The Extractions That Left Marks
A 28-year-old client with Fitzpatrick V skin is on a six-visit series for acne. Ten days ago you performed extractions on six closed comedones and two pustules on her cheeks. Today she returns with brown patches exactly where the pustules were. She reports she 'helped' a few spots by squeezing at home, used a walnut scrub twice a day, and started a 10% benzoyl peroxide leave-on. She now has three new inflamed papules and asks for 'the same extractions plus whatever lightens this.' Your room has a high-frequency unit, a 10% vitamin C serum, and a mild enzyme exfoliant.
1. What most likely caused the dark patches, and how does that change how you extract from now on?
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The patches are almost certainly post-inflammatory hyperpigmentation (PIH) - melanin deposited in response to inflammation, far more common and more persistent in Fitzpatrick IV-VI skin. The triggers line up:
- The pustules were already inflamed; extracting a pustule ruptures it and adds inflammation.
- She squeezed spots at home - trauma plus bacteria plus more inflammation.
- A walnut scrub twice daily is physical abrasion on irritated skin.
- A 10% benzoyl peroxide leave-on can irritate and dry at that strength for many people.
How this changes technique: extract only soft, closed comedones and non-inflamed lesions; leave papules and pustules alone; use minimal, directed pressure; stop immediately if the lesion will not release; never squeeze a pustule to 'empty' it. Today: no extractions on the three inflamed papules.
2. Should you apply the vitamin C serum today to start fading the pigment? Explain your reasoning.
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Not today, and not as the headline of the treatment.
- The three papules mean her skin is actively inflamed. Actives - even well-formulated vitamin C - sting and can add to inflammation when the barrier is compromised. Adding a new active to angry skin also makes it impossible to tell what helped and what hurt.
- Fix the inputs first. She has to stop the mechanical scrub and re-evaluate the 10% BP (lower strength, short-contact, or a gentler alternative). Irritation removed means less new pigment.
- UV is the multiplier. Without daily broad-spectrum SPF 30+, existing pigment darkens and lasts longer. This is the highest-yield recommendation today.
- High-frequency is reasonable over intact, non-excoriated areas but should skip excoriations.
A defensible plan: calming treatment today, vitamin C introduced in 2-3 weeks once the papules settle, and a lightening conversation (with realistic expectations) after that.
3. Rewrite her home care and set realistic expectations for the pigment.
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Home care rewrite:
- Gentle non-foaming cleanser twice daily; stop the walnut scrub entirely.
- Benzoyl peroxide: reduce strength or switch to short-contact (apply, wait, rinse) rather than a full-strength leave-on, or use a gentler alternative.
- Light, non-comedogenic moisturizer to rebuild the barrier.
- Broad-spectrum SPF 30+ every morning and reapply - non-negotiable for PIH.
- Hands off: no picking or squeezing; offer pimple patches as a substitute behavior.
Expectations: PIH fades over months, not weeks, and darker skin fades more slowly. Improvement is measured by photos taken under the same lighting every 4-6 weeks, not by how it looks on any single day. If the acne does not come under control or the pigment is unchanged after a few months of good home care, refer to a dermatologist - persistent or deep pigment is not a salon problem to keep treating.