All About Postinflammatory Hyperpigmentation and Those Brown Spots

Dr. Furnas (00:02):
Let's say you just won a tropical island trip for two to look your best. You schedule a skin rejuvenating chemical peel 10 days before all those little fine lines gone and such great texture, what could go wrong? Welcome to Skintuition. I'm Heather Furnas.

Dr. Korman (00:25):
And I'm Josh Korman. As two plastic surgeons, we lay aside our scalpels and explore the nonsurgical world to bring you what's new, what's safe, and what to look for when you're ready to hit refresh.

Dr. Furnas (00:38):
So Josh, what could go wrong?

Dr. Korman (00:41):
Oh, nothing because we're talking about it. You know how oil and vinegar don't mix? Wound healing and sunshine aren't exactly friends. Wait a minute, and you'll have pretty patchy brown spots to prove it.

Dr. Furnas (00:58):
So it happens pretty quickly. The topic of this episode is the non-sexy topic of post-inflammatory hyperpigmentation.

Dr. Korman (01:10):
Wow, post-inflammatory, that's like 12 syllables. And PIH is only three syllables.

Dr. Furnas (01:18):
So yeah, let's go with PIH. It's much easier. But let's break down that 12 syllable name post-inflammatory to start with.

Dr. Korman (01:29):
Yeah, after inflammation, I think that's basically what it means. And hyperpigmentation means a lot, or probably by implication, too much pigmentation.

Dr. Furnas (01:40):
So, confusing, isn't it? But because we don't usually think of inflammation as part of healing. People talk about a bug bite or an infected area as being inflamed, something that results from an injury or chemical irritant or something like that.

Dr. Korman (01:58):
Well, anytime the skin is disrupted, whether by laser or surgery or acne or injury.

Dr. Furnas (02:06):
Or psoriasis or burns or chemical peels.

Dr. Korman (02:11):
So anytime the skin is disrupted, mostly the skin barrier is disrupted. For whatever reason, the area becomes inflamed because inflammation is how the body heals.

Dr. Furnas (02:24):
And that leads us to that word inflammatory.

Dr. Korman (02:29):
So we can usually tell when an area is inflamed because the classical signs of inflammation are redness. Did I say redness? Redness, swelling, and warmth.

Dr. Furnas (02:40):
So when the skin is injured, the reaction is inflammation. Sounds simple, but it's actually quite complicated on a molecular level.

Dr. Korman (02:52):
So for my benefit, we'll skip over that part.

Dr. Furnas (02:55):
So all you have to know is these molecules are floating around acting like a chemical bullhorn, just sending messages, telling white blood cells to come to the site of injury.

Dr. Korman (03:09):
And the white cells respond to this alert and swarm the area, like people arriving at a Taylor Swift concert.

Dr. Furnas (03:18):
So they're all over the place, but they're all given jobs. And in this way they're kind of like ants in an ant colony. Some white blood cells clean up debris, some attack bacteria, and some lay down collagen.

Dr. Korman (03:35):
And they all end up in a movie called a Bug's Life. Actually, collagen, we've mentioned collagen on other episodes, collagen is the main protein in scar, and we have a lot of collagen in our skin.

Dr. Furnas (03:50):
Which unfortunately we lose with age. That's one reason older skin is thinner and has less robust tone. So building collagen is one way to improve the appearance and the tone of our skin.

Dr. Korman (04:08):
Which is why chemical peels and lasers are so effective at rejuvenating our skin. Injury, inflammation, collagen building.

Dr. Furnas (04:17):
Okay, we've covered the words post and inflammatory. Now let's talk about hyperpigmentation, too much pigmentation. We're talking about it as if it were a problem, yet a lot of fair skin people spend their time and money getting a nice bronze tan. They want that pigmentation, fake or real.

Dr. Korman (04:38):
A nice bronze, even tan, not splotches and spots that are darker than the surrounding skin. And that's actually what happens with PIH.

Dr. Furnas (04:49):
So it's the blotchiness. We talked about all those molecules released during inflammation. Some of them tell the pigment making cells to make more pigment. So the pigment production is abnormally high. It goes into overdrive, and then the pigment is deposited in an abnormal way too.

Dr. Korman (05:12):
So I think basically a lot of things, collagen and the pigmentation, it's not that it's bad to have it, it's all a question of balance. And when you have too much or the ratio at any given time is too much, that's when you get these problems. So we're talking irregular blotches and patches that can be tan, brown, dark brown. So without treatment, PIH tends to improve over six to 12 months, but it can last for years.

