How to manage hyperpigmentation caused by urticaria treatment?

Management of Hyperpigmentation Following Urticaria Treatment

For hyperpigmentation that develops after urticaria treatment, initiate topical retinoids combined with chemical peels (glycolic acid 20-70% or salicylic acid 20-30%) applied every 15 days for 4-6 months, while ensuring strict photoprotection and immediate anti-inflammatory management to prevent worsening. 1

Understanding the Mechanism

The hyperpigmentation you're seeing is post-inflammatory hyperpigmentation (PIH), which occurs when inflammatory mediators from urticaria—particularly histamine and arachidonic acid metabolites released from mast cells—directly stimulate melanocytes to increase tyrosinase production and melanin synthesis. 2 This is the same mechanism seen in urticaria pigmentosa, where mast cell mediators cause persistent hyperpigmentation. 2

First-Line Treatment Protocol

Topical Retinoids

• Start topical retinoids immediately as they increase keratinocyte turnover and are particularly effective for epidermal PIH. 1
• Retinoids should be initiated as early as possible in patients with skin of color, as PIH often causes more distress than the original condition. 3
• Use novel formulations or combine with moisturizers to reduce irritation, which itself can worsen PIH. 3

Chemical Peels

• Glycolic acid peels (20-70%) or salicylic acid peels (20-30%) are the most effective first-line treatment for PIH, showing superior results compared to other modalities. 1
• Apply every 15 days for 4-6 months as the standard protocol. 1
• Chemical peels demonstrate superior efficacy compared to treatments like PRP. 1

Azelaic Acid

• Azelaic acid is specifically recommended for postinflammatory dyspigmentation and can be used as an alternative or adjunct to retinoids. 1

Critical Anti-Inflammatory Management

Immediately after any procedural treatment, apply anti-inflammatory agents to reduce the inflammation that perpetuates PIH. 1

• Use 0.1% prednisolone solution or other topical corticosteroids immediately post-procedure to minimize inflammatory response. 1
• This is distinct from systemic corticosteroids for urticaria management—topical application here specifically targets prevention of treatment-induced PIH. 1

Essential Photoprotection Protocol

• Implement strict photoprotection for at least 48 hours after any treatment, with continued protection throughout the entire treatment course. 1
• Use sunscreens protective against both UV and visible light, as visible light can worsen hyperpigmentation particularly in skin of color. 4
• Photoprotection is recommended for all individuals with hyperpigmentation disorders. 4

Additional Treatment Options

Non-Phenolic Agents

• Kojic acid, arbutin, and licorice extract can be used as adjunctive topical agents. 5
• Ascorbic acid (vitamin C) provides antioxidant properties that help manage PIH. 1

Emerging Therapies

• Tranexamic acid is being investigated for PIH management and may be considered for resistant cases. 1
• For maintenance after initial improvement, non-hydroquinone agents are recommended. 1

Hydroquinone Consideration

• While hydroquinone remains the gold standard for hyperpigmentation, it can be used alone or in combination with other agents. 4
• However, given the context of post-urticaria PIH, starting with retinoids and chemical peels is preferred. 1

Critical Pitfalls to Avoid

Monitor Post-Procedural Inflammation

• Post-procedural inflammation from chemical peels can paradoxically exacerbate hyperpigmentation if not properly managed. 1
• This is why immediate anti-inflammatory application is mandatory. 1

Avoid Urticaria Triggers

• Ensure the underlying urticaria is well-controlled, as ongoing inflammation will perpetuate PIH. 2
• Avoid NSAIDs, aspirin, codeine, and alcohol as these can exacerbate chronic urticaria and potentially worsen inflammation-driven hyperpigmentation. 6

Manage Patient Expectations

• PIH typically resolves weeks to months after the primary inflammatory condition improves. 3
• Setting realistic expectations reduces patient frustration and improves compliance with the prolonged treatment course. 3

Special Considerations for Skin of Color

• Exercise increased caution with chemical peels and laser therapies in richly pigmented skin due to higher risk of worsening PIH. 4
• Biological differences in skin of color require additional consideration when selecting treatment modalities. 4

Treatment Duration and Monitoring

• Chemical peel protocols typically require 4-6 months of treatment every 15 days. 1
• Topical retinoids and other agents should be continued throughout this period. 1, 3
• Assess response regularly, as treatments for hyperpigmentation often take considerable time to show visible effects. 7