Fractional Photothermolysis for the Treatmentof Postinflammatory Hyperpigmentation

TRACY M. KATZ, MD,! LEONARD H. GOLDBERG, MD,!y BAHAR F. FIROZ, MD,! AND

PAUL M. FRIEDMAN, MD!yz

The authors have indicated no significant interest with commercial supporters.

Postinflammatory hyperpigmentation (PIH) is

an acquired hypermelanosis of the skin.

Development of PIH can occur after any type of

inflammation of the skin but is typically seen in

association with acne, folliculitis, eczema, and

trauma and as a complication of laser resurfacing.

Other diseases that may produce this change are

lichen planus, lichenoid drug reaction, lupus

erythematosus, fixed drug reaction, pityriasis rosea,

herpes zoster, insect bite reactions, contact

dermatitis, and superficial burns.1 It is thought

that inflammatory interruption of the

epidermal–dermal junction is responsible for the

development of PIH and that the degree of

inflammation and disruption of the

epidermal–dermal junction affects the severity of

the PIH. Arachidonic acid metabolites and

histamine, found in large amounts in inflamed skin,

may play a role in the initiation of the development

of PIH.2 Histopathology reveals high levels of

epidermal melanin, with melanophages present in

the superficial dermis.3 Lymphohistiocytes are vari-

ably present around superficial blood vessels in the

dermal papillae.3 Clinically, lesions appear as irreg-

ularly shaped, darkly pigmented macules that

coalesce and may persist for months or become

permanent. PIH is more commonly seen in people

with darker skin types and is found equally in men

and women.

PIH can occur anywhere on the body and at any

age. Resulting cosmetic disfigurement may lead to

problems with self-esteem, social interactions and to

distress. Treatments for PIH include topical agents

such as retinoids, hydroquinone bleaching creams,

corticosteroids, dermabrasion, and chemical peels.4–

6 These treatment modalities have been used with

varying success. Topical hydroquinones have been

associated with undesirable depigmentation, irritant

dermatitis, and ochronosis.6–9 Chemical peels and

microdermabrasion may cause dyspigmentation and

hypertrophic scarring.4 The Q-switched ruby laser

has been used for the treatment of PIH with variable

results and for postsclerotherapy hyper-

pigmentation.10,11 Owing to the success of fractional

photothermolysis in treating epidermal and

dermal pigmented lesions and conditions, it was

conjectured that PIH could also be treated with

this technology.12–18

Patient and Methods

A dermatologist referred a 50-year-old woman

(Fitzpatrick skin type IV) with a 2-year history of an

irregular brown patch on the left lateral neck. The

lesion was clinically diagnosed as PIH. The patient

did not recall a skin rash before developing the pig-

mentation, but she stated that this was where her

automobile seatbelt rubbed against her skin. No

& 2009 by the American Society for Dermatologic Surgery, Inc. ! Published by Wiley Periodicals, Inc. !ISSN: 1076-0512 ! Dermatol Surg 2009;35:1844–1848 ! DOI: 10.1111/j.1524-4725.2009.01303.x

1844

!DermSurgery Associates, Houston, Texas; yDepartment of Dermatology, Weill Cornell Medical College, MethodistHospital, Houston, Texas; zUniversity of Texas Medical School, Houston, Texas

other relevant medical history was reported. Previ-

ous treatments for the PIH on the left lateral neck

included an acid peel (unknown type) performed 3

months before presentation and a 2-month course of

bleaching creams. These treatments were unsuccess-

ful. The patient used a moisturizer with a sun

protection factor (SPF) of 15 daily. Daily medica-

tions included multivitamins. Physical examination

revealed a 6-" 4-cm brown and partly erythematous

patch with irregular borders on the left lateral neck

(Figure 1).

Although the patient had previously used a bleaching

agent with no change in the PIH, PIH is a theoretical

complication after treatment with fractional photo-

thermolysis, which may be reduced with pre- or

post-treatment regimens of hydroquinone or treti-

noin. For this reason, our patient was concurrently

started on Triluma (Triluma, Galderma Laboratories

L.P., Fort Worth, Texas) 1 week after the first

laser treatment.

Treatments were conducted with the 1,550-nm

wavelength erbium-doped Fraxel SR 1500 laser

(Reliant Technologies, Inc., Mountain View, CA).

The treatment area was cleansed before the proce-

dure using a mild soap (Cetaphil Gentle Skin

Cleanser, Galderma Laboratories, L.P.). A topical

triple anesthetic of 10% benzocaine, 6% lidocaine,

and 4% tetracaine (New England Compounding

Center, Framingham, MA) was applied under

occlusion to the treatment area of the left lateral

neck for 1 hour before treatment. An ointment

(LipoThene Inc., Pacific Grove, CA) was applied so

that the laser handpiece could glide smoothly over

this area.