Dr. Furnas (05:44):
And a blue, gray color actually means that the deep layer of the skin, the dermis is involved, and that color can be permanent.

Dr. Korman (05:54):
So PIH can happen with anyone and to anyone, but the darker the natural skin color, the more intense and persistent it tends to be. So the reason some lasers aren't a great option for those with darker skin tones is because of the increase in sometimes high risk of PIH.

Dr. Furnas (06:12):
Before we talk about treatment for PIH, let's first talk about prevention. No matter the injury to your skin, whether it's acne or a cut, or bug bite surgery, laser, chemical peel, whatever.

Dr. Korman (06:28):
Avoid the tanning beds. Let me repeat that, avoid the tanning beds and also direct sun, reflected sun and UV rays of any type. So it's use a broad spectrum sunscreen with an SPF of 30 or more, and make sure you apply it at least 30 minutes before you're in the sun, not two seconds before in the sun or worse after you get in the water. And don't forget to protect your skin from the sun, UV protective hats, clothing, glasses, and sunglasses. And I know that actually means you look kind of dorky if you're on the beach, but then wanting to go later in the afternoon or get a big tent so you don't have to look like that. But the sun, we all need it and love it, but too much is a bad thing.

Dr. Furnas (07:13):
And when we say UV protective hats, that means no baseball hats. So let's move on to treatment. A combination therapy works best. Aggressive therapy that irritates the skin can, ironically, result in more hyperpigmentation, but might be necessary to treat at a reasonable non-aggressive way for months and even years.

Dr. Korman (07:41):
So the mainstay of treatment is a combination of topical lightning agents, retinoids, which is a derivative of vitamin A and steroids. A common combination is hydroquinone, 4% Tretinoin 0.05%, and fluocinolone, which is actually the fluocinolone acetonide, and I can't pronounce all these words because they're more than too many syllables, but it's just some kind of steroid at 0.01%.

Dr. Furnas (08:16):
So the lightening agent, which is the hydroquinone, inhibits pigment production literally at the melanocyte at that pigment forming cell. And then the retinoid, the tretinoin, spreads the pigment more evenly, so it's less blotchy. And then the steroid is an anti-inflammatory. And if the skin gets irritated from either the tretinoin or the hydroquinone, then this kind of calms that. The steroid, however, can have its bad effects. So it should not be used any longer than eight weeks. Otherwise you can have skin atrophy and actually loss of pigment that's permanent due to the steroid. And there are other problems, and we've already talked about inflammation. So what else?

Dr. Korman (09:04):
Well, there are many things else, but there are other topical agents, but we've covered the most common. As far as procedures, you can do superficial chemical peels that can remove the cells that contain excess pigment. You choose an experienced clinician because it's important, because an aggressive peel can cause skin irritation and additional hyperpigmentation. So when you're the day after the procedure and you're freaking out, when you look in the mirror, you need an experienced clinician who can both calm down your skin and calm you down.

Dr. Furnas (09:38):
So certain types of lasers can also break up the pigment, but like peels, they can cause hyperpigmentation. So proceed with caution as best to start out with just the topical treatment that we talked about before, moving to chemical peels or laser.

Dr. Korman (09:55):
So if we're going back to your first question, Heather, what could go wrong. If you're planning a sun drenched vacation right after a peel or laser, either postpone the treatment or postpone the vacation. I have so many patients over many years who come and they are about to go on vacation, cuz they want to look their best, and they're going in the next month. It's like I always tell them, go on vacation, have a nice time, and come back and do it because no one's looking at you, they're looking at themselves on vacation. So just go and have a nice time and come back and recover.

Dr. Furnas (10:30):
And there are also people with a certain lifestyle, if they're ranchers or they're sailors, they're always out, the treatment, laser or chemical peels, actually just not for them. If you can't stay out of the sun, it's better just not to have that treatment because once you deal with post-inflammatory hyperpigmentation, PIH, it can be permanent and it can be difficult to treat and time consuming.

Dr. Korman (10:59):
So I think it's really important to overall understand the limits of treatments and your own limits in terms of your lifestyle. So join us every two weeks as we tackle various topics from hair loss to hormones and pimples to wrinkles, discovering new ways to feel better about ourselves.

Dr. Furnas (11:20):
If you enjoyed this podcast, please rate us, review us and share. Have an idea for another topic? We'd love to hear from you. Theme music by Diego Canales, production and engineering by The Axis.