Post Inflammatory Hyperpigmentation
Your acne is clearing up and your skin is looking better every day. But then you notice dark pink or brown spots on your skin where the acne lesions have healed. Is it scarring? And what can you do about it?
What is Post Inflammatory Hyperpigmentation?
Post Inflammatory hyperpigmentation, or PIH, is the medical term given to discoloration of the skin that follows an inflammatory wound. It is the skin's natural response to inflammation.
It is a frequently encountered problem and represents the sequelae of various cutaneous disorders as well as therapeutic interventions. This acquired excess of pigment can be attributed to various preceding disease processes that affect the skin; these processes include infections, allergic reactions, mechanical injuries, reactions to medications, phototoxic eruptions, trauma (eg, burns), and inflammatory diseases (eg, lichen planus, lupus erythematosus, atopic dermatitis).
PIH is caused by 1 of 2 mechanisms that result in either epidermal melanosis or dermal melanosis. The epidermal inflammatory response (ie, dermatitis) results in the release and subsequent oxidation of arachidonic acid to prostaglandins, leukotrienes, and other products. These products of inflammation alter the activity of both immune cells and melanocytes. Specifically, these inflammatory products stimulate epidermal melanocytes, causing them to increase the synthesis of melanin and subsequently to increase the transfer of pigment to surrounding keratinocytes. Such increased stimulation and transfer of melanin granules results in epidermal hypermelanosis. On the contrary, dermal melanosis occurs when inflammation disrupts the basal cell layer, causing melanin pigment to be released and subsequently trapped by macrophages in the papillary dermis, also known as pigmentary incontinence.
- PIH can occur with various disease processes that affect the skin. These processes include allergic reactions, infections, trauma, and phototoxic eruptions. Fractional laser photothermolysis occasionally induces PIH.
- Common inflammatory diseases that result in PIH include acne excoriée, lichen planus, systemic lupus erythematosus, chronic dermatitis, and cutaneous T-cell lymphoma, especially erythrodermic variants.
- Furthermore, lesions of PIH can darken with exposure to UV light and various chemicals and medications, such as tetracycline, bleomycin, doxorubicin, 5-fluorouracil, busulfan, arsenicals, silver, gold, antimalarial drugs, hormones, and clofazimine.
PIH presents itself as a flat area of discoloration on the skin (macule) ranging from pink to red, purple, brown or black, depending on your skin tone and depth of the discoloration.
Color changes come in three basic flavors: post inflammatory erythema (pink and purple patches at the site of acne lesions), post inflammatory hyperpigmentation (brown/black discoloration at the site of the acne lesion), and post inflammatory hypopigmentation (white marks at the site of a healed acne lesion).
Post inflammatory hyperpigmentation develops when a wound, rash, pimple, or other stimuli causes skin inflammation, which triggers the skin to produce too much melanin. Melanin is the protein in the skin that gives the skin its color. The excess melanin darkens and discolors the wounded area. This discoloration remains even after the wound or rash has healed.
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.
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.
There are many different conditions that can cause discoloration, but the most common are Post-Inflammatory Hyperpigmentation and Melasma.
The treatment of PIH tends to be a difficult and prolonged process that often takes 6-12 months to achieve the desired results of depigmentation. Each of these treatment options potentially improves epidermal hypermelanosis, but none is proven effective for dermal hypermelanosis.
What causes the dark spots around my acne lesions?
Post-Inflammatory Hyperpigmentation is very common among acne sufferers. It can occur in all skin types, although it is more common in darker skin tones. It affects both men and women equally. Luckily, Post-Inflammatory Hyperpigmentation is not a true scar.
Inflammation caused by acne leads to redness of the skin. Redness usually starts when the acne lesion is active. Even after the acne lesion has improved, however, inflammation may continue deep in the skin, causing persistent redness of the skin. Inflammation also stimulates the production of the pigment molecule called melanin, leading to brown or black discoloration. Thus, in those who tan easily or with darker skin tones, melanin production is stimulated by the inflammation leading to brown discoloration around the acne lesion. Although the discoloration lasts longer than the acne lesion itself, the discoloration will fade with time- sometimes several months.
Ethnic Skin and Acne Scars
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.
Acne is one of the most common skin conditions in people with darker skin. African Americans usually have post inflammatory hyperpigmentation and are at higher risk of scarring. Hispanics and those of Middle Eastern descent also commonly have post inflammatory hyperpigmentation. Asians have a lower risk of hyperpigmentation than African Americans, but higher risk than Caucasian patients. The risk of hypertrophic and keloidal scars is 5 to15 times higher in African American people and 3 to 5 times higher in those of Asian descent. Thus, treating acne early, before scar formation and discoloration is recommended.
