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36 NOVEMBER/DECEMBER 2015 | Med Esthetics TONE IT DOWN melasma that there is no cure; it's an ongoing maintenance of sun avoidance and protection, and some type of lightening agent," he says. POST-INFLAMMATORY HYPERPIGMENTATION The best way to get around post-infl ammatory hyperpig- mentation (PIH) is to preemptively avoid it, particularly in patients with darker skin types. "The pigmentation process is the same for all skin types and colors. What differs is the likelihood to express hyperpigmentation as a primary skin concern," says Green, noting that Fitzpatrick types IV-VI and often type III are more likely to develop irregular pigmenta- tion. "From a formulation perspective, when treating skin of color, it is very important to avoid overly aggressive formu- lations that can lead to post-infl ammatory hyperpigmentation as a side effect," she says. Dr. Dover agrees that, in general, the darker the skin type, the higher the risk of pigmentation problems. "With all of these conditions, light skin types are easier to treat than darker skin types. Skin types I to II do best, III is slightly more diffi cult and IV is a challenge," he says. With that in mind, selecting a modality to treat PIH depends on what caused it in the fi rst place. "It's not uncommon to de- velop hemosiderin deposition after a lower lid blepharoplasty or even a liposuction. Those can be treated with a Q-switched or PicoSure tattoo removal laser because the hemosiderin essentially acts like tattoo pigment would within the skin," says Dr. Nikolaidis. "On the other hand, with post-infl ammatory laser or chemical peel hyperpigmentation I'm going with topi- cal cream—again, Cosmelan and/or Lytera." Dr. Dover points out that PIH is particularly diffi cult to treat because there is a risk of making it worse; he too opts for topical treatments to err on the side of safety. "For the most part, hydroquinone is marginally effective, as is Kligman's formula," he says. "High energy Q-switched lasers and IPL sometimes produce temporary improvement but in the end can make this condition worse. Low fl uence Q-switched lasers, especially the Q-switched Nd:YAG laser, have shown some early promise." Dr. Nikolaidis is reluctant to use laser treatments for PIH because overshooting means starting over, which is especially frustrating—for both the patient and the provider—as laser- or peel-related PIH typically resolves on its own. "What you're doing with topical agents in those cases is shortening the duration of what would happen naturally," he says. "The main thing that I've learned over the last 15 years is that patience is a virtue. Try not to move the needle too quickly with hyper- pigmentation; it's more about slow improvement over time rather than trying to get an immediate, drastic reduction." Laura Beliz is the associate editor of MedEsthetics. "I counsel my patients with melasma that there is no cure; it's an ongoing maintenance of sun avoidance and protection, and some type of lightening agent." © GETTY IMAGES