What is the best treatment for postinflammatory hyperpigmentation (PIH) on the face?

Treatment of Postinflammatory Hyperpigmentation on Face

The most effective first-line treatment for postinflammatory hyperpigmentation (PIH) on the face is a combination therapy consisting of 4% hydroquinone, a retinoid, and strict sun protection with broad-spectrum SPF 70 or higher. 1

Understanding PIH

Postinflammatory hyperpigmentation is a common reactive condition that develops following cutaneous inflammation or injury, resulting in darker patches of skin. It:

• Is more common and severe in patients with darker skin types
• Can significantly impact quality of life
• Requires early intervention to prevent long-term pigmentation

Treatment Algorithm

First-Line Treatment

1. Topical depigmenting agents

   • 4% hydroquinone cream: The gold standard for treating PIH 1, 2
   • Apply twice daily for up to 6 months
   • Most effective for epidermal PIH 3

2. Triple combination therapy (when available)

   • 4% hydroquinone + 0.05% tretinoin + 0.01% fluocinolone acetonide
   • Achieves clear or almost clear skin in 77-94% of patients 1
   • Enhanced efficacy compared to monotherapy

3. Modified Kligman formula

   • 2% hydroquinone + 0.05% tretinoin + 1% hydrocortisone
   • Effective alternative when triple combination is unavailable 4
   • Steroid component should be limited to 2 weeks continuously, then weekends only 2

4. Sun protection

   • Mandatory broad-spectrum SPF 70+ sunscreen
   • Inadequate sun protection is the most common reason for treatment failure 1
   • Must be continued indefinitely, even after clearing

Second-Line Options (for resistant cases after 8-12 weeks)

1. Alternative topical agents

   • Azelaic acid (15-20%)
   • Kojic acid
   • Arbutin
   • Niacinamide
   • Vitamin C
   • These have fewer side effects but may be less effective than hydroquinone 1, 3

2. Chemical peels

   • Glycolic acid peels combined with topical therapy
   • Shown to be more effective than topical therapy alone in dark-skinned patients 4
   • Requires 3-4 sessions spaced one month apart

3. Oral tranexamic acid

   • 250 mg twice daily for moderate to severe resistant cases
   • Requires monitoring for thromboembolic risk 1

Third-Line Options (for highly resistant cases)

1. Laser and energy-based devices
   • Achieve complete response in 18.1% of patients 5
   • Use with extreme caution in darker skin types
   • Risk of worsening hyperpigmentation in 2.6% of patients 5

Treatment Monitoring and Evaluation

• Evaluate response every 4-6 weeks using standardized photography
• Use Melasma Area and Severity Index (MASI) score to track progress
• Adjust treatment if no improvement after 8-12 weeks 1
• Monitor for side effects:
  • Irritation (burning, stinging, dryness)
  • Ochronosis with prolonged hydroquinone use beyond 6 months
  • Worsening hyperpigmentation

Important Considerations and Pitfalls

• Avoid irritation: Any irritation can worsen PIH; start with lower concentrations and increase gradually
• Limit steroid use: Prolonged facial steroid use can cause atrophy and telangiectasia
• Treat underlying cause: Addressing the primary inflammatory condition is essential
• Set realistic expectations: Complete resolution may take months, and recurrence is possible
• Combination approach: The highest partial response rates (84.9%) are achieved with combination therapies 5
• Hydroquinone cycling: Consider intermittent use for maintenance to prevent ochronosis 1

Special Considerations for Darker Skin Types

• Higher risk of treatment-related hyperpigmentation
• More cautious approach with chemical peels and lasers
• May require longer treatment courses
• Higher risk of recurrence

The systematic review evidence shows that complete resolution of PIH is difficult to achieve with any single modality, with combination therapies showing the best outcomes for partial improvement 5. Early intervention with the first-line treatment regimen offers the best chance for improvement in quality of life.