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Post Acne Hyperpigmentation: A Brief Review

Hari Kishan Kumar Yadalla
, Sacchidanand Aradhya
Department of Dermatology, M.V.J. Medical College & Research Hospital,
Hoskote, Bangalore, India
Department of Dermatology, Bangalore Medical College, Victoria Hospital,
Bangalore, India
Corresponding author: Dr. Hari Kishan Kumar Yadalla
Our Dermatol Online. 2011; 2(4): 230-231 Date of submission: 13.07.2011 / acceptance: 22.07.2011
Conflicts of interest: None
Postinflammatory 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. PIH presents itself as a flat
area of discoloration on the skin (macule) ranging from
pink to red, purple, brown or black, depending on skin
type and depth of the discoloration. PIH is characterized
by an acquired increase in cutaneous pigmentation
secondary to an inflammatory process. Excess pigment
deposition may occur in the epidermis or in both the
epidermis and the dermis [1].
PIH is very common among acne sufferers. It
can occur in all skin types, although it is more common
in darker skin types. It affects both men and women
equally. PIH is not a true scar. Postinflammatory
hyperpigmentation may be a sequela of conditions such
as acne, allergic reactions, drug eruptions,
papulosquamous disorders, eczematoid disorders, and
vesiculobullous disorders etc [2,3].
PIH is caused by 1 of 2 mechanisms that result
in either epidermal melanosis or dermal melanosis. The
epidermal inflammatory response 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 [1].
In case of Acne, papules and pustules, infection
may spread to deep skin layer called dermis. Infected
area produces more melanin than normal causing unusual
darkness. Thus, infection of hair follicles and sebaceous
glands are the real causes of Hyperpigmentation. In most
cases, if acne is not severe, it does not leave
Hyperpigmentation. Squeezing and popping the pimples
also produce Hyperpigmentation. Sun exposure is a
leading cause of acne and Hyperpigmentation.
Melanocytes are activated by sun light (ultra violet rays)
to produce excessive melanin [4].
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 skin tone. The
bigger the contrast between the macule and natural skin
tone, the longer it will take to fade.
There are various treatment options available to
help fade postinflammatory hyperpigmentation more
quickly [5]. However, 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,
improvement will take time of months rather than weeks.
Firstly - avoid sun exposure
Ultra Violet light can cause hyper-pigmented
areas to darken further and thus prolong them. Use non-
comedogenic facial moisturisers or facial sunscreens
which contain a high SPF of at least 15+.
Topical Treatments for PIH
Typically treatments for PIH bleach pigment
OR block pigment formation OR accelerate the rate of
exfoliation OR a combination.
Letter to Editor / List do Redakcji
© Our Dermatol Online 4.2011
Bleachs pigment OR block pigment formation
Kojic Acid
Benzoyl peroxide
Azeliac Acid
Accelerate the rate of exfoliation
The Tape Method of Exfoliation
The Vinegar Method of Exfoliation
Alpha Hydroxy Acid (i.e. Lactic Acid, Malic Acid, Fruit
Enzyme etc.)
TCA, GA, SA chemical peels
Mandelic Acid
Non-topical Treatments for PIH
Microdermabrasion and non ablative lasers are
being used specifically for treating pigmentation
problems. These treatments may be unsuitable for people
who suffer from active acne. Laser treatment is generally
expensive and carries a risk of causing new acne, PIH
and scarring.
Post inflammatory Hyperpigmentation usually
occurs after severe acne has healed. It may take years to
disappear if acne is not properly treated immediately.
Squeezing the acne spread infection up to dermis. The
deeper the infection, the darker the pigmentation will be.
Vinegar is the safest and most effective natural treatment
for Hyperpigmentation. With all topical and laser
treatments for PIH there is a some risk of causing new
outbreaks, new pigmentation problems and possibly even
new scarring. Risk of these occurences will probably
grow with increasing strength or invasiveness of topical
or laser procedures. Some treatments are NOT suitable
for people with active acne, sensitive skin or darker skin
tones. There is no single treatment that works for
everyone. The effectiveness of each treatments varies
and treatments may have to be used in conjunction with
each other.
1. Nordlund JJ, Boissy RE, Hearing VJ, King RA, Oetting
WS, Ortonne JP: The pigmentary system: Physiology and
pathophysiology. 2 nd ed. Malden, MA, USA: Blackwell
Publishing; 2006.
2. Lacz NL, Vafaie J, Kihiczak NI, Schwartz
RA: Postinflammatory hyperpigmentation: a common but
troubling condition. Int J Dermatol. May 2004; 43: 362-
3. Davis EC, Callender VD: Postinflammatory
Hyperpigmentation: A Review of the Epidemiology,
Clinical Features, and Treatment Options in Skin of Color. J
Clin Aesthet Dermatol. 2010; 3: 20–31.
