Post-Inflammatory Hyperpigmentation (PIH) is a change in pigmentation or colour of the skin after inflammation caused by skin conditions like acne or eczema. In this article, Alaa Hassan charts her own personal journey with eczema and PIH, and explains why it's so important for PIH to be recognised and treated appropriately in people of colour.
My eczema story
It is estimated that about 15 million people suffer from atopic eczema in the UK, including 1 in every 5 children. I've suffered from eczema since birth, making me one of the 15 million.
My eczema generally affects the neck, the insides of my elbows, my knees and also my fingers. It was pretty unmanageable while I was in primary school. I recall one instance in particular that has been engraved into my memory: I was in the park and some children I was playing with innocently asked me why I had ‘panda eyes’, referring to the halos around my eyes that had been caused by eczema.
I also vividly remember being nine years old and having an unusually bad flare-up, which so bad it even worried the teaching assistants at my school. My eyes were swollen and so puffy they were almost closed, to the point that I could hardly see. The skin around my face was sore, flaky and ultimately dry. I could not even open my mouth without reopening wounds. I was barely able to speak for days.
Eczema is a chronic (long-term) condition and there's currently no cure, although symptoms tend to decline as people get older. As I’ve grown up, I’ve learned to manage my eczema, initially with the use of prescription steroids and emollients. Now I place an increased focus on my diet, avoiding products that'll generate sensitivity or cause a reaction. By the time I was 16, I had firm control of my eczema; I hardly had any flare-ups, and if I did, I managed them efficiently and systematically. The period when my eczema was dormant lasted about four years, until I was 20, when the change in weather while I was on holiday triggered a recurrence.
How eczema manifests on skin of colour
There are many symptoms of skin conditions such as eczema that do not translate the same on different skin shades. They include erythema, better known as redness of the skin, caused by an increased flow of blood. Redness is clearly visible only on pale skin, but if the skin is slightly pigmented, redness might only be seen under bright lighting. On darker skin, however, it can be very hard to see, and the symptom is missed.
Another condition, lichenification, describes the thickening of the skin caused by chronic scratching. On white skin, this thickening is visible in the form of a pink-dark pink colour, dryness and a superficial criss-cross pattern. Dark skin is usually hyper-pigmented, which makes the thicker skin look increasingly darker than the surrounding skin.
Pigmentation as a result of eczema is known medically as post-inflammatory hyperpigmentation. It's difficult to distinguish eczema from other skin diseases in people of colour (POC), as hyperpigmentation often looks purplish-black in people of darker skin tones, rather than the flushed pink or red it appears on white skin.
Structural bias in dermatology
The study of dermatology needs to be aware and inclusive of skin colour, but, as obvious as this sounds, dermatologists frequently aren’t thoroughly trained to identify the nuances between lighter and darker skin tones, and how they manifest in different skin conditions. This can result in a misdiagnosis or ineffective treatment.
Dermatology can be seen as being biased as it mainly focuses on the study of fairer complexions, using white skin as examples of conditions, in the way that they're represented in pictures and described with words. For example, there's a condition called ‘red skin syndrome’ (a consequence of topical steroid withdrawal), which thoughtlessly ignores people with darker skin who may also be affected by topical steroid withdrawal, but whose skin doesn't show the same red discolouration.
There needs a greater emphasis on inclusivity of skin colour within the field of dermatology.
Self-image and problematic ideas of beauty
There's also an important conversation to be had with reference to hyperpigmentation about skin bleaching. This is generally a taboo topic, yet it's widely and commonly practiced across the world, so needs to be talked about openly. Skin bleaching is when bleaching products are used on dark complexions or areas of skin affected by hyperpigmentation in order to achieve an overall fairer skin tone. It's done with a range of products, such as bleaching creams, soaps, and pills, but they come with some significant side effects, which include mercury poisoning; thinning of the skin; blood vessels becoming visible in the skin; kidney, liver and nerve damage, and foetal abnormalities if used during pregnancy.
