Melanin-Rich Skin: Post-Inflammatory Hyperpigmentation Treatment

Affecting approximately 65% of African Americans, 52% of Hispanics, and 47% of Asians, post-inflammatory hyperpigmentation is one of the most common pigmentary disorders occurring amongst skin of color clients.¹ Melanin-rich skin types are at higher risk of developing post-inflammatory hyperpigmentation due to the overproduction of melanin that this population tends to experience following the initiation of inflammatory processes, injury, or trauma. {mprestriction ids=”3,4,26,18,6,7,8,9,14,18,43,44″}

Practical treatment options should yield the greatest result of depigmentation, presenting with the lowest risk of side effects possible.⁴ Treatment of this condition is highly dependent on whether it is epidermal or dermal. When treating skin of color, the goal is to maintain the integrity of the skin barrier while ensuring to not cause rebound hyperpigmentation in clients. To effectively eradicate dyspigmentation, inflammation must be resolved at the root, or the recurring inflammation will continue to leave the client at risk for developing pigmentary disorders, such as post-inflammatory hyperpigmentation.

MONOTHERAPY

Considered the golden standard and first line of therapy for improving hyperpigmentation, hydroquinone has been utilized as a depigmenting agent for many cases over the years. Hydroquinone functions as a tyrosinase inhibitor which stops the conversion of dihydroxyphenylalanine to melanin. It is available over-the-counter concentrated at a strength of up to 2% but exists as prescription only ranging from 3% to 10%. However, hydroquinone is typically used in concentrations of 2% to 4% for treatment of dyschromia, yet it has been determined that irritation tends to develop when concentrations of 3% to 5% are utilized.^4,5

Common adverse effects affecting skin of color while using hydroquinone include but are not limited to hypopigmentation (specifically the halo effect), contact dermatitis, rebound hyperpigmentation or re-pigmentation, and exogenous ochronosis.^4,5 When using hydroquinone on skin of color, irritation must be limited to lessen the risk of worsening pigmentation.

Hydroquinone usage should be limited to three months at a time and then cycled to reduce risk of irritation.^6,7 Clients should be reviewed every three months to ensure that adverse effects are not present.¹¹ Although certain concentrations of hydroquinone may cause irritation and adverse side effects, previous cases have determined hydroquinone to be effective at depigmenting skin. However, it has been proven that its efficacy can be boosted when formulated with other ingredients.⁴

ALTERNATIVE DEPIGMENTING OPTIONS

Other tyrosinase inhibitors that have been used for monotherapy include but are not limited to mequinol, tretinoin, adapalene, tarzarotene, azelaic acid, arbutin, ascorbic acid, kojic acid, licorice extracts, soy, and other topical retinoids.^8,9 Products such as niacinamide, soy, tranexamic acid, and resveratrol may also be used to interfere with other stages of melanogenesis-affecting mechanisms of action like melanosome transfer and irritant-inducing melanin synthesis for example.⁸ These alternatives are useful to implement if the client has an allergy to hydroquinone or has used it for a prolonged period.¹⁰ However, most of these therapeutics have been evaluated for efficacy regarding melasma as opposed to post-inflammatory hyperpigmentation.¹² Therefore, more studies researching the efficacy of these treatments on post-inflammatory hyperpigmentation specifically on skin of color are warranted.

COMBINATION THERAPY

The first line of defense for combination therapy typically consists of a tyrosinase inhibitor used in conjunction with a retinoid and photoprotection.⁵ Various case studies have shown that hydroquinone is less irritating at higher concentrations when formulated with corticosteroids.⁵ This is greatly beneficial for skin of color as it lessens the risk of re-pigmentation. The Kligman formula would be an example of this. It consists of hydroquinone, tretinoin, and dexamethasone; however, there are other formulas that include other ingredients such as fluocinolone acetonide. These formulations have shown to be more efficacious than monotherapy for skin of color due to the low risk of irritation.

Once the first line of defense has been administered, procedures may be added two to three months later to assist with depigmentation.⁵ Common procedures include resurfacing techniques such chemical peels and laser therapy. As with topical agents, adverse effects of further pigmentation are a concern with the services as well. It is important to note that topical agents are beneficial for treating epidermal post-inflammatory hyperpigmentation only. Deep peels affect the dermis which could alter dermal post-inflammatory hyperpigmentation, but laser therapy would be the optimal option for treating this type of pigmentation.

For skin of color, the best prevention of post-inflammatory hyperpigmentation is photoprotection as it is truly the first line of defense. Consistent use of sunscreen with a sun protection factor of 30 or more helps with avoiding the process of melanogenesis. Stepwise approaches to treatment should be utilized for skin of color, as it minimizes the risk for adverse side effects, especially re-pigmentation. Hydroquinone usage should be monitored by the respective licensed professional based on concentration. Aestheticians play a vital role in guiding clients who are using over-the-counter hydroquinone as prolonged usage can result in undesired results. Properly caring for post-inflammatory hyperpigmentation in skin of color could improve clients’ quality of life as it can be a detrimental experience.⁴