4. Kubba R, Bajaj AK, Thappa DM, Sharma R,
Vedamurthy M, Dhar S, et al: Postinflammatory
hyperpigmentation in acne. Indian J Dermatol Venereol
Leprol 2009; 75: 54.
5. Goodman GJ: Acne & Acne scarring: Why should we
treat? Med J 1999; 171: 62-63
© Our Dermatol Online 4.2011
Copyright Hari Kishan Kumar Yadalla et al. This is an open access article distributed under the terms of the Creative Commons Attribution
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... In PIH, there is either excess melanin production or an abnormal distribution of melanin pigment deposited in the epidermis and/or dermis (2). The epidermal hypermelanosis results from the increase of melanin synthesis stimulated by inflammatory mediators (such as interleukin-1a and endothelin-1 released from inflammatory cells) or reactive oxygen species, resulting in the deposition of pigment in the surrounding keratinocytes (3,5,6), mainly in the dermal-epidermal junction (DEJ). In the upper dermis, when there is destruction of basal keratinocytes (2,6) the melanin is phagocytozed by macrophages (melanophages) (7,8), causing this lesion to be more persistent in some cases (2). ...
... Na HPI, há excesso de produção de melanina ou distribuição anormal de pigmento de melanina depositado na epiderme e/ou derme (2). A hipermelanose epidérmica resulta do aumento da síntese de melanina estimulada por mediadores inflamatórios (como a interleucina-1a e a endotelina-1 liberados por células inflamatórias) ou espécies reativas de oxigênio, resultando na deposição de pigmento nos queratinócitos adjacentes (3,5,6), principalmente na junção dermo-epidérmica (DEJ). Na derme superior, quando há destruição de queratinócitos basais (2,6), a melanina é fagocitada por macrófagos (melanófagos) (7,8), tornando essa lesão mais persistente em alguns casos (3). ...
... PIH typically appears as asymptomatic macules, hyperchromic patches that may be symmetric or asymmetric, circumscribed or diffuse, depending on the distribution of the original inflammatory dermatosis (2), and mainly affects skin phototypes III, IV and V (6,18). Asymptomatic brown macules were demonstrated by the dermoscopy of a skin region affected by postinflammatory hyperpigmentation ( Figure 1) and an increased pigmentation in lesional region was observed in images obtained by RCM through an increase of brightness of the basal cell layer (Figure 2). ...
Full-text available
Post-Inflammatory Hyperpigmentation (PIH) is a common pigmentary disorder in patients with pigmented skin. Histological and clinical exams have been used for the diagnosis of PIH and to determine the correct treatment. However, Reflectance Confocal Microscopy (RCM) has the potential to replace these methods since it is a noninvasive advanced technique and has a higher diagnostic accuracy than dermatoscopy. The aim of this study was to characterize PIH and correlate the main aspects observed by RCM with the macroscopic characteristics of acne-related PIH. Thus, 12 subjects with previously diagnosed acne and PIH were selected for the study. PIH was evaluated by RCM. The brightness of the basal cell layer, the dermal-epidermal junction (DEJ) thickness, and the depth of dermal papillae were quantified and the morphological and structural features of the DEJ were analyzed. The results showed an increase of epidermal pigmentation, a reduction of DEJ thickness, and no change in epidermal thickness. Melanophages were observed in the papillary dermis, as well as changes in the size and shape of dermal papillae. Finally, the study describes the characteristics of PIH and can help dermatologists to diagnose PIH with an innovative method that reduces the stress associated with a histological biopsy.
... 3 PIH can be epidermal or dermal. 10 One mechanism suggested is increased production and transfer of melanocytes to other epidermal cells induced by inflammatory cytokines. 3 Inflammatory damage to basal keratinocytes and melanophage formation lead to dermal pigmentation. ...
... 3 Inflammatory damage to basal keratinocytes and melanophage formation lead to dermal pigmentation. 10 Various treatment modalities available for PIH include 2-4% hydroquinone (tyrosinase inhibitor) used alone or in combination with a steroid and tretinoin (Kligman's formula). Though this has remained the mainstay of management of hyperpigmentation, particularly PIH for a long time, a number of side effects have been reported following the use of this regimen. ...
