P112 Strategies to reduce pathological scarring and postinflammatory hyperpigmentation in Fitzpatrick skin types IV–VI

Abstract

Patients with Fitzpatrick skin types IV–VI are at increased risk of pathological scarring, including hypertrophic scars and keloids, as well as postinflammatory hyperpigmentation following dermatological surgery. These outcomes are influenced by wound tension, inflammatory burden and melanocyte activity, yet practical guidance for operative decision making remains fragmented. We synthesized the existing literature and delineate concrete, ­evidence-informed surgical strategies that may reduce pathological scarring and pigmentary complications in Fitzpatrick skin types IV–VI. Using a clinically focused narrative synthesis, we organized evidence around modifiable operative and postoperative decisions, with attention to higher-risk settings including high-tension anatomical sites and strategies to mitigate postoperative inflammation and pigmentary change. Excessive wound tension was a consistent modifiable driver of hypertrophic scarring and keloids, supporting layered closure with deep dermal support, tension-reducing techniques and postoperative offloading, particularly in high-risk sites such as the chest, shoulders and back. Incision placement parallel to relaxed skin tension lines and minimization of perpendicular vectors were associated with improved scar quality and lower rates of hypertrophic scarring in select studies. Monofilament sutures, including poliglecaprone and polypropylene, were associated with lower inflammatory response and reduced hypertrophic scarring compared with braided alternatives. Postoperative scar modulation strategies with the strongest supporting evidence included silicone-based therapies and early intralesional corticosteroid use in select high-risk wounds. Prevention of postinflammatory hyperpigmentation focused on photoprotection, early control of postoperative inflammation, and cautious use of energy-based devices and topical depigmenting agents. Operative planning, closure technique and tailored aftercare are actionable determinants of scar and pigmentary outcomes in dermatological surgery. This narrative synthesis identifies specific, modifiable surgical considerations that may help mitigate risk in practice, while highlighting the need for higher-quality, skin-type-specific studies to further inform ­evidence-based surgical decision making.