We have a patient that has come to us from another office with some post-inflammatory hyperpigmentation after being "burned" by an IPL. They tried to treat it with HQ and a couple of chemical peels to no avail. Is this something that can be adequately treated using a pigment laser (we have the 755 Alex that we use for pigment)? Maybe a Levulan treatment? Can you even treat this type of hyperpigmentation (the type that is induced like this)?

i would not recommend continued injury to the skin. leave it alone. hydroquinone creams for now. true PIH last at least 3-4 months based on clical trials. if its not PIH may be scar formation. the number one malpractice issue for aesthetics is IPL.

Have you ever had any luck using azelaic acid by itself or in combination for PIH?

Azelex does work for PIH, but it's a secondary agent, IMO. I usually go with HQ first, but use kojic acid or Azelex if they have issues with the HQ. I get a 6% HQ cream compounded locally for stubborn cases.

Many things work on hyperpigmentation. See the science:

http://www.skinandaging.com/supplements/pdf/1005SkinMedSupp.pdf

PIH caused by repetitive IPL is a common problem seen in my patient population. I am often referred by local medspas to take care of these PIH patients. I start treating these patients with Hydroquinone 4% q HS for 1 month. Next I would use the 1064nm Q switched laser 3mm spot size, 6-7 J/Cm @ 10 Hz to target the darker PIH areas. The PIH area usually respond well to the laser treatment. The PIH afflicted area usually is a few shades lighter 1 week after the erythema subsides. I may start using the KTP 532nm laser at 3mm, 2-3J/CM, 10HZ for the light brownish spots.

I experienced PIH after IPL x 3 for the same spot. Then I was given HQ with fading-- then was seen by a dermatologist who treated my spot with alexandrite. The PIH returned 3 weeks later and still exists. I have tried to get over it, but it is in the shape of a circle-- so is noticeable. I used HQ for about 3 months. It is lighter, but seems to be a permanent mark for me. The alexandrite treatment was 6 months ago. Any suggestions? Fraxel?

May be you should try the Obagi skin care system. It works quite well for PIH.

To Dr. Kenneth Wang,

Where do you practice, and is it possible to call and discuss treatment?

Dr. Wang

I posted on 2/24/08 regarding PIH/scar from IPL. I am currently trying Revitalize peels and have started Retin-A. I really don't want to use HQ anymore as it causes irritation to the site. I live in Chapel Hill, NC and have seen a dermatologic surgeon twice for this problem. The first time she used alexandrite with response--but the spot returned in about 2-3 weeks. She recommended another treatment with alexandrite w/ "deeper" setting but am unsure whether this would be resonable. I don't want to pay or undergo the treatment if it won't work-- or will make it worse. I would appreciate any input you may have.

Thank You.

I just want you to know that PIH from IPL takes a longer than 4 months to resolve. In fact, it may take a year! I have a tan color PIH from IPL done this Feb. It's still there and visible. I haven't really treated it except with cosmelan 2, which dried my skin. I will try topicals like meladerm before using any laser. Lasers can cause more PIH. I was told my doctors that treating PIH with any laser can cause more PIH or could resolve it. It is a gamble.

At the ASLMS Conference in Orlando, Fl in April, a physician from Japan gave a presentation during the "Treating Patients of Color" Forum. She used IPL (600 nm Filter) to treat PIH in East Asians. She pretreated and post treated with Hydroquinone (HQ), RetinA (RA) and Hydrocortisone (HC) to make the treatments more effective.

PIH usually resides in the epidermis, that is why IPL can work. I will find and give the details in my next entry after Memorial Day (I have to look it up). I am not sure this will work in other ethnicities (She was from Japan and her experience was in Japanees patients).

In Eastern Asians, she stated that HQ, RA, HC prevents PIH when using the Q-Switched laser to treat dermal pigmentation (Nevus of Ota) and it helps the IPL work better when treating epidermal pigmentation (PIH, Lentigos, etc). I need to look up the wavelength of the Q-Switched treatments.

What impressed me greatly about this forum (put together by Eliot Battle, MD) is that you have to think about patients differently depending on their ethnicity. African-Americans, East Asians, Southern Asians (India, Middle East), Med (Italy, Greece), Latin (Central and South Americans) are all different. The skin acts and reacts differently. This has to be factored with the Fitzpatrick skin type 1-6 classifications. Of course, in America,many times you get mixtures of different ethnicities.

