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What will the patient tell you? (History)
What will the patient tell you? (History)
The patient will describe the appearance of flat, dark marks (brown, dark brown, grey-brown, or blue-grey) that developed exactly at the site of a previous skin injury or inflammatory condition.
The most common reported triggers include:
Active or resolving conditions like acne, eczema, psoriasis, or lichen planus.
Infections (e.g., impetigo) or traumatic injuries (e.g., insect bites, burns, friction, or scratching).
Procedures such as chemical peels, laser treatments, waxing, or cryotherapy.
The pigmentation is often described as developing as the initial inflammation settles, and it can outlast the original rash by months to years. While the marks are usually asymptomatic, patients frequently report a major psychological impact, with the hyperpigmentation often causing more distress than the initial disease itself.
Risk Factors / Triggers:
Any inflammatory or traumatic skin condition.
Darker skin tones (Fitzpatrick III–VI) are at higher risk of developing more intense and persistent PIH.
Delayed or undertreated inflammatory skin diseases.
Habits such as picking, scratching, or the use of harsh, irritating products.
Exposure to UV and visible light, which significantly darkens existing PIH.
What will it look like? (Examination)
The examination will reveal macules or patches that perfectly follow the pattern and location of the prior inflammation or injury. The skin texture is typically flat, with no scale, unless the underlying disease is still active.
Colour Findings (Indicating Depth):
Epidermal PIH: Appears tan to dark brown. This form tends to fade faster.
Dermal PIH: Appears slate-grey, blue-grey, or violaceous. This form is much more resistant to treatment.
Clinical assessment, sometimes aided by a Wood's lamp, helps confirm the depth: epidermal pigment is accentuated under the lamp, while dermal pigment is not.
Key Considerations in Darker Skin Tones:
PIH is extremely common and often presents as darker, more widespread marks, creating a sharp cosmetic contrast.
It is critical to distinguish PIH from other primary pigmentary disorders, such as melasma, lichen planus pigmentosus, or exogenous ochronosis.
The clinician must evaluate for any ongoing triggers, including active disease or the use of harsh, unregulated "whitening" creams.
How can you help? (Treatment)
The core principles of management are: treat the underlying cause, ensure strict light protection, and use gentle, pigment-safe therapies. It is essential to set realistic expectations, as improvement is slow, often measured in months, not weeks.
General Measures:
Control Inflammation: Aggressively treat any underlying active disease (e.g., proper control of acne, eczema, or psoriasis).
Photoprotection (Non-Negotiable): Patients must use a daily broad-spectrum SPF 30–50+ that covers UVA, UVB, and visible light. Tinted sunscreens containing iron oxides or mineral filters are preferred in darker skin tones for better visible light coverage.
Gentle Skin Care: Encourage the use of mild cleansers and regular moisturisation. Instruct the patient to avoid scrubs, irritating toners, and picking or scratching the skin.
Topical Treatments: These are best for epidermal or mixed PIH and are often used in combination. In darker skin tones, start treatments at a lower frequency (2–3 times per week) and build up slowly to avoid irritation and paradoxical rebound PIH.
First-line Agents: Hydroquinone (short-term, targeted use), Azelaic acid, and Topical Retinoids (tretinoin, adapalene).
Adjunctive Agents: Cysteamine, Vitamin C, Kojic acid, Niacinamide, and Licorice extract.
Triple Combination Therapy: For marked PIH, a combination of hydroquinone, a retinoid, and a mild topical steroid may be used, but the steroid duration must be strictly limited.
Procedural Treatments: These should only be performed by specialists experienced with darker phototypes due to the high risk of irritation and worsening PIH.
Chemical Peels: Superficial peels (e.g., low-strength glycolic, lactic, mandelic) may be considered, but pre-treatment with lightening agents is necessary.
Lasers/IPL: Must be used with extreme caution and conservative settings, typically only for stubborn epidermal pigment. These are often not effective for deep dermal PIH.
Counseling:
Reassure the patient that while PIH is common and treatable, it takes 6–12 months for epidermal pigment to fade. Dermal pigment may only partially fade or persist.
Strongly advise against the use of unregulated "bleaching" creams (which may contain illegal hydroquinone, potent steroids, or mercury).
Encourage consistency and patience. Cosmetic camouflage is a valid and helpful option.
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