Scarring and Dyschromias in Fitzpatrick Skin Type IV-VI: A Review of Dermatologic Treatment Protocols

July 2023 | Volume 22 | Issue 7 | 7253 | Copyright © July 2023


Published online June 6, 2023

doi:10.36849/JDD.7253

Julien Bourgeois , Jacob Beer , Leah Jacob , Michelle Henry

aDepartment of Dermatology, Tulane University School of Medicine, New Orleans, LA
bDepartment of Dermatology, Weill Cornell Medical College, New York, NY

Abstract
Importance: Managing chronic conditions is an essential aspect of dermatologic care, especially regarding the resolution of inflammatory dermatologic disease and recovery of skin lesions. Short-term complications of healing include infection, edema, dehiscence, hematoma formation, and tissue necrosis. At the same time, longer-term sequelae may consist of scarring and scar widening, hypertrophic scars, keloids, and pigmentary changes. This review will focus on dermatologic complications of chronic wound healing in patients with Fitzpatrick skin type (FPS) IV-VI or skin of color (SOC), with an emphasis on hypertrophy/scarring and dyschromias. It will focus on current treatment protocols and the potential complications specific to patients with FPS IV-VI.
Observations: There are multiple complications of wound healing that are more prevalent in SOC, including dyschromias and hypertrophic scarring. These complications are challenging to treat, and current protocols are not without complications and side effects that must be considered when offering therapy to patients with FPS IV-VI.
Conclusions and Relevance: When treating pigmentary and scarring disorders in patients with skin types FPS IV-VI, it is essential to implement a stepwise approach to management that is conscious of the side effect profile of current interventions.

J Drugs Dermatol. 2023;22(7): doi:10.36849/JDD.7253

INTRODUCTION

As with much of dermatology, most research on wound healing has been based on afflictions in light skin, resulting in a dearth of evidence-based protocols on the management of wound healing disorders and complications of healing more common in FPS IV-VI or skin of color (SOC). Wound healing in patients with SOC is more likely to be complicated by dyschromia (hyperpigmentation and hypopigmentation) and the formation of hypertrophic scars and keloids.1-3 Dyschromias may be caused by injury to the skin, or they may be post-inflammatory, secondary to dermatitis, infection, UV exposure, or drug reactions, among others.3,4 Hypertrophic scarring and keloids are often secondary to injury, surgical procedures, or other therapies.5,6 Disordered wound healing has been extensively studied in the literature.7-11 Still, given the relative incidence of pathologic wound healing complications in SOC, physicians must be prepared to counsel all patients on the possibility of disordered healing as well as the treatments for these complications. It is important to note that many of these interventions come with their own side effects that must be included in patient education and shared decision-making.

RESULTS

Dermatologic Complications of Wound Healing in Skin of Color
While disorders and complications of wound healing in SOC patients can take many forms, many cases tend to take on two different dermatologic pathologies: scarring and dyschromia.1 Wound hypertrophy, keloid, or scarring may develop as complications of overactive cellular mechanisms in wound healing.12,13 Dyschromias in wound healing are secondary to the effects of inflammation on melanocytes or deposition of exogenous substances.14 In both hyperpigmented and hypopigmented wounds, disordered production, transport, or distribution of melanin causes observed pigmentation changes.15

Management of Wound Healing Complications in Skin of Color
Disordered wound healing is managed on a case-by-case basis specific to the etiology of the complication. Multiple therapies exist for the prevention and management of disordered scarring and dyschromia, but the possible sequelae of these therapies must be considered when treating patients with FPS IV-VI.

Hypertrophic Scarring and Keloids
Prevention
Silicone sheeting is frequently used in post-operative prevention and management of hypertrophic scars, and it may have some efficacy in preventing keloid.5 It is theorized that silicone sheeting decreases fibroblast activation via hydration and occlusion of a wound.16,17 One study showed a significant reduction of hypertrophic scarring in patients treated with silicone dressings compared to placebo (RR=0.7, P= 04).18 Pressure therapy has also been suggested, though it is primarily used post-operatively
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