When discussing PIH, Melasma and Pigmentation problems, I think it is very helpful to know the patient's ethnicity and skin type. For example, East Asians may look light and look like a skin type 3 or 4, but their skin acts like skin type 5! Many Asians practice strict sun avoidance because their culture values lighter skin. They look light because of this, but they are truely a darker skin type and their skin acts this way. You have to be aware of this.

In patients of color, they have the same number of melanocytes as the northen europeans, but their melanocytes are much more active and reactive, producing much more melanin. Their skin is much more reactive. It requires great skill and knowledge to treat. Be careful. Learn as much as you can about "skin of color". I believe that if you can treat "patients of color", you can better treat all patients.

We use a regimen of retinoids and hydroquinone when treating with laser any of our patients who are type 3 or darker. We primarily do this when doing erbium and fractional peels. We were taught this by Jason Pozner, a plastic in Boca. After a peel we do: first 2 weeks every third day, next two weeks every 2nd day, and final 2 weeks every day. He calls it the rule of 2's and it has worked very well for us. One thing we have definitely found that is much easier to just do this as part of our normal regimen instead of waiting for the hyperpigmentation to happen. Hydroquinone seems to do a great job of preventing hyperpigmentation by suppressing the melanocytes but is not nearly as effective if you are using after it has already occurred. Using this protocol also allows us to get them started on after skin care products which we believe helps maintain the results we give them with laser.

Tracy:
It appeared to me that your derm was not very knowledgeable in managing your problem. A failed 755nm Alexandrite treatment would definitely NOT call for a deeper second treatment. Give it some time. YOur skin will find its way back to normal. Jay was correct in his comment.
Dermacare Advisor and Dexter:
I agreed with what you said. In general, I treat all Asian skin as being at least type IV regardless of the "outside" appearences. If of Eastern Asians, I would treat as type V.
Dexter:
For retinoids, do you use retinol or Retin-A or retinoic acid?? Which skincare brand do you use or do you have your own compounding version??

"The PIH afflicted area usually is a few shades lighter 1 week after the erythema subsides. I may start using the KTP 532nm laser at 3mm, 2-3J/CM, 10HZ for the light brownish spots.

02.13.2008 | Kenneth Wang"

Ken,

Are you referring to the Q-Switched 532 laser for light brownish spots?

pmdoc,

How would you treat PIH and/or pigment in East Asians (Japan, Korea). What type of IPL? What wavelenght and what settings?

How would you treat PIH in African-Americans?

Thanks.

For a great review of treating Hyperpigmentation go to www.geocities.com/foxydog1064 and print the Suppliment to the September 2005 Issue of Skin & Aging. "Evaluating the Risks and Benefits of Treatment Modalities for Hyperpigmentation: Experts Discuss Practical Approaches to Treating this Condition".

I just saw a patient with PIH from acne scars 10 years ago. He is asian. There are 5 spots about 3-5 mm in diameter on his forehead and cheeks. The Woods Light makes them flouresce "white". When you feel them, you feel the scar tissue. So he has dark spots with scar tissue under (kind of like a scab).

A Couple of Medlite 1064 treatments did not do much. I just did a fraxel and plan to do 5-10 more fraxels over these spots to get the scar tissue as well as the pigment.

Any thoughts or comments? Any help would be appreciated.

MDR

Fraxel works well for this. There shoud be a palpable difference after a few Tx. Consider Aldara cream during and post, there is some literature it helps and even works on keloids. The only down side is during treatment you have almost constant irritation

MDR:
Not sure if the PIH from 10 years ago would change much. I would love to find out how it turns out
CHMD:
Sorry for the late reply. I don't have any experience in treating African American clients. For Asians with PIH's, I would treat with 590, 640 or 690 heads with lower fluency and "more of a floating technique rather than contact one" and do "more passes". what I look for as being "clinically effective" would be the client feeling "pinched" and/or more darkening of those spots right after.

Help my face has hyperpigmentation because the smoothbean laser was on outragesous of 595. I have given it two years to heal to no avail. There are still red white and brown discolorations. I need to have my face repaired but don't know where to turn.

I had IPL done 3x in the same area. at first it looked better and now I have a large brown patch on my face. I am of Italian decent and tan easily. I went to my dematologist and he prescribed me a hydrocortisone cream. Is this going to help or am I just spinning my wheels. I can get hydrquinone from the place where I had my IPL, is that a better option? Is this common? Will it eventually go away?

