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Melasma or PIH : skin's natural response to inflammation
 If your
complexion is being punished by unsightly brown patches that never seem to
go away, you may have melasma or post inflammatory hyperpigmentation (PIH). Post
Inflammatory 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.
Post-inflammatory hyperpigmentation (PIH) causes skin darkening and
discoloration that show up as
spots, or as
large patches on a person's body. This is because cells that normally produce
brown pigment evenly across your skin go into overdrive and produce too much
melanin. This happens because of an
inflammatory
reaction in, or to an injury to, the skin. If the excess melanin is produced
in the upper layer of skin (epidermis), the pigmentation color is a darker shade
of brown. If the excess melanin is produced in the lower layer of skin (the
dermis), a gray or blue discoloration becomes visible.
Causes
The most common causes are injuries such as scratches, burns, cuts, or
bruises. Rashes of any type can cause PIH (examples of which include
eczema,
psoriasis, pityriasis
rosea, lichen planus, and fungal infections). Ordinary conditions such as
acne or pimples are a
very common cause of PIH in individuals with brown skin. PIH can also be caused
by injury to the skin resulting from
sunburns, surgery
or cosmetic procedures such as
chemical
peels, dermabrasion, lasers and cryotherapy (liquid nitrogen treatments).
Skin inflammation from allergic reactions, facial waxing (especially above the
lip) or spots can trigger hyperpigmentation. Sun exposure is the big culprit.
Pigment may be located in the epidermis or skin’s outer layer, the dermis or
deeper layer, or a combination of both. The more superficial, the easier it will
lighten.
Treatment
 PIH that is more recent responds better to treatment.
Hydroquinone is the
most effective skin lightening agent. Agents like kojic acid are often combined
with azelaic acid, glycolic acids, lactic acid, retinol, ascorbic acid and
botanical lighteners such as liquorice and bearberry extracts. Most skin
lightening ingredients work better in tandem than on their own.
Skin lightening is not a quick process. It can take 6-12 weeks to see results.
Non-prescription lightening creams can go only so far. For more dramatic
improvement, look to more invasive remedies like peels and lasers to blend
darkened areas. Microdermbrasion can remove superficial pigmented cells and
allow lightening creams to penetrate better. Devices such as the pulse dye
laser, Q-switched ruby and Nd:Yag can reduce brown coloured pigment. These
systems utilize bursts of energy to target pigmented areas and destroy pigment
cells. Minimizing
sun exposure prevents darkening of existing patches, as well as new areas.
Once you have successfully lightened areas, maintenance is needed for the long
term.
 It is available over-the-counter at 1% to 2% strength, and
in 3% to 4% prescription creams. Hydroquinone works by blocking the enzyme
responsible for melanin production, thereby lightening the skin. Hydroquinone
creams often contain additional lightening ingredients, such as kojic acid,
glycolic acid, tretinoin and other retinoids, or vitamin C. These combination
creams can give you better results than using hydroquinone alone. Hydroquinone
creams should be carefully applied to darkened areas only, to prevent the
unwanted lightening of your natural
skin color. Hydroquinone may
cause irritation in sensitive individuals. It's worth talking to your doctor
before beginning hydroquinone treatment.
One scientific study demonstrated that 80% of individuals who used a 4%
hydroquinone product combined with glycolic acid had an improvement in their PIH
after 3-months time. Because the lightening agent can sometimes cause other skin
conditions, your treatment should not exceed 6 months.
Retinoids, such as tretinoin and
tazarotene, are often prescribed to acne patients. Retinoids help clear acne by
speeding up cell turnover rates. It is this rapid exfoliation that can also help
clear PIH. Retinoid creams include Retin-A, Tazorac, and Differin. The fact that
they lessen post inflammatory hyperpigmentation as they treat acne breakouts is
an added benefit for many people.
Obvious results may not be apparent for several weeks to several months after
beginning treatment. Topical retinoids may cause excessive
dryness, redness, and/or
irritation, which may in turn increase hyperpigmentation. Let your doctor know
right if you experience any of these side effects
 Glycolic acid is an alpha
hydroxy acid found in many skin care products. It effectively exfoliates the
skin, helping to lighten post inflammatory hyperpigmentation. Available in
cleansers, creams, and gels, glycolic acid not only helps improve
postinflammatory hyperpigmentation, but also leaves your skin smooth and soft.
Cleansers,
gels, pads, and lotions containing glycolic acid are available over-the-counter.
Higher concentrations are available with a prescription only. As with all
products, improvement may not be seen for several months. Monitor your skin for
irritation, and inform your doctor if it occurs.
Chemical Peels are a more intensive treatment used in cases of more
persistent PIH or to hasten the lightening effects of the topical prescription
products. Peels work by exfoliating the upper-most layer of your skin and the
dark area with it. There are many different types of peels and they are usually
solutions that the dermatologist applies to the skin. The peels that are used
most often to treat PIH in brown skin are the alpha-hydroxy acid (glycolic acid)
or beta-hydroxy acid (salicylic acid) peels.
 Microdermabrasion is a cosmetic procedure, performed in the dermatologist’s
office, in which fine crystals are sprayed onto the skin’s surface to gently
sand away the upper-most layers of the skin. As with chemical peels,
microdermabrasion works by exfoliating the upper-most layer of your skin and the
dark area with it. This procedure is particularly well suited for individuals
who have sensitive skin (many individuals with brown skin) or those who have had
a previous reaction to a chemical peeling agent. The procedure is performed with
a machine that gently sprays the tiny crystals onto the skin’s surface and uses
gentle suction to remove the dead superficial skin. The entire procedure takes
about 20-30 minutes. You are then able to resume you normal activities.
Use of Sunscreen
People with PIH should use sunscreen on a daily basis to prevent any further
darkening of lesions. By regularly using a sunscreen containing an SPF of 15 or
30, even in winter, you can prevent the further darkening of areas of existing
PIH. The best products to use are considered “broad spectrum” because they block
both UVA and UVB rays. Patients concerned about
oily skin
should look for sunscreen sprays and gels in order to avoid further skin surface
oil.
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