Melasma and Post Inflammatory Hyperpigmentation: Management Update and Expert Opinion

Bryan Sofen, MD; Giselle Prado, BS; Jason Emer, MD

Disclosures

Skin Therapy Letter. 2016;21(1) 

In This Article

Abstract and Introduction

Abstract

Dyschromia is a leading cause for cosmetic consultation, especially in those with diverse skin types (mixture of ethnicities) and with the rise of non-core and untrained physicians performing cosmetic procedures. Melasma and post-inflammatory hyperpigmentation (PIH) account for the majority of cases and are characterized by pigmented macules and patches distributed symmetrically in sun-exposed areas of the forehead, cheeks, and chin in melasma, and irregularly in areas of inflammation or an inciting traumatic event with PIH. Treatment is challenging and focused on a variety of mechanisms to stop, hinder, and/or prevent steps in the pigment production (melanocytic hyperactivity) process, breaking down deposited pigment for internal removal or external release, exfoliating cells to enhance turnover, and decreasing inflammation. Topical lightening therapy in combination with sun protection is essential for potential improvement. The most commonly prescribed and researched topical lightening agents are hydroquinone (HQ), azelaic acid (AzA), and retinoids - although only HQ and a triple combination cream (Tri-Luma®; fluocinolone acetonide 0.01%, HQ 4%, tretinoin 0.05%) are US FDA-approved for "bleaching of hyperpigmented skin" (HQ) and "melasma" (Tri-Luma®). Numerous non-HQ brightening/lightening agents, including antioxidant and botanical cosmeceuticals, have recently flooded the market with improvements that claim less irritant potential, as well as avoiding the stigmata associated with HQ agents such as carcinogenesis and cutaneous ochronosis. Combining topical therapy with procedures such as chemical peels, intense pulsed light (IPL), fractional non-ablative lasers or radiofrequency, pigment lasers (microsecond, picosecond, Q-switched), and microneedling, enhances results. With proper treatment, melasma can be controlled, improved, and maintained; alternatively, PIH can be cured in most cases. Herein, we review treatments for both conditions and provide an opinion on proper management for enhanced results.

Introduction

Dyschromia is a frequent complaint in the cosmetic consultation as it is psychologically distressing and may be a signal of systemic changes (e.g., hormones, sun sensitivity/autoimmune, medications).[1] Although dyschromia is more commonly reported in those with darker or diverse skin types, there is an increasing number of patients of all skin types seen in practice presenting with irregular macules and patches of hyper and hypopigmentation from improperly performed cosmetic procedures by non-core or untrained physicians inducing color changes (Figures 1a and 1b). Given the degree of importance patients place on a clear complexion with regards to color and tone, we set forth to describe updated treatment options for melasma and post-inflammatory hyperpigmentation (PIH) to guide proper management.

Figure 1a.

Dyschromia from IPL on a patient with skin type 4 who was not an appropriate candidate for this treatment. Notice the broad areas of hyper and hypopigmentation.

Figure 1b.

Melasma. Hyperpigmented patches in the classicdistribution of the face of a female with worsening skin complaints despite topical hydroquinone and sunscreen.

Melasma is an acquired disorder of pigmentation that is characterized by symmetrically distributed pigmented macules and patches in sun-exposed areas of the face such as the forehead, cheeks and chin. Although the pathogenesis is not completely understood, hyperactive melanocytes stimulated by ultraviolet (UV) light exposure is the most widely accepted cause. UV exposure stimulates an increase in tyrosinemediated melanogenesis and melanosome transfer to epidermal keratinocytes, which is reflective of what we see clinically with worsening of pigmented patches after sun exposure or burn. Other causes such as genetics, photosensitizing medications, and hormones/endocrinopathies also play a role and may contribute to UV sensitivity.[2] Estrogen, associated with pregnancy or oral contraceptive pills, induces the release of melanocyte-stimulating hormone (MSH), stimulating tyrosinase; a reason the majority of cases are seen in females versus males.[3]

In lesional skin of patients with melasma, there is upregulation of vascular endothelial growth factor (VEGF), stem cell factor (kit-ligand), Wnt (Wingless-related integration site) signaling modulating genes, and reactive oxygen species, all of which are byproducts of UV induced dermal inflammation that in turn promote vascularization and stimulate melanocyte hyperactivity.[4] This local inflammatory milieu is also seen in PIH.[3]

PIH represents another form of reactive hypermelanosis that occurs following an inciting event, which causes cutaneous inflammation such as inflammatory skin conditions (e.g., psoriasis, eczema, acne), trauma (e.g., picking, burns), or cosmetic procedures (Figure 2).[5] The majority of cases are irregularly placed and not symmetrical or necessarily in sunexposed areas, as seen in melasma. Patients with darker or diverse skin types are more prone to PIH due to higher basal amounts of epidermal melanin. PIH is gender neutral, conversely, melasma is much more common in females due to hormonal influences.[5] Histologically, there is no difference between either entity and clinical correlation is essential. Epidermal and dermal pigmentation may be differentiated on biopsy or with Wood's lamp examination to dictate the nature of treatments offered at the onset.

Figure 2.

PIH. Linear hyperpigmented streaks and residual erythema in a patient 3 weeks after full face erbium laser resurfacing.

Treatment of disorders of pigmentation can be challenging. For PIH, the key component guiding all other treatment remains prevention. PIH may be prevented or minimized by using pre-procedural topical lightening/bleaching agents, antiinflammatories, and/or retinoids. In contrast, melasma prevention is quite difficult. Patients with a family history of melasma or a diverse or ethnic skin type, who are pregnant, on hormonal therapy, or taking a photosensitizing medication, should be counseled on appropriate skin care with photoprotection, antioxidants, and lightening agents. While PIH may resolve spontaneously without treatment, melasma has no cure and needs continuous topical therapy focused on protection from UV damage in addition to targeted lightening/bleaching. This paper will review the common topical and procedural treatments for melasma and PIH.

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