either be permanent or resolve over
a protracted period of time if left untreated.1,15 The
intensity of PIH may also correlate with higher skin
phototypes (Figures 4A and 4B), although studies are
needed to confirm this finding. In addition, PIH can
worsen with ultraviolet (UV) irradiation or with persistent
or recurrent inflammation.16
TREATMENT
The management of PIH should begin first with
addressing the underlying inflammatory dermatosis.
Initiating treatment early for PIH may help hasten its
resolution and prevent further darkening. However, it is
important to always be mindful of the potential the
treatment itself has to cause or exacerbate PIH by causing
irritation.17 There are a variety of medications and
procedures in addition to photoprotection that can safely
and effectively treat PIH in darker skinned patients.
Topical depigmenting agents, such as hydroquinone,
azelaic acid, kojic acid, licorice extract, and retinoids, can
be effective alone or in combination with other agents, and
procedures such as chemexfoliation and laser therapy can
also be incorporated into the management strategy if
needed (Table 2). Of note, topical agents are typically used
to treat epidermal PIH as deeper pigmentation does not
respond well to these agents.16
Figures 4A and 4B. Postinflammatory hyperpigmentation in Fitzpatrick skin type IV (A) versus VI (B). Note the
greater intensity of pigmentation in darker skin.
23
THERAPY
Hydroquinone 4%*
Sunscreen
Additional treatment
needed after 812
weeks of therapy
Laser/light therapy
Blue light photodynamic therapy
Fractional photothermolysis
Nd:YAG laser
Sunscreen
Additional treatment
needed after 812
weeks of therapy
25
easy application.108 There are four basic foundations: oilbased for dry skin, water-based for dry-to-normal skin, oilfree for oily skin, and water-free, which mixes oils with waxes
to form thicker creams that can incorporate higher amounts
of pigment to match the patients normal skin color.104
Cosmetic covers can be applied for subtle coverage up to full
concealment,109 and color correctors use the lesions color
opposite to neutralize its intensity.104
Emerging therapies. Continued research is constantly
fueled by the demand for newer, more effective
depigmenting agents. Undecylenoyl phenylalanine 2% has
been shown to safely and effectively treat solar lentigines
in a recent randomized, double-blind, vehicle-controlled
clinical trial.110 There have also been case reports and
clinical studies that have shown that topical 5%
methimazole,111 aloesin,112 and dioic acid113 can successfully
treat hyperpigmentation secondary to a variety of
etiologies. Other agents that have shown some
depigmenting properties but require further research
include 4-(1-phenylethyl)1,3-benzenediol, paper mulberry,
ellagic acid, quinolines, piperlonguminine, luteolin,
calycosin, emblica, and multivitamins.10,114,115
CONCLUSION
In skin of color, postinflammatory hyperpigmentation
can be a common yet troubling sequelae of cutaneous
inflammation. However, there are many safe and effective
treatments for this patient population including a variety of
topical depigmenting agents. It is important to initiate
treatment early while at the same time use caution with
these agents to prevent further worsening of the
hyperpigmentation. Procedures such as chemical peeling
and laser therapy provide alternatives or adjuncts to
topical therapy. Adding sunscreen to the treatment
regimen and patient education regarding sun protection
measures will also be beneficial in the management of
patients with PIH.
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