From November through February, the patient

underwent three treatment sessions at 4- to 8-week

intervals. Treatments were performed at an energy

fluence of 15mJ and a treatment level of 6 (manually

selected on the laser device monitor), corresponding

to 17% surface coverage. Final densities (determined

according to treatment level) were 880 to 1,100

microscopic treatment zones per square centimeter

(MTZ/cm2). Each treatment included eight to 10

passes at a density of 110MTZs/cm2 per pass. A

cold-air cooling system (Cryo 5, Zimmer Medizin

Systems, Irvine, CA) was used to cool the skin during

the treatment and to minimize patient discomfort

(fan power 4, 10–14 cm from the skin). The patient

was advised to begin using a daily broad-spectrum

sunscreen with ultraviolet (UV)A and UVB protec-

tion (minimum SPF 45) on the treated areas and to

avoid sun exposure for 7 days after the treatment.

During the treatment, the patient experienced mild

pain and moderate postprocedural erythema and

edema, which resolved in 24 to 48 hours.

Photographic documentation using identical camera

settings, lighting, and patient positioning was

Figure 1. Postinflammatory hyperpigmentation on theleft lateral neck before treatment with fractional photo-thermolysis.

35 : 1 1 :NOVEMBER 2009 1845

KATZ ET AL

obtained at baseline, before each treatment, and

at a 7-month follow-up visit the following Septem-

ber. The evaluating physician noted near-complete

clearing of the PIH (495%), with no post-proce-

dural complications or recurrence, 7 months

after her third treatment (Figure 2). The patient’s

degree of satisfaction with the treatment paralleled

the physician’s assessment of improvement of the

lesion.

Discussion

Although there are many published reports on the

use of fractional photothermolyis for the treatment

of pigmentary dyschromias, this is the first reported

case for PIH. Fractional photothermolysis is a new

technology whereby thermal columns of injury in the

dermis, known as MTZs, are created, surrounded by

zones of undisturbed tissue.19 This allows for rapid

healing of the treated area through epidermal cell

migration from adjacent viable epidermis aided by

the intact stratum corneum. The mechanism by

which the melanin in this patient may have been

eliminated involves the extrusion and transepidermal

vacuolar elimination of dermal and epidermal con-

tent known as microscopic epidermal necrotic debris

through a compromised dermal–epidermal junction.

Fractional photothermolysis initiates this transport

system.20

Although PIH is more commonly seen as a side effect

of ablative laser therapy (seen in 2.8% of 104

patients),21 it is a rare complication of fractional

photothermolysis (found in 0.73% of 961 patients

treated with fractional photothermolysis) and has

been observed with greater frequency in darker

skin.22 Chan and colleagues found that the risk of

PIH after fractional photothermolysis is reduced by

lowering treatment densities and using cooling in

conjunction with laser treatments.12 Kono and col-

leagues found that greater density was more likely to

produce swelling, redness, and hyperpigmentation

than greater energy.13

Most studies investigating the treatments of

PIH have been conducted with patients with

darker skin types, because PIH is a more common

finding in this population. Common treatment

modalities for PIH, such as peels, bleaching agents,

and retinoids, have had variable results.

Combination therapies have achieved greater

success. Mequinol 2%, tretinoin 0.01%, and

flucinolone acetonide 0.01% combination therapy

is efficacious, as is a combination of hydroquinone

4% and tretinoin 0.05%.4

There are many reports on the use of ablative

and nonablative lasers for the successful treatment

of melasma, nevus of Ota-like macules, and

lentigines.12–17,23,24 The treatment of postinflam-

matory dyspigmentations is more difficult. A studyFigure 2. Seven months after the third treatment.

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FRACTIONAL PHOTOTHERMOLYS I S FOR P IH

on the Q-switched ruby laser for the treatment of

PIH was inconclusive,10 although it yielded better

results for the treatment of postsclerotherapy

hyperpigmentation. Ninety-two percent of lesions

studied were found to be lighter after treatment, with

significant (75–100%) resolution of hyperpigmen-

tation in 58% of treated areas.11 Recently, blue

pigmentation due to minocycline treatment was

treated with fractional photothermolysis at energy

fluences up to 60mJ.25

Because of the inherent tendency of PIH to

recur after sun exposure, follow-up was obtained

after the summer months to confirm long-term

improvement. We were able to successfully treat

PIH in a patient with Fitzpatrick skin type IV

using a fractionated device. After the completion

of her series of laser treatments, the patient

continued to apply Triluma cream twice a week for

6 months. Because the patient had used a bleaching

agent before the laser treatments with no change in

the dyspigmentation, we believe that the role of

Triluma in this case was only in preventing

recurrence, although we recognize this as a possible

confounding factor. This case demonstrated marked

improvement of PIH on the neck after a series of

fractional photothermolysis treatments. Controlled

studies are warranted to better understand the effi-

cacy, longevity, and optimal laser settings for this

indication.

References

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2. Tomita Y, Maeda K, Tagami H. Mechanisms for hyperpigmenta-tion in postinflammatory pigmentation, urticaria pigmentosa andsunburn. Dermatologica 1989;179(Suppl 1):49–53.

3. Elder D, Elenitsas R, Jaworsky C, Johnson B, eds. Lever’sHistopathology of the Skin. 8. Philadelphia: Lippencott-RavenPublishers; 1997.

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Address correspondence and reprint requests to:Paul M. Friedman, MD, 7515 Main St. Suite 240, Houston,Texas 77030, or e-mail: pmfriedman@dermsurgery.org

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