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p class="abstract"> Background: Post-inflammatory hyperpigmentation (PIH), also has psychosocial implications. Hydroquinone containing preparations though effective, have unacceptable side effects. Molecules like kojic acid, arbutin, vitamins C and E, niacinamide and many others have depigmenting effect, singly or in combination. The objective of this study was to assess the effectiveness and tolerability of a cream containing a combination of niacinamide-4.0%, glycolic acid-2.0%, vitamin E acetate-0.1%, kojic acid dipalmitate-2.0%, soy isoflavones-0.5%, arbutin-2.0%, pterowhite-0.12%, licorice-40% CA-0.12%, ascorbyl glucoside-0.1% (Melaglow-Rich, Abbott Healthcare Pvt. Ltd.) in treatment of PIH. The specific objectives were to evaluate the changes in pigmentation, safety of the cream and patient opinion regarding the cream after 90 days of use. Methods: After IEC approval, adult males and non-pregnant, non-lactating females aged upto 50 years with PIH were included. Those with endocrinopathies who received systemic steroid therapy in the preceding month were excluded. 114 participants who were enrolled in this open-label, non-comparative study, applied study medication (b.i.d) and sunscreen (SPF-30; q.d). Effectiveness was assessed by PIH severity scale, Mexameter assessment, Patients’ and Physicians’ Global Assessment Scale and clinical photographs. Adverse events were documented. Results: Mean PIH score and mean mexameter reading for melanin and erythema in the hyperpigmented and non-hyperpigmented skin reduced by day 90 (p=0.0009, p<0.0001, p<0.001). Significant reduction in physicians’ (p=0.004) and patients’ (p=0.006) global assessment score was evident by day 90. Itching (n=1), burning (n=3) and stinging (n=3) were noted. Conclusions: Melaglow rich cream was found to be effective and well-tolerated in the treatment of PIH.</p
... Particularly such products stimulate epidermal melanocyte which leads to higher levels of melanin synthesis. This in turn causes more pigments to move towards keratinocytes (12). Generally, the pathogenesis of post-acne pigmentation includes an increase in melanocyte activity and transfer of melanin granules to surrounding kerationcytes: In addition, accumulation of melanophages in the upper dermis (12). ...
... This in turn causes more pigments to move towards keratinocytes (12). Generally, the pathogenesis of post-acne pigmentation includes an increase in melanocyte activity and transfer of melanin granules to surrounding kerationcytes: In addition, accumulation of melanophages in the upper dermis (12). Common hormonal pathways may be suggested as an explanation for this association. ...
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Although, melasma is most prevalent among Asian young women, and also darkly pigmented individuals are particularly prone to developing post inflammatory hyperpigmentation, to the best of our knowledge, there are rare or no studies about the association of melasma and Post inflammatory hyperpigmentation. The aim of this study was to investigate how likely is a melasma patient to developed post inflammatory hyperpigmentation when compared to patients with inflammatory acne lesions who do not have melasma. This comparative study was conducted on 400 participants, 200 subjects involved with pigmented lesions of melasma and inflammatory acne lesions and200 involved only with inflammatory Acne lesions without melasma. Melasma, acne and post inflammatory hyper pigmentation, if existed, were assessed by a dermatologist, and pigmentation depth was assessed by wood's lamp. Multivariate logistic regression analysis suitable for study design was used to assess the association between melasma and post-acne pigmentation. We found out that 24.1% of patients without melasma had post-acne pigmentation compared to 66.8% in melasma group (P < 0.001). The likelihood of observing post-acne pigmentation was found to be nearly six times more in melasma patients versus those without melasma. Association existed after controlling for possible confounders such as melanin score and time length of self-reported sun exposure, and acne severity score. Melasma appears to increase the likelihood of post-acne pigmentation.
... 6 Treatments involve bleaching or blocking pigment formation (i.e., hydroquinone, tretinoin, azelaic acid, corticosteroids), accelerating the rate of exfoliation (i.e., chemical peeling), and physical agents (i.e., dermabrasion or laser). 7 Salicylic acid (SA) is 2-hydroxybenzoic acid or orthohydrobenzoic acid, sometimes classified as a beta hydroxy acid. 5,9 It is a lipophilic, keratolytic, comedolytic, and sebolytic agent and is therefore miscible with epidermal lipids and sebaceous gland lipids in hair follicles. ...
