Case for Diagnosis
Patchy Facial Hyperpigmentation
Hiperpigmentación facial parcheada
S. Kindem
, C. Serra-Guillén, C. Guillén
Corresponding author
Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, Spain
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A, Facial lentigines. B, Hyperpigmented lesions of various sizes on the lower limbs; the largest was located on the right buttock.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "T.T. Ramos-Geldres, P. Dávila-Seijo, A. Duat-Rodríguez, L. Noguera-Morel, B. Ezquieta-Zubicaray, E. Rosón-López, A. Hernández-Martín, A. Torrelo-Fernández" "autores" => array:8 [ 0 => array:2 [ "nombre" => "T.T." "apellidos" => "Ramos-Geldres" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Dávila-Seijo" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Duat-Rodríguez" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Noguera-Morel" ] 4 => array:2 [ "nombre" => "B." "apellidos" => "Ezquieta-Zubicaray" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Rosón-López" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Hernández-Martín" ] 7 => array:2 [ "nombre" => "A." 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Kindem, C. Serra-Guillén, C. Guillén" "autores" => array:3 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Kindem" "email" => array:1 [ 0 => "sabrinakindemgomez@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Serra-Guillén" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Guillén" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hiperpigmentación facial parcheada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 500 "Ancho" => 667 "Tamanyo" => 205298 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 62-year-old Brazilian woman who had been resident in Spain for 3 years. She consulted for pigmented facial spots that had developed progressively over the previous 2 years. She had no past medical history of interest and stated she was not taking any medication. The lesions were asymptomatic and did not give rise to pruritus or pain.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient's skin was phototype V of the Fitzpatrick classification. Physical examination revealed poorly defined patches of hyperpigmentation formed of palpable minute grayish papules on a brownish base bilaterally in the malar, zygomatic, temporal, and supraciliary regions. No signs of inflammation or superficial flaking were observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and no similar lesions were detected at other sites.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histology of one of the lesions showed an intact epidermis and the deposition of a dark-yellow material between the collagen fibers in the superficial dermis; the accumulations of this material showed a variable morphology. The adnexa were not affected and there was no inflammatory infiltrate. No signs of melanocyte proliferation or increased melanic pigment in the basement membrane were observed and no melanophages were present in the superficial dermis (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">No other additional tests were requested.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Hydroquinone-induced exogenous ochronosis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical course</span><p id="par0035" class="elsevierStylePara elsevierViewall">During the diagnostic workup, the patient revealed that for more than 20 years she had been applying a hydroquinone-containing product topically to the facial area to reduce her pigmentation. She was instructed to discontinue using the product and treatment was started with topical retinoids.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">The term “cutaneous ochronosis” was first used by Virchow in 1866 to describe the accumulation of homogentisic acid in the papillary dermis. However, the term was being used in reference to ochronosis secondary to an endogenous pathogenic mechanism in a hereditary disease known as alcaptonuria, in which there is an alteration of the enzyme homogentisate 1,2-dioxygenase.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It was not until 1975 that Findlay described a form of ochronosis caused by the prolonged use of skin-bleaching creams containing hydroquinone; by the 1980s, this had become the main worldwide cause of exogenous ochronosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Hydroquinone-induced exogenous ochronosis develops due to the prolonged topical application of hydroquinone; onset of the condition is more closely related to the duration of administration than to the concentration of the agent. It most commonly affects phototypes IV and V, which are those in which skin-bleaching treatments are typically used. This prolonged use produces an inhibition of the enzyme homogentisate 1,2-dioxygenase, leading to an accumulation of homogentisic acid in the dermis. Clinically, patients present patches of hyperpigmented papules that resemble caviar eggs; these papules block the follicular openings. The changes are most evident in the area of the zygomatic arches and in the supraciliary region.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Early stages may only present minimal erythema with mild inflammation. The differential diagnosis should include melasma, which is much more common but does not have papular lesions or follicular plugs, and hyperpigmentation secondary to metal accumulation (pseudo-ochronosis), in which the hyperpigmentation is typically widespread and affects the sclera and mucosas.