Rashes of any type can cause PIH (examples of which include eczema, psoriasis, pityriasis rosea, lichen planus, and fungal infections).
Treatment of Discoloration From Acne
Discoloration from acne (red, purple, brown, black, and white) is less permanent and easier to treat than acne scarring. However, it is also much more common. Both topical medications and surgical methods are employed.
Post inflammatory hyperpigmentation and acne
A post inflammatory hyperpigmentation macule often is the remnant of an inflamed acne lesion. PIH macules can follow relatively minor pimples and papules, in addition to more serious lesions. However, the more inflamed a breakout, the larger and darker the PIH macule tends to be. Picking or popping a pimple increases the chance of developing post inflammatory hyperpigmentation.
You can identify post inflammatory hyperpigmentation by carefully examining the skin. PIH macules can be a range of colors, however, the skin will not be pitted or depressed. It may look like a discolored freckle on the skin, or it may present as a larger, dark discoloration of the skin. PIH macules may look shiny, or like "new skin."
Most acne sufferers are relieved to learn that post inflammatory hyperpigmentation is not scarring. PIH will fade away over time, even without treatment. It can take three to 24 months for PIH to fully fade, although in some cases it may take longer. The length of time it takes for PIH to fade depends on how dark the PIH macule is compared to your skin tone. The bigger the contrast between the macule and your natural skin tone, the longer it will take to fade.
There are treatment options available to help fade post inflammatory hyperpigmentation more quickly. However, your acne should be under control before beginning any treatment for PIH. Otherwise, each new pimple could cause another PIH macule, reducing the effectiveness of treatment.
Whatever treatment option you choose, understand that improvement will take time. Think in terms of months rather than weeks. Also, many dermatologist recommend using a broad-spectrum sunscreen daily. The sun may darken the discolorations and increase fading time.
Mild cases of post inflammatory hyperpigmentation may respond well to over-the-counter products. A variety of topical treatments have been used to treat epidermal PIH, with varying degrees of success. These agents include hydroquinone, tretinoin cream, corticosteroids, glycolic acid (GA), and azelaic acid. Lightening of hyperpigmented areas may be achieved with one of the previously named topical agents; however, a combination of topical creams and gels, chemical peels, and sunscreens may be necessary for significant improvement.
Pigmented makeup creams have also been successfully used to camouflage hyperpigmented skin to a hue similar to that of the surrounding unaffected skin.
Hydroquinone is a widely used treatment for post inflammatory hyperpigmentation. It is available over-the-counter at 1% to 2% strength, and in 3% to 4% prescription creams. Hydroquinone works by blocking the enzyme responsible for melanin production, thereby lightening the skin.
Hydroquinone creams often contain additional lightening ingredients, such as kojic acid, glycolic acid, tretinoin and other retinoids, or vitamin C. These combination creams can give you better results than using hydroquinone alone.
Hydroquinone creams should be carefully applied to darkened areas only, to prevent the unwanted lightening of your natural skin color. Hydroquinone may cause irritation in sensitive individuals. It's worth talking to your doctor before beginning hydroquinone treatment.
Retinoids, such as tretinoin and tazarotene, are often prescribed to acne patients. Retinoids help clear acne by speeding up cell turnover rates. It is this rapid exfoliation that can also help clear PIH. Retinoid creams include Retin-A, Tazorac, and Differin. The fact that they lessen post inflammatory hyperpigmentation as they treat acne breakouts is an added benefit for many people.
Obvious results may not be apparent for several weeks to several months after beginning treatment. Topical retinoids may cause excessive dryness, redness, and/or irritation, which may in turn increase hyperpigmentation. Let your doctor know right if you experience any of these side effects.
Glycolic acid is an alpha hydroxy acid found in many skin care products. It effectively exfoliates the skin, helping to lighten post inflammatory hyperpigmentation. Available in cleansers, creams, and gels, glycolic acid not only helps improve postinflammatory hyperpigmentation, but also leaves your skin smooth and soft.
Cleansers, gels, pads, and lotions containing glycolic acid are available over-the-counter. Higher concentrations are available with a prescription only. As with all products, improvement may not be seen for several months. Monitor your skin for irritation, and inform your doctor if it occurs.
People with PIH should use sunscreen on a daily basis to prevent any further darkening of lesions.
- Patients should never be treated with monobenzyl ether of hydroquinone because of the risk of developing disfiguring depigmented patches of skin either at the application site or at distal cutaneous sites.
- PIH tends to fade with time and therapy, as previously discussed.
- Remnants of epidermal hyperpigmentation may persist for indefinite periods, typically 6-12 months, after the initial inflammatory process resolves.
- Dermal PIH may even persist for years.
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