Introduction and Objective Antibiotics and retinoids have been used for acne vulgaris for decades. Though effective, each has its own drawbacks. Chemical peels have been used for treatment of acne vulgaris with inadequate clinical evidence. We sought to determine the efficacy and safety of Jessner’s solution (JS) in comparison with salicylic acid (SA) 30% in the management of acne vulgaris and postacne hyperpigmentation in patients with colored skin. Methods A total of 36 subjects (94.5% Fitzpatick Type IV‐V) were recruited in this randomized double‐blinded, split‐face, controlled trial. Each side of the face was randomly assigned for treatment with either JS or SA. Subjects were treated once fortnightly for a total of three sessions. Lesion counting, Michaelsson acne score (MAS), photographs, and postacne hyperpigmentation index (PAHPI) were used to objectively assess the improvement. Complications were assessed during each visit. Statistical analysis was conducted using SPSS v22.0. Significance was set at P = 0.05. Results At the end of therapy, significant reduction in inflammatory, noninflammatory lesions, MAS, and PAHPI scores (P < 0.001, respectively) were noted in comparison to baseline. Mixed model analysis revealed no significant outcome difference between the two groups. Patients who reported good and very good outcome were 76.4% (JS) and 85.3% (SA). Burning, stinging sensation, and exfoliation were the common complications reported. Postinflammatory hyperpigmentation was reported only once in the JS arm. Conclusion Both JS and SA were equally effective in the treatment of acne vulgaris and reducing postacne hyperpigmentation in patients with colored skin.
... until recently, it was thought that supportive treatment was unnecessary. However, local application of retinoids for 6 months 2-5 weeks after the initial treatment course is recommended [8,9]. ...
Full-text available
Background: Acne scars are a common problem for those suffering from acne vulgaris. They may result in low self-esteem, especially if located in visible places such as the face. They may even impede normal societal functioning and withdrawal from the environment. Aim of the study: To investigate the effects of 20% glycol acid and fractional mesotherapy on the reduction of acne scars. Material and methods: We used interviews, case analysis and assessment of the effects of glycolic acid treatment and fractional mesotherapy on a 33-year-old female patient who experienced severe phlegmonosa acne. Case report: This 33-year-old female patient was struggling with acne at age 29. Purulent cysts were located on the cheeks and jaws on both sides of her face, leaving deep scars that disturbed everyday functioning. She was alternately given four 20% glycolic acid treatments and four fractional mesotherapy treatments. Conclusions: The combination of fractional mesotherapy treatments and exfoliation with 20% glycolic acid resulted in significant improvement. Reduced inflammation contributed to decreased acne scars as well as improvement in life quality.
... 5 ' Isotretinoin (13-cis-retinoic acid) is a retinoid that has been used to treat a wide variety of conditions, some with great success. 5,9 Although it is beneficial in many skin conditions, the side effects and toxicities of oral retinoids require careful monitoring by experienced physicians. We have treated more than a 1200 cases using oral isotretinoin and this is the first case to be reported. ...
Full-text available
p>We described a case of psoriasis possibly resulting from isotretinoin therapy in acne. A 17-year-old patient started treatment with oral isotretinoin (30mg of drug) due to acne vulgaris. After 4 weeks, of treatment, the patient complains for the presence of scattered erythematous plaques and papules. The clinical picture suggested psoriasis (this is also confirmed by histopathological study). The history revealed that the patient’s mother suffered from psoriasis for 30 years. J MEDICINE January 2017; 18 (1) : 37-38</p
Full-text available
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.
The most comprehensive and integrated book on pigmentation. The Pigmentary System, Second Edition, gathers into one convenient, all-inclusive volume a wealth of information about the science of pigmentation and all the common and rare clinical disorders that affect skin color. The two parts, physiology (science) and pathophysiology (clinical disorders), are complementary and annotated so that those reading one part can easily refer to relevant sections in the other. For the clinician interested in common or rare pigment disorders or the principles of teaching about such disorders, this book provides an immediate and complete resource on the biologic bases for these disorders. For the scientist studying the biology of melanocyte function, the book provides a list of disorders that are related to basic biological functions of melanocytes. New features of this Second Edition include: Completely new section on the basic science of pigmentation - explaining the integration of melanocyte functions with other epidermal cells and with various organ systems like the immune system. New chapters on pigmentary disorders related to intestinal diseases, the malignant melanocyte, benign proliferations of melanocytes (nevi) and phototherapy with narrow band UV. All clinical chapters include the latest genetic findings and advances in therapy. More than 400 color images of virtually all clinical disorders. The book is ideal for all dermatologists and especially those interested in disorders of pigmentation. It is of particular use for pediatric dermatologists and medical geneticists caring for patients with congenital and genetic pigmentary disorders. This authoritative volume will fill the gap for dermatology training programs that do not have local experts on pigmentation. Basic and cosmetic scientists studying pigmentation and melanocytes will find the science and clinical correlations very useful in showing human significance and relevance to the results of their studies.
Reasons for early medical intervention, and options for treatment of scarring