Methods for preventing and correcting post-inflammatory hyperpigmentation

Olga Antonyuk , dermatovenerologist, international trainer of Skin Tech Pharma Group, national trainer of the Academy of Scientific Beauty - Ukraine (Ukraine)

For some reason, many experts believe that the best prevention of post-inflammatory hyperpigmentation (PIHI) during abrasive, invasive and other procedures with relatively traumatic technologies is not to perform these procedures. That is, instead of teaching the patient how to properly care for his skin post-procedure, reminding him of the importance of moisturizing and using products with SPF, it’s easier for us to dissuade him and do nothing? Ignoring problems has never been an effective solution!

Mistrust and lack of adequate communication between specialist and patient always provoke problems of mutual understanding. As a result, most people, after the procedure, answer the question: “Did you not tear off the scabs, did you use SPF cream three times a day?” – they answer in the affirmative, shifting all moral and financial responsibility only to the doctor.

More than once I have come across a situation where, before performing a new course of peeling procedures, I prescribe SPF to a patient and in response I hear that she “has some leftover from last time” or has “her own cream” (which we know nothing about). Something is wrong here: a 50 ml tube of cream, applied three times to the entire face for at least two weeks, has no chance of surviving until the next time.

Etiopathogenesis of post-procedural hyperpigmentation

The principle of the pathogenesis of PIGP involves a step-by-step protocol and regular high-quality implementation of doctor’s recommendations.

We all know that pigmentation can be epidermal, dermal and mixed. The most difficult to treat dermal pigmentation is in the deep layers of the dermis. But, even if we talk about superficial hyperpigmentation, when melanin lies in the upper layers of the epidermis, in which the use of peelings and laser correction gives results the first time, the lack of proper post-procedural care will lead to a rapid new accumulation of melanin due to the activity of hyperstimulated melanocytes, which will nullify excellent correction result.

Let's take a systematic approach and analyze the therapy step by step.

Prevention of hyperpigmentation

It is easier to prevent PIGP than to remove it: A series of experiments by Philippe Depres demonstrated that stopping the inflammatory process reduces the likelihood of PIGP by 80% (not to mention a sharp reduction in pain).

It is this principle that underlies the operating principle of special post-peeling masks, but they protect against excessive inflammation only in the first hours. Lack of proper care that protects sensitive, renewed skin will lead to hyperstimulation of melanocytes through secondary inflammation caused by UV radiation, and, accordingly, to the same PIGP. Philippe Despres was the first to add mandatory triple application of sunscreen to the protocols for post-procedure patient care: for example, at 9, 12, 15 o’clock. β-spectrum UV rays reach our skin through all gadgets (phone, laptop) - we must counteract this process.

Patients, deceived by mass market advertising, unfortunately, continue to believe in a magical SPF cream, which, with a single application in the morning, will last throughout the day, even after a pool or sea swim. Numerous studies show that even active sweating reduces the effectiveness of sunscreen. It is necessary to spend time and convey to the patient that only the physical and chemical presence of sun protection on the face will protect them from sun exposure.

Strategy for working with a patient with PIGP during the period of active insolation

A number of standard questions immediately arise:

• “Choose abrasive peeling, taking into account all the above mental and traditionalist features?” – this is definitely to subscribe to problems on the part of the patient. After all, before he has time to go online, he will immediately receive a huge number of terrible stories and professional recommendations (usually from people who do not have any medical education).
• "Wait for a season with lower insolation levels?" – it is unlikely that a patient will like to observe spots on his skin in the period from May to September and not take any action.
• “Can I carry out a cycle of so-called summer peels with a low pH (and, as a rule, with the same low effect)?” – in the case of superficial hyperpigmentation, this approach may work, but we can prescribe a topical whitening/skin tone-evening product with absolutely the same success.

According to in vitro research, topical products in direct contact with melanin have a more pronounced effect than acids and special implants, but do not forget about the transdermal barrier, which will reduce the activity of the ingredients by an order of magnitude.

But what strategy should you choose in case of mixed or dermal hyperpigmentation? First of all, it is necessary to remove the inflammatory factor (of any origin), if present. Next, you should begin therapy for sedation of melanocytes and only then begin to physically remove the layers of pigment.

Often what we mistake for dermal hyperpigmentation turns out to be mixed, which explains cases of ineffectiveness of topical products, even when used correctly.

The most commonly used diagnostic tool, the Wood's lamp, misleads us: it may not reveal deep-lying melanin. This is why I prefer to treat the vast majority of patients as potentially having a mixed type of hyperpigmentation. Accordingly, in the summer, the protocol will necessarily include injectable mesoimplants with the effect of sedating melanocytes, which block tyrosinase and affect the processes of polymerization of tyrosine into melanin. Ideally, such a drug should have an effect on eumelanin synthesis.

The key success factor in the fight against hyperpigmentation after the procedure is the correct care for therapy and protection from UV rays. Depigmenting, antioxidant products also enhance skin whitening - they should be used in combination with peelings and injection implants. And the use of SPF products containing not only chemical and physical filters, but also heat shock protein activators, provides an additional level of protection and prevention.

The treatment of age spots, like any other skin defects, requires a professional comprehensive approach. But we should also not forget that an equally important part of therapy is establishing communication and trusting relationships between the specialist and the patient.

First published in ​"Les Nouvelles Esthétiques Ukraine" No. 3 (109) /2018