Almost every procedural decision in pigmented skin comes back to one question: how much inflammation will this cause? Post-inflammatory hyperpigmentation is not a rare complication in Fitzpatrick types IV to VI — it is the expected consequence of any dermal injury, and it lasts months.
That reframes the consent conversation. A patient presenting for a pigmentary lesion is at risk of leaving with a worse pigmentary problem, and they need to hear that before treatment rather than after. Say the number: with an aggressive endpoint, roughly one in four develops it.
The technical corollaries follow from the same principle. Prefer larger spots and lower fluence over smaller spots and higher energy. Space sessions widely enough that inflammation has fully resolved. Test-spot before treating a face. And treat any active inflammatory dermatosis — acne, eczema, contact dermatitis — before any procedure, because inflamed skin pigments more.
Photoprotection is the part that gets prescribed and not explained. A broad-spectrum sunscreen with visible-light protection, meaning iron oxides in a tinted formulation, matters more in darker skin than in lighter skin, because visible light drives melanogenesis in type IV and above in a way UV-only filters do not address. Applied once in the morning and never reapplied, it does very little.
And set the timeline honestly. Post-inflammatory hyperpigmentation from a dermal injury can take six to twelve months to fade. A patient who expects weeks will seek a second procedure to fix the first one, which is how the cycle continues.
- Warn explicitly about post-inflammatory hyperpigmentation before any procedure in type IV skin and above
- Prefer larger spot sizes and lower fluences, and test-spot before treating a face
- Treat active acne, eczema or contact dermatitis before any elective procedure — inflamed skin pigments more
- Prescribe a tinted, iron oxide-containing broad-spectrum sunscreen and explain reapplication, because visible light drives melanogenesis
- Set a six to twelve month expectation for fading, so the patient does not seek another procedure to correct the first
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