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The definitive diagnosis is made on histology, confirming the presence of ochre-colored bodies in the superficial dermis, between the collagen bundles; the epidermis and adnexa are not affected. These ochre-colored bodies can adopt different shapes, the most typical being banana-shaped, as can be observed in Figure<span class="elsevierStyleHsp" style=""></span>3 in a biopsy from our patient.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> It is important to remember that these bodies are not arranged around the excretory ducts of the eccrine glands, a feature characteristic of other diseases that are associated with hyperpigmentation but that are not due to the accumulation of homogentisic acid, such as silver accumulation, known as argyria. Pseudo-ochronosis is a more common condition.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therapeutically, the first measure is to discontinue the use of hydroquinone. Numerous treatments have been described, including topical retinoids, chemical peeling with glycolic acid, and carbon dioxide laser.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Currently, the best results are achieved by treatment with the neodymium-doped yttrium aluminium garnet (Nd:YAG) laser, which fragments the ochre bodies and facilitates their phagocytosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical course" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Kindem S, Serra-Guillén C, Guillén C. Hiperpigmentación facial parcheada. Actas Dermosifiliogr. 2015;106:317–318.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 700 "Ancho" => 876 "Tamanyo" => 145604 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical photograph of the patchy, granular hyperpigmentation present in the left temporal region.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 500 "Ancho" => 667 "Tamanyo" => 149186 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>20.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 500 "Ancho" => 667 "Tamanyo" => 205298 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Endogenous ochronosis: A case description]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 6 | 13 |
| 2024 October | 47 | 51 | 98 |
| 2024 September | 72 | 46 | 118 |
| 2024 August | 96 | 53 | 149 |
| 2024 July | 80 | 57 | 137 |
| 2024 June | 81 | 36 | 117 |
| 2024 May | 80 | 38 | 118 |
| 2024 April | 85 | 31 | 116 |
| 2024 March | 84 | 39 | 123 |
| 2024 February | 96 | 36 | 132 |
| 2024 January | 71 | 41 | 112 |
| 2023 December | 100 | 20 | 120 |
| 2023 November | 103 | 44 | 147 |
| 2023 October | 103 | 40 | 143 |
| 2023 September | 125 | 38 | 163 |
| 2023 August | 112 | 30 | 142 |
| 2023 July | 118 | 68 | 186 |
| 2023 June | 116 | 37 | 153 |
| 2023 May | 125 | 66 | 191 |
| 2023 April | 98 | 47 | 145 |
| 2023 March | 63 | 43 | 106 |
| 2023 February | 72 | 38 | 110 |
| 2023 January | 65 | 32 | 97 |
| 2022 December | 61 | 34 | 95 |
| 2022 November | 24 | 35 | 59 |
| 2022 October | 25 | 32 | 57 |
| 2022 September | 33 | 56 | 89 |
| 2022 August | 25 | 32 | 57 |
| 2022 July | 30 | 43 | 73 |
| 2022 June | 21 | 17 | 38 |
| 2022 May | 78 | 54 | 132 |
| 2022 April | 76 | 42 | 118 |
| 2022 March | 75 | 49 | 124 |
| 2022 February | 72 | 39 | 111 |
| 2022 January | 85 | 48 | 133 |
| 2021 December | 64 | 43 | 107 |
| 2021 November | 78 | 47 | 125 |
| 2021 October | 55 | 49 | 104 |
| 2021 September | 51 | 31 | 82 |
| 2021 August | 54 | 33 | 87 |
| 2021 July | 36 | 51 | 87 |
| 2021 June | 33 | 27 | 60 |
| 2021 May | 29 | 34 | 63 |
| 2021 April | 73 | 64 | 137 |
| 2021 March | 60 | 24 | 84 |
| 2021 February | 59 | 29 | 88 |
| 2021 January | 42 | 22 | 64 |
| 2020 December | 35 | 17 | 52 |
| 2020 November | 33 | 31 | 64 |
| 2020 October | 19 | 10 | 29 |
| 2020 September | 32 | 10 | 42 |
| 2020 August | 28 | 13 | 41 |
| 2020 July | 30 | 13 | 43 |
| 2020 June | 44 | 23 | 67 |
| 2020 May | 26 | 25 | 51 |
| 2020 April | 32 | 21 | 53 |
| 2020 March | 33 | 22 | 55 |
| 2020 February | 2 | 10 | 12 |
| 2020 January | 0 | 11 | 11 |
| 2019 December | 4 | 3 | 7 |
| 2019 November | 0 | 2 | 2 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 4 | 6 | 10 |
| 2019 August | 0 | 4 | 4 |
| 2019 July | 0 | 9 | 9 |
| 2019 June | 2 | 22 | 24 |
| 2019 May | 2 | 13 | 15 |
| 2019 April | 0 | 21 | 21 |
| 2019 March | 2 | 9 | 11 |
| 2019 February | 0 | 4 | 4 |
| 2019 January | 4 | 3 | 7 |
| 2018 December | 1 | 4 | 5 |
| 2018 November | 1 | 3 | 4 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 6 | 1 | 7 |
| 2018 August | 0 | 5 | 5 |
| 2018 July | 0 | 6 | 6 |
| 2018 June | 0 | 1 | 1 |
| 2018 May | 0 | 6 | 6 |
| 2018 April | 0 | 2 | 2 |
| 2018 March | 9 | 3 | 12 |
| 2018 February | 12 | 6 | 18 |
| 2018 January | 39 | 5 | 44 |
| 2017 December | 39 | 10 | 49 |
| 2017 November | 24 | 3 | 27 |
| 2017 October | 22 | 4 | 26 |
| 2017 September | 14 | 13 | 27 |
| 2017 August | 14 | 17 | 31 |
| 2017 July | 16 | 7 | 23 |
| 2017 June | 22 | 49 | 71 |
| 2017 May | 21 | 16 | 37 |
| 2017 April | 16 | 18 | 34 |
| 2017 March | 24 | 16 | 40 |
| 2017 February | 19 | 17 | 36 |
| 2017 January | 15 | 4 | 19 |
| 2016 December | 30 | 13 | 43 |
| 2016 November | 41 | 9 | 50 |
| 2016 October | 34 | 13 | 47 |
| 2016 September | 0 | 1 | 1 |
| 2016 August | 0 | 1 | 1 |
| 2016 July | 10 | 1 | 11 |
| 2016 June | 12 | 3 | 15 |
| 2016 May | 11 | 3 | 14 |
| 2016 April | 13 | 7 | 20 |
| 2016 March | 6 | 5 | 11 |
| 2016 February | 12 | 1 | 13 |
| 2016 January | 12 | 1 | 13 |
| 2015 December | 12 | 0 | 12 |
| 2015 November | 8 | 2 | 10 |
| 2015 September | 0 | 1 | 1 |
| 2015 August | 0 | 1 | 1 |
| 2015 July | 5 | 2 | 7 |
| 2015 June | 5 | 2 | 7 |
| 2015 May | 7 | 3 | 10 |
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