Managing Patients With Post-Inflammatory Hyperpigmentation and Skin of Color

Management of patients with post-inflammatory hyperpigmentation (PIH) and skin of color should include addressing underlying inflammatory dermatoses and practicing sun-protective behaviors, researchers reported in a study published in the Journal of Cosmetic Dermatology.

Effective management of patients with PIH and darker skin begins with educating them about risk factors and promoting preventive practices, advise the study authors.

The first-line treatment is topical triple therapy of hydroquinone, retinoid, and steroids. Other options include azelaic acid and vitamin C. Second-line treatment options include chemical peels with salicylic acid (SA) or glycolic acid combined with topicals, or lasers.

The researchers noted that existing studies have shown that triple therapy was superior to stand-alone hydroquinone for decreasing hyperpigmentation after 8 weeks in a cohort of Asian patients.

Azelaic acid has been found to be efficacious for decreasing hyperpigmentation in patients with darker skin. Vitamin C combined with hydroquinone may be well-tolerated among patients with darker skin.

Patients who are Fitzpatrick types IV to VI have an increased risk for developing and exacerbating PIH post-peel compared with patients with lighter skin types, and so deep peels should be avoided in patients with darker skin, according to the researchers. There is also evidence that the combination of SA and topical tretinoin can lead to significant clinical improvement compared with each individual therapy.

Identifying optimal lasers for patients with darker skin while minimizing the side effects such as hyperpigmentation, pain, blistering, and scarring can be challenging, noted the researchers. Use of low-fluence Q switched Nd:YAG laser resulted in a 54% decrease in hyperpigmentation and few side effects in 1 study of Korean patients with Fitzpatrick skin types III to IV with melasma, they wrote.

Platelet-rich plasma (PRP), tranexamic acid (TXA), and botanical products are potential alternative treatment options for patients with PIH. PRP may be an option for patients who cannot tolerate chemical peels, and TXA may also be used in treating patients with melasma owing to its tyrosinase inhibitory activity.

Botanical products such as bakuchiol, an extract from the tree Psoralea corylifolia, which has anti-inflammatory and anti-oxidative properties, have been increasingly used in the treatment of patients with PIH.

“Clinicians must work with patients to find the most suitable treatment options and establish reasonable expectations for disease course,” the study authors advised. “In a disease that disproportionately affects patients of color, utilizing patient-centric language that is both culturally and racially sensitive is vital to effectively communicate the available treatment options.”

Reference

Anvery N, Christensen RE, Dirr MA. Management of post-inflammatory hyperpigmentation in skin of color: a short review.J Cosmet Dermatol. Published online March 15, 2022. doi:10.1111/jocd.14916