Skin of Color

Managing Postinflammatory Hyperpigmentation in Pediatric Patients With Skin of Color

In Collaboration With the Skin of Color Society

Cutis. 2019 February;103(2):71-73

Postinflammatory hyperpigmentation (PIH) is common in patients with skin of color. Notably, the US population of children with skin of color is growing rapidly. Postinflammatory hyperpigmentation can be quite distressing in pediatric patients, particularly among adolescents and their parents/guardians. Therefore, it is crucial that dermatologists can identify and treat underlying inciting inflammatory dermatoses in this patient population. In this article, management strategies for PIH in pediatric patients with skin of color are presented.

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Practice Points

The US population of children with skin of color is growing rapidly.
Treating the underlying inflammatory dermatosis is the most important step in managing postinflammatory hyperpigmentation (PIH); however, many pediatric PIH patients and their parents/guardians presenting with a chief concern of pigmentary changes are unaware of the associated inflammatory condition.
When appropriate, choose treatments for the underlying inflammatory condition that can simultaneously improve any existing PIH. Gentle skin care, avoidance of rubbing and scrubbing the skin, and photoprotection are essential to halt worsening of PIH.
Patients’ parents/guardians may consent to more aggressive PIH treatment in select cases (eg, emotional distress in adolescents).

References

Broughton A. Minorities expected to be majority in 2050. CNN. August 13, 2008. Accessed January 2, 2019.
Colby SL, Ortman JM. Projections of the Size and Composition of the US Population: 2014 to 2060. Washington, DC: US Census Bureau; 2014. Current Population Reports, P25-1143. Published March 2015. Accessed January 23, 2019.
Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20-31.
Eichenfield LF, Ahluwalia J, Waldman A, et al. Current guidelines for the evaluation and management of atopic dermatitis: a comparison of the Joint Task Force Practice Parameter and American Academy of Dermatology guidelines. J Allergy Clin Immunol. 2017;139(4S):S49-S57.
Taylor SC, Cook-Bolden F, Rahman Z, et al. Acne vulgaris in skin of color. J Am Acad Dermatol. 2002;46(2 suppl):S98-S106.
Napolitano M, Ruggiero G, Monfrecola G, et al. Acne prevalence in 9 to 14-year-old patients attending pediatric ambulatory clinics in Italy. Int J Dermatol. 2018;57:1320-1323.
Mancini AJ, Baldwin HE, Eichenfield LF. Acne life cycle: the spectrum of pediatric disease. Semin Cutan Med Surg 2011;30:2-5.
Lowe NJ, Rizk D, Grimes P, et al. Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients. Clin Ther. 1998;20:945-959.
Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study. Cutis. 2006;77:45-50.
Bulengo-Ransby SM, Griffiths CE, Kimbrough-Green CK, et al. Topical tretinoin (retinoid acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med. 1993;328:1438-1443.
American Academy of Pediatrics. Choosing an insect repellent for your child. Healthy Children website. Updated July 18, 2018. Accessed January 8, 2019.
Agbai ON, Buster K, Sanchez M, et al. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol. 2014;70:312-317.
Buster KJ, You Z, Fouad M, et al. Skin cancer risk perceptions: a comparison across ethnicity, age, education, gender, and income. J Am Acad Dermatol. 2012;66:771-779.
Downie J. Help prevent and reverse post-inflammatory hyperpigmentation. Pract Dermatol Pediatr. May/June 2011:12-14. Accessed January 18, 2019.
Ammonium lactate lotion 12% [package insert]. Bronx, New York: Perrigo New York, Inc; 2006.
Grimes PE. Management of hyperpigmentation in darker racial ethnic groups. Semin Cutan Med Surg. 2009;28:77-85.

Postnflammatory hyperpigmentation (PIH) is an acquired hypermelanosis that can occur in children and adults following an inflammatory cutaneous disease or trauma. Postinflammatory hyperpigmentation may last for months to even years. Although PIH may occur in all skin types, it is more common and presents with greater severity and intensity in individuals with skin of color. By the year 2050, 1 in 3 US residents is projected to be Hispanic.¹ It is projected that by 2044, non-Hispanic white individuals (all ages) will make up less than 50% of the US population.² Currently, the majority of the US residents younger than 18 years are minorities. The majority minority population in the United States already exists in those younger than 18 years and is predicted to occur in the adult population by 2044.²

Effective treatment options and management strategies for PIH in adults with skin of color have been described in the literature.³ Due to a paucity of research, the approach to management of PIH in children with skin of color has been based on clinical experience and lessons learned from adult patients. This article focuses on management of PIH in pediatric patients with skin of color, which includes black/African American, African-Caribbean, Hispanic, Asian, Pacific Islander, and American Indian individuals.

Underlying Inflammatory Dermatoses Resulting in PIH

There are numerous conditions that may result in PIH, including but not limited to atopic dermatitis (AD), acne, arthropod bites, and injuries to the skin. Postinflammatory hyperpigmentation may have more of a psychological impact than the inciting disease or injury itself. The most important step in the approach to managing PIH is treating the underlying inflammatory condition that caused the pigmentation.

Parents/guardians may report a chief concern of dark spots, manchas (stains), blemishes, or stains on the skin, often with no mention of a coexisting inflammatory dermatosis. Parents/guardians of children with skin of color often have personally experienced PIH and may be determined to shield their children from similar angst associated with the condition. Although physicians may see just another pediatric patient with PIH, the child’s parents/guardians may see a condition that will be readily perceptible during major life events, such as the child’s prom or even his/her wedding day. Promptly diagnosing and instituting early treatment of inflammatory conditions associated with PIH may accelerate resolution and prevent worsening of the pigmentation.³

Select inflammatory dermatoses that are common in children with skin of color and may lead to PIH are highlighted below. Although this list is not comprehensive, the approach and management strategies should prompt creation of plans that keep PIH in mind when treating primary inflammatory skin diseases.

Atopic Dermatitis
Atopic dermatitis may induce PIH or hypopigmentation of the skin in children with skin of color. Developing a plan for AD flare prevention, as well as management of mild, moderate, and severe AD flares, is imperative in pediatric patients. Prevention plans should include gentle skin care, twice-daily application of emollients to the full body, and reduction of Staphylococcus aureus loads on the skin. The treatment action plan for mild to moderate flares may include topical corticosteroids, immunomodulators, and nonsteroidal agents. Treatment options for severe AD or patients who were unsuccessfully treated with other therapies may include phototherapy, biologics, and methotrexate, among others.⁴ Creating action plans for AD flares is a vital step in the prevention of PIH in patients with skin of color. Additionally, PIH should not be considered a sign of AD treatment failure.

Managing Postinflammatory Hyperpigmentation in Pediatric Patients With Skin of Color

In Collaboration With the Skin of Color Society

References

Underlying Inflammatory Dermatoses Resulting in PIH

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