Here is what happened to my skin. I am asian and had one IPL palomar treatment in Feb. 04. I ended up with I thought was a tan discoloration. It was flat and shiny. Then I used cosmelan 2, did the cosmelan mask 2x and ended up wiht thicker skin. The skin in the area, about 3 inches wide and 2 inches in lenght is thick, shiny and different in texture. The color is not bad, but the thickness is what bothers me the most. I have not gone to a dermatologist to look at it since this occurred. Right now, I am just trying to get over it. The IPL DID NOT cause any burns on me, so i am not quite sure how all this happened. I believed that the strong peel from Cosmelan made things a lot worse. I think it a scar tissue formation, which is here to stay.

Great discussion everyone! I recently had a patient FST2-3 do a fraxel treatment and it is taking a looonnnggg time to heal. She had erythema for about 3 weeks and now has defined pigmentation, I assume PIH, over much of the area treated. I have tried HQ and retinols at varying strengths and she complains about irritation. I don't want to use hydrocortisone due to the atrophy effect on her already thin skin (she is early 20's). She is refusing any other alternative treatments to correct the discoloration at this point and I am not even sure what i would be able to suggest as she is extremely sensitive to any product. unfortunately we have discovered this after the fact. I also expect some of the discoloration is because she has not properly protected herself from the sun while healing.

Any thoughts?

I am now on the 4th week of Obagi-- and I am really pleased with the results. The PIH from IPL "injury" has faded nicely and I can easily cover it with makeup. I tried Triluma and 6% Hydroquinone on separate occassions prior to using Obagi with average results. If the PIH is at the epidermal/dermal junction or in the dermis-- will Obagi be able to completely remove the spot or will i always have to stay on maintenance?

Hi. I had a CO2 fractional laser done on my face 7 weeks ago. I have hyperpigmentation post the laser. Altough my face has faded, I have very dark eye circles that are not getting lighter. My eyes also seem very irritated and they get tired very easily - I am not sure whether this is because of the laser (they did it on my eye lids as well). Am not sure what I should do. Is there any cream that I can put on to fade the dark circles? Should I just leave it and will it then fade naturally? Do I need to see a dermatologist and an eye specialist? I'm getting vey scared and worried. Would appreciate any advise or information. Thanks.

CJ, give it more time. You might consider using Hydroquinone. PIH usually fades over a few months. What type of CO2 laser was used? Was the "Cool Scan" feature ON?

Hi Dr.Joe. Thanks so much for your reply. The laser used was the Korean CO2 fractional laser. am not sure whether the cool scan was on but my face swelled up terribly after the laser and i had blisters but these have gone. I find that when I don't put anything for my eyes they are not irritated. I tried hydroquinine but it made my under eyes sore and darker so I stopped. When you say that this will fade, do you mean naturally like without using any product? Is there anything really gentle that you can recommend. Thanks so much for your attention on this.

It will fade on its own. Hydroquinone will help it fade faster. Use HQ less frequently (every 3 days) and only leave it on for a few hours at first. Increase the wearing time to all night and increas the freq to each day. Do this gradually. You might also try OTC HQ which is 2%

Thanks Dr.Joe. I will try your suggestion and let you know what happens. Thanks again for taking the trouble with this.

I have a pigmented scar from IPL and alexandrite. I have used Obagi Nu-Derm with some result but still have background pigment. Anyway-- I am wondering if I should consider the Obagi Blue Peel or Jessner's/TCA?

How old is it?

It is 14 months since last treatment-- 22 months since initial injury.

Hi Dr.Joe. It's been almost 4 months since my laser. My eyes have lightened a little doing nothing. I am thinking of using Eldoquin 2% Bleaching cream once at night on my under-eyes - it has hydroquonine. However, all the research I've done so far says that hydroquonine should not be put near the eyes. Is it safe and will it cause permanent depigmentation?

I don't see a problem near the eyes as long as you don't get it in the eyes. Put on a very thin layer using a cotton tip applicator (q-tip). Make sure this is ok to do by asking your pharmacist.

Hi Dr.Joe. Thanks for your reply. I had gone to see a dermatologist at an asthetics centre here and he recommended the cream for the under eyes and it is by prescription only. If I were to put the cream just under my eyes, won't the rest of my face look uneven? Also, can I layer moisturiser after the application. Thanks.

The ingredients of the cream are:-
hydroquinine
glycerol monostearate
mineral oil
polyoxyethylene (25) propylene glycol stearate
polyoxl 40 stearate
propylene glycol
propylparaben
sodium metabisulfite
squalane
stearic acid
purified water

Seeja,

Put the cream on tne dark areas and not on the light areas. You want to "Blend the color". When the dark area is as light as the light area, you can use the cream on both areas or stop.