These side effects mean that non-prescription creams containing hydroquinone, corticosteroids or mercury are banned in the UK, as they can be extremely harmful if used incorrectly or not under supervision. 
I was in my early teens when I was first introduced to the idea of skin bleaching. Because of the insecurities caused by my hyperpigmentation, I even considered doing it myself over the years. As it was widely practiced back home, I didn’t realise how much of a bad idea this was, as it was simply ‘the norm’. It's a pretty common practice all over Africa and Asia; people bleach their healthy skin with chemicals, permanently damaging it, in order to fit a Eurocentric perspective of beauty. It has be said that it's a very negative mentality to be exposed to at such a young age, when children are developing their conception of body image.
People with fairer skin find consider a suntan attractive, even though it exposes them to accelerated skin ageing and increases the risk of developing skin cancer. In African and Asian populations where there are people of brown and darker skin tones, the opposite is true: people are not at all interested in having a tan, since many want their skin to be as light as possible.
The cultural importance placed on fairer skin is why patients and the parents of affected children find it very difficult to live with the kind of pigmentation disorders (such as dyschromia, which refers to patchy, uneven skin colouration) associated with skin diseases like atopic dermatitis. Thus, they seek any solution that will minimise hyperpigmentation, even damaging ones.
My own experience with hyperpigmentation
It was in my late teens and early twenties that I experienced the consequences of those insecurities most severely in relation to my self-image. I was becoming increasingly aware of my body and appearance and began to wear make-up to conceal the hyperpigmentation on my face. While this made me feel ‘normal’ on the outside, it really made me feel like my authentic self could never be good enough to fit society’s standards.
From a young age, I’ve been prescribed steroid creams to manage my flare-ups. Emollients on their own never seemed to be strong enough, especially when only treating the symptoms of dry, flaky skin, but not improving the overall issue. Problems generally occur when topical steroids are used for long periods of time: these include thinning of the skin, fluid collection, and discolouration which is particularly noticeable with darker skin.
I came across the term ‘Topical Steroid Withdrawal’ (TSW) when looking at alternative solutions to replace steroids. I had not been officially diagnosed by a GP but experienced the reoccurring symptoms of TSW after my prolonged use of steroids. I often saw it to be a vicious cycle as I believed that I was treating my eczema flare-ups. As I gradually reduced my use and reliance on steroids, I would begin to experience another, what I assumed to be a flare-up.
What needs to change
In conclusion atopic dermatitis (better known as eczema) is common in all populations, indiscriminate of skin colour, but with people of a darker complexion, inflammation can, and usually does, cause pigmentation disorders. In light of this, here are three important changes that need to happen:
1. Clinicians must pay particular attention and care to offer early and effective treatment for eczema flare-ups, in order to minimise inflammation and its consequences.
2. There needs to be a move to avoid the excessive use of topical corticosteroids, as they can have a depigmenting (the lightening or loss of pigment in the skin) effect.
3. Lastly, there needs to be a greater significance placed on understanding the insecurities that arise from skin conditions such as eczema, psoriasis, topical steroid withdrawal, etc. Society generally expects people who suffer from such conditions to just carry on living their lives, without acknowledging how depleting and devastating the effects of PIH can be.
Because eczema and PIH is so rarely shown on skin of colour, Alaa has kindly provided us with examples of her own experience with PIH here:
She says: "Since using Balmonds product range, I've seen a massive improvement in how frequently I get flare-ups, as well as how long I usually get flare-ups for. The use of natural ingredients minimises the likelihood of sensitivities on the affected area, and beeswax allows the skin to be well hydrated and locks in moisture for hours on end. I started seeing improvements in the first two weeks of use."
Find out more on post-inflammatory hyperpigmentation on our Info Hub.
Alaa Hassan is a final year Law student living in London. She has suffered from eczema since childhood. She explores the concept of hyperpigmentation throughout her blog in order to alleviate a lack of awareness within the community.