Post-inflammatory pigment alteration (PIPA) is temporary pigmentation that follows an injury or inflammatory skin disorder. Also known as acquired melanosis, PIPA is a major and underrecognized contributor to disease burden in psoriasis and has a disproportionate negative impact on patients with skin of color.
More strongly associated with quality-of-life impairment than symptom relief or overall skin clearance, PIPA can result in depression and anxiety as psoriasis lesions resolve, leaving behind unwanted changes in pigmentation. A recent VISIBLE trial evaluated guselkumab efficacy and safety in participants, as well as corresponding quality-of-life outcomes, and the results indicated successful outcomes for most.
Clear Skin and Improved Outlook
The trial, a phase 3b randomized, double-blind, placebo-controlled study, enrolled adults with moderate-to-severe plaque psoriasis (cohort A) or scalp psoriasis (cohort B). Participants were randomly assigned 3:1 to receive subcutaneous guselkumab 100 mg or placebo at weeks 0, 4, and 12, with placebo crossover to guselkumab at week 16 and continued treatment through week 48 for the main study period, with an additional extension period through week 112.
The results, published in Dermatology and Therapy, indicate that following treatment with guselkumab, most participants achieved clear or almost clear skin, along with substantial improvements in skin discoloration.
The study also examined patient-reported impact of dyspigmentation on quality of life, as assessed by the Skin Discoloration Impact Evaluation Questionnaire (SDIEQ). Correlations between SDIEQ, Psoriasis Area and Severity Index (PASI), and Dermatology Life Quality Index (DLQI) were assessed, with pigmentation changes tracked using standard and cross-polarized photographs evaluated for erythema, pigmentation, and skin tone evenness. These exploratory assessments of the quality-of-life impact of pigmentation changes as psoriasis lesions resolve, and of correlations between dyspigmentation and clinical and patient-reported outcomes, offer insight into the connection between clearer skin and reduced anxiety and depression.
Researchers found that, across treatment and Fitzpatrick skin type groups, mean SDIEQ scores decreased from moderate impact at baseline to mild impact at week 48, and photographic improvements in pigmentation were also observed. The majority of guselkumab-treated participants achieved clear or almost clear skin at week 48.
In cohort A, mean percent PASI improvement from baseline was 94.9%; in cohort B, mean percent Psoriasis Scalp Severity Index improvement was 94.6%, and at week 48, correlation between SDIEQ and DLQI was stronger than between PASI and DLQI.
Concluding Thoughts
PIPA is an example of how achieving symptomatic relief is only one aspect of psoriasis treatment, and how even the clearance of psoriasis-associated lesions can leave patients, especially those with skin of color, at risk for quality-of-life issues. Exploratory analyses showed SDIEQ improvements had a more positive impact on quality of life than PASI improvements, a conclusion that suggests that truly comprehensive psoriasis management requires greater attention to PIPA, especially for patients with skin of color.