If you lighten the dark area and the lighter area, you will still have a contrast in colors which you do not want.

Hope this helps.

Hi Dr.Joe. Thanks so much for your reply. I will do as you say. Thanks again.

Hi Dr.Joe. Am wondering whether exposure to flourecent lighting at home is ok whilst I am on the hydroquinine therapy. I understand I need to have sunblock during the day which I am doing but I don't put any on in the evenings before bedtime. Thanks.

Dr.Joe I have also just had my eyes checked with an optician and he says I have pingeculae. I had my eyes checked earlier this year and it was fine. I think it's the result of the laser. I am quite terrified now. Will this lead to my sight being affected? Thanks.

I don't know where the pingeculae came from. This is a definition and it being used in a sentence. Ask your opthomologist where they came from. I don't think they should effect your vision. I am not an eye doctor.

growths on the conjunctiva (pingeculae)

I've suffered from dry eyes and MGD for several years, along with growths on the conjunctiva (pingeculae) and numerous surgeries later for removal of these growths as well as what the doctor diagnosed as conjunctivochalasis, my eyes improved somewhat but not significantly.

Hi Dr.Joe. Thanks for sharing. Here in London an optician checks your eyes first before an opthomologist looks at you if there's any concern. After a thorough check, he said my eyes and vision were fine. He just said that I had pingeculae on the whites of my eyes that were giving a slightly yellow colour. He said that this is age related. I did some research and it says that it is usually a result of UV rays and environmental stress. I never had this before which is why I am concerned that the laser may have caused it rather than age seeing that it was done on my eye lids as well. In your experience, can the laser have caused this? I have the hyperpigmentation around my eyes which is why I am concerned. If it's age related, then I can live with that.

I have started with the hydroquinone therapy. Seems to be doing alright so far - in the sense no irritation. How long should I give it to see any improvement? Is it ok to be under flourocent lighting at home when under going therapy as I don't wear sunblock at night. A number of questions here - really appreciate your attention. Thanks.

Hi Dr. Joe
I had laser done on a few brown spots about 9 weeks ago. I have brownish red spots there now which i believe is from the laser. It was done with the Alexandrite laser. I am using 4% hydroquinone right now mixed with a bit of moisturizer because it irritates my skin. I am not seeing any changes or reduction in colour so far. The spots seem to be a stand still in terms of the pigmentation.

I would really appreciate any suggestions!!!!

...The spots are on my cheeks by the way.

Thanks.

Eva, what is your ethnicity and do you burn when you go in the sun or do you tan easily. Are you dark or light? How often are you using the Hydroquinone and how long do you leave it on? Are the brownish red spots worse than the original brown spots?

Thanks for your response!!! I am medium skin tone but more toward the lighter side. My parents of eastern european background. I used to burn when I was younger on my cheeks. Now I take better care and protect my face from the sun. I am 28 years old now. The marks from the laser are worse than the spots that were on my cheeks. I have been using the hydroquinone for 2 weeks. I usually apply a thin layer before bed and in the morning and then I put my makeup over it.

Eva,

Use the Hydroquinone for a few hours every third day. Let things calm down. The question is whether the redness is vacular or pigment (post inflammatory hyperpigmentation) or irritation from the Hydroquinone. Sometimes you will get redness after a Q-Switched Laser Treatment. This usually fades over time but can take 3-6 months to fade away. Check back with your doctor. Find out what type of laser he used and ask him to ask the laser company for advice (or they can connect him with an experienced user of their laser). See if he can tell whether it is vascular, pigment or irritation.

Get back to us here and let us know how things turn out.

Ok, thanks very much Dr. Joe!! I really appreciate it!

I just talked to my sister- in-law who is an esthetician- she said the spots are definitely pigmented and irritated if that helps any.

Thanks!

I am soooo desperate Doctor, crying as I write this post. I had a very nice body and due to mild weight lifting, few very thin almost unnoticeable white strech marks....as all fitness pros, we try so seek perfection and there is when we play with fire...the dr. told me he could help and diminish the appearance of this mild lines by 40 % with laser....he did it and the first days it was fire red, the after 6-8 days itcrusted and started to peel...then it peeled and a pink color on the strech mark stie is very noticeable not...i am desperate....he prescribed 4% hidroquinona or obagi regime if the first does not work...i am so depressed do not even want to go out...I am a bikini model so you can imagine how I feel...i just want to go back to my old self....these new red/pick lines are so obvious and shinny....please help