References

1. Taylor SC, Cook-Bolden F, Rahman Z, et al. Acne vulgaris in skin of color. J Am Acad Dermatol. 2002;46(Suppl 2):S98–S106.
2. Brenner, M., & Hearing, V. J. (2008). Modifying skin pigmentation – approaches through intrinsic biochemistry and exogenous agents. Drug discovery today. Disease mechanisms, 5(2), e189–e199. https://doi.org/10.1016/j.ddmec.2008.02.001
3. Savory, S., & Pandya, A. (2014). Dermatology Atlas for Skin of Color. Dallas: Springer.
4. Grimes, P. E. (2009). Management of hyperpigmentation in darker racial ethnic groups.Seminars in Cutaneous Medicine and Surgery, 28(2), 77-85. https://doi.org/10.1016/j.sder.2009.04.001
5. Callender, V. D., St. Surin-Lord, S., Davis, E. C., & Maclin, M. (2012;2011;). Postinflammatory hyperpigmentation: Etiologic and therapeutic considerations.American Journal of Clinical Dermatology, 12(2), 87-99. https://doi.org/10.2165/11536930-000000000-00000
6. Searle, T., Al‐Niaimi, F., & Ali, F. R. (2021). Hydroquinone: Myths and reality.Clinical and Experimental Dermatology, 46(4), 636-640. https://doi.org/10.1111/ced.14480
7. Price, L., Vashi, N., & Ferguson, N. (n.d.). Hydroquinone. Skin of Color Society. https://skinofcolorsociety.org/patient-dermatology-education/additional-patient-information/hydroquinone/
8. Elbuluk, N., Grimes, P., Chien, A., Hamzavi, I., Alexis, A., Taylor, S., Gonzalez, N., Weiss, J., Desai, S. R., & Kang, S. (2021). The pathogenesis and management of acne-induced post-inflammatory hyperpigmentation.American Journal of Clinical Dermatology, 22(6), 829-836. https://doi.org/10.1007/s40257-021-00633-4
9. Taylor, S., Grimes, P., Lim, J., Im, S., & Lui, H. (2009). Postinflammatory hyperpigmentation. SAGE Publications. https://doi.org/10.2310/7750.2009.08077
10. Davis, E. C., & Callender, V. D. (2010). Postinflammatory hyperpigmentation: A review of the epidemiology, clinical features, and treatment options in skin of color.The Journal of Clinical and Aesthetic Dermatology, 3(7), 20-31.
11. Searle, T., Al‐Niaimi, F., & Ali, F. R. (2021). Hydroquinone: Myths and reality.Clinical and Experimental Dermatology, 46(4), 636-640. https://doi.org/10.1111/ced.14480
12. Sarma, N., Chakraborty, S., Poojary, S. A., Rathi, S., Kumaran, S., Nirmal, B., Felicita, J., Sarkar, R., Jaiswal, P., D’Souza, P., Donthula, N., Sethi, S., Ailawadi, P., & Joseph, B. (2017). Evidence-based review, grade of recommendation, and suggested treatment recommendations for melasma.Indian Dermatology Online Journal, 8(6), 406-442. https://doi.org/10.4103/idoj.IDOJ_187_17
13. Taylor SC, Cook-Bolden F, Rahman Z, et al. Acne vulgaris in skin of color. J Am Acad Dermatol. 2002;46(Suppl 2):S98–S106.
14. Brenner, M., & Hearing, V. J. (2008). Modifying skin pigmentation – approaches through intrinsic biochemistry and exogenous agents. Drug discovery today. Disease mechanisms, 5(2), e189–e199. https://doi.org/10.1016/j.ddmec.2008.02.001
15. Savory, S., & Pandya, A. (2014). Dermatology Atlas for Skin of Color. Dallas: Springer.
16. Grimes, P. E. (2009). Management of hyperpigmentation in darker racial ethnic groups.Seminars in Cutaneous Medicine and Surgery, 28(2), 77-85. https://doi.org/10.1016/j.sder.2009.04.001
17. Callender, V. D., St. Surin-Lord, S., Davis, E. C., & Maclin, M. (2012;2011;). Postinflammatory hyperpigmentation: Etiologic and therapeutic considerations.American Journal of Clinical Dermatology, 12(2), 87-99. https://doi.org/10.2165/11536930-000000000-00000
18. Searle, T., Al‐Niaimi, F., & Ali, F. R. (2021). Hydroquinone: Myths and reality.Clinical and Experimental Dermatology, 46(4), 636-640. https://doi.org/10.1111/ced.14480
19. Price, L., Vashi, N., & Ferguson, N. (n.d.). Hydroquinone. Skin of Color Society. https://skinofcolorsociety.org/patient-dermatology-education/additional-patient-information/hydroquinone/
20. Elbuluk, N., Grimes, P., Chien, A., Hamzavi, I., Alexis, A., Taylor, S., Gonzalez, N., Weiss, J., Desai, S. R., & Kang, S. (2021). The pathogenesis and management of acne-induced post-inflammatory hyperpigmentation.American Journal of Clinical Dermatology, 22(6), 829-836. https://doi.org/10.1007/s40257-021-00633-4
21. Taylor, S., Grimes, P., Lim, J., Im, S., & Lui, H. (2009). Postinflammatory hyperpigmentation. SAGE Publications. https://doi.org/10.2310/7750.2009.08077
22. Davis, E. C., & Callender, V. D. (2010). Postinflammatory hyperpigmentation: A review of the epidemiology, clinical features, and treatment options in skin of color.The Journal of Clinical and Aesthetic Dermatology, 3(7), 20-31.
23. Searle, T., Al‐Niaimi, F., & Ali, F. R. (2021). Hydroquinone: Myths and reality.Clinical and Experimental Dermatology, 46(4), 636-640. https://doi.org/10.1111/ced.14480
24. Sarma, N., Chakraborty, S., Poojary, S. A., Rathi, S., Kumaran, S., Nirmal, B., Felicita, J., Sarkar, R., Jaiswal, P., D’Souza, P., Donthula, N., Sethi, S., Ailawadi, P., & Joseph, B. (2017). Evidence-based review, grade of recommendation, and suggested treatment recommendations for melasma.Indian Dermatology Online Journal, 8(6), 406-442. https://doi.org/10.4103/idoj.IDOJ_187_17

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