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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.
DERMATOLOGIC SURGERY1846
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
1. Trout CR, Levine N, Chang MW. Disorders of hyperpigmenta-tion. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology.London: Elsevier Science; 2003. p. 991–2.
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.
4. Taylor SC, Burgess CM, Callender VD, et al. Postinflammatoryhyperpigmentation: evolving combination treatment strategies.Cutis 2006;78(2 Suppl 2):6–19.
5. Burns RL, Prevost-Blank PL, Lawry MA, et al. Glycolic acidpeels for postinflammatory hyperpigmentation in black patients.
A comparative study. Dermatol Surg 1997;23:171–4; discussion175.
6. Bulengo-Ransby SM, Christopher G, Kimbrough-Green CK, et al.Topical tretinoin (retinoic acid) therapy for hyperpigmentedlesions caused by inflammation of the skin in black patients.NEJM 1993;328:1438–43.
7. McDonald CJ. Dermatological problems in black skin. ProgDermatol 1973;7:15–20.
8. Kligman AM, Willis I. A new formula for depigmenting humanskin. Arch Dermatol 1975;111:40–8.
9. Findlay GH, Morrison JGL, Simson IW. Exogenous ochronosisand pigmented colloid milium from hydroquinone bleachingcreams in American Blacks. Arch Dermatol 1985;121:105–8.
10. Taylor CR, Anderson RR. Ineffective treatment of refractorymelasma and postinflammatory hyperpigmentation byQ-switched ruby laser. J Dermatol Surg Oncol 1994;20:592–7.
11. Tafazzoli A, Rostan EF, Goldman MP. Q-Switched ruby lasertreatment for postsclerotherapy hyperpigmentation. DermatolSurg 2000;26:653–6.
12. Chan HL, Manstein D, Yu CS, et al. The prevalence and riskfactors of post-inflammatory hyperpigmentation after fractionalresurfacing in Asians. Lasers Surg Med 2007;38:381–5.
13. Kono T, Chan HH, Groff WF, et al. Prospective direct comparisonstudy of fractional resurfacing using different fluences and den-sities for skin rejuvenation in Asians. Lasers Surg Med2007;39:311–4.
14. Naito SK. Fractional photothermolysis treatment for resistantmelasma in Chinese females. J Cosmet Laser Therapy2007;9:161–3.
15. Tannous ZS, Astner S. Utilizing fractional resurfacing in thetreatment of therapy-resistant melasma. J Cosmet Laser Therapy2005;7:39–43.
16. Rokhsar CK, Fitzpatrick RE. The treatment of melasma withfractional photothermolysis: a pilot study. Dermatol Surg2005;31:1645–50.
17. Goldberg DJ, Berlin AL, Phelps R. Histologic and ultrastructuralanalysis of melasma after fractional resurfacing. Lasers Surg Med2008;40:134–8.
18. Glaich AS, Goldberg LH, Dai T, et al. Fractional resurfacing:a new modality for Becker’s nevus. Arch Dermtol 2007;143:1488–90.
19. Manstein D, Herron GS, Sink RK, et al. Fractional photo-thermolysis: a new concept for cutaneous remodeling usingmicroscopic patterns of thermal injury. Lasers Surg Med2004;34:426–38.
20. Hantash BM, Bedi VP, Sudireddy V, et al. Laser induced trans-epidermal elimination of dermal content by fractional photo-thermolysis. J Biomed Opt 2006;11:041115.
21. Bernstein LJ, Kauvar AB, Grossman MC, et al. The short- andlong-term side effects of carbon dioxide laser resurfacing.Dermatol Surg 1997;23:519–25.
22. Graber EM, Tanzi EL, Alster TS. Side effects and complicationsof fractional laser photothermolysis: experience with 961 treat-ments. Dermatol Surg 2008;34:301–7.
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23. Park JM, Tsao H, Tsao S. Combined use of intense pulsed lightand Q-switched ruby laser for complex dyspigmentation amongAsian patients. Lasers Surg Med 2008;40:128–33.
24. Momosawa A, Yoshimura K, Uchida G, et al. Combined therapyusing Q-switched ruby laser and bleaching treament with tretinoinand hydroquinone for acquired dermal melanocytosis. DermatolSurg 2003;29:1001–7.
25. Izikson L, Anderson RR. Resolution of blue minocycline pig-mentation of the face after fractional photothermolysis. LasersSurg Med 2008;40:399–401.
Address correspondence and reprint requests to:Paul M. Friedman, MD, 7515 Main St. Suite 240, Houston,Texas 77030, or e-mail: pmfriedman@dermsurgery.org
DERMATOLOGIC SURGERY1848
FRACTIONAL PHOTOTHERMOLYS I S FOR P IH
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