Prevent Acne-Related PIH: Treat Acne Early
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Dr. Desai is Founder and Medical Director of Innovative Dermatology and Clinical Assistant Professor at University of Texas/Southwestern in Dallas.
I have a passionate love/hate relationship with PIH or post-inflammatory hyperpigmentation. I love it when I can make my patients better and happier and allow them to feel better about their skin. I hate it, because it can be very difficult to treat. Given the challenges of management, one of my main philosophies in approaching PIH is to take all possible measures to prevent it.
One of the most common reasons patients with darker skin types develop PIH is as a result of acne. For example, one recent analysis showed that nearly 60% of acne patients from seven Asian countries had associated PIH. The analyzed population consisted mainly (80%) of individuals with mild to moderate acne. (J Dermatol. 2016 Jul;43(7):826-8) This tells us that PIH is not just a result of severe acne. When acne is left untreated or treated not aggressively from the onset, the risk for PIH increases. Once PIH develops, the patient and dermatologist face the challenge of lightening those spots. In the above mentioned Asian study, more than half of subjects had had PIH for one year and 22% had had it for five years or more. In efforts to prevent PIH from developing, I tend to treat acne very aggressively, especially in my patients with darker skin.
As its name indicates, PIH is inflammatory at its core, with good evidence that inflammatory mediators drive the condition. (J Eur Acad Dermatol Venereol. 2015 Jun;29 Suppl 4:3-11) Topical therapies that target acne while providing anti-inflammatory effects are ideal. Topical retinoids can be beneficial for addressing PIH, as they are recognized to provide anti-inflammatory effects while they promote epidermal cell turnover.
Clinicians should not overlook interventions like chemical peels that can also address both active acne and PIH. I tend to prefer salicylic acid peels, which seem to reduce skin oiliness, help to clear congested pores, promote exfoliation, and can help reduce PIH. It is essential that the patient stop any retinoid (tretinoin, tazarotene, adapalene, etc.) at least five to seven days before the chemical peel is performed. They can continue using other therapies, such as topical antibacterial formulations. While the retinoid may an valuable part of the treatment algorithm, improper timing of medications could lead to an adverse event, such as peel-induced burn. It is therefore important to know when to time these products.
Acne-related PIH is indeed a challenge, and we welcome development of new treatment options. In the meantime, if we start treating acne early, there's much more likelihood of success preventing PIH from even developing.