Case for Diagnosis
Patchy Facial Hyperpigmentation
Hiperpigmentación facial parcheada
S. Kindem
, C. Serra-Guillén, C. Guillén
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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." "apellidos" => "Torrelo-Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731014004803" "doi" => "10.1016/j.ad.2014.11.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731014004803?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015000566?idApp=UINPBA000044" "url" => "/15782190/0000010600000004/v2_201505051007/S1578219015000566/v2_201505051007/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case for Diagnosis</span>" "titulo" => "Patchy Facial Hyperpigmentation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "317" "paginaFinal" => "318" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. 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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 6 | 12 |
| 2024 Octubre | 47 | 51 | 98 |
| 2024 Septiembre | 72 | 46 | 118 |
| 2024 Agosto | 96 | 53 | 149 |
| 2024 Julio | 80 | 57 | 137 |
| 2024 Junio | 81 | 36 | 117 |
| 2024 Mayo | 80 | 38 | 118 |
| 2024 Abril | 85 | 31 | 116 |
| 2024 Marzo | 84 | 39 | 123 |
| 2024 Febrero | 96 | 36 | 132 |
| 2024 Enero | 71 | 41 | 112 |
| 2023 Diciembre | 100 | 20 | 120 |
| 2023 Noviembre | 103 | 44 | 147 |
| 2023 Octubre | 103 | 40 | 143 |
| 2023 Septiembre | 125 | 38 | 163 |
| 2023 Agosto | 112 | 30 | 142 |
| 2023 Julio | 118 | 68 | 186 |
| 2023 Junio | 116 | 37 | 153 |
| 2023 Mayo | 125 | 66 | 191 |
| 2023 Abril | 98 | 47 | 145 |
| 2023 Marzo | 63 | 43 | 106 |
| 2023 Febrero | 72 | 38 | 110 |
| 2023 Enero | 65 | 32 | 97 |
| 2022 Diciembre | 61 | 34 | 95 |
| 2022 Noviembre | 24 | 35 | 59 |
| 2022 Octubre | 25 | 32 | 57 |
| 2022 Septiembre | 33 | 56 | 89 |
| 2022 Agosto | 25 | 32 | 57 |
| 2022 Julio | 30 | 43 | 73 |
| 2022 Junio | 21 | 17 | 38 |
| 2022 Mayo | 78 | 54 | 132 |
| 2022 Abril | 76 | 42 | 118 |
| 2022 Marzo | 75 | 49 | 124 |
| 2022 Febrero | 72 | 39 | 111 |
| 2022 Enero | 85 | 48 | 133 |
| 2021 Diciembre | 64 | 43 | 107 |
| 2021 Noviembre | 78 | 47 | 125 |
| 2021 Octubre | 55 | 49 | 104 |
| 2021 Septiembre | 51 | 31 | 82 |
| 2021 Agosto | 54 | 33 | 87 |
| 2021 Julio | 36 | 51 | 87 |
| 2021 Junio | 33 | 27 | 60 |
| 2021 Mayo | 29 | 34 | 63 |
| 2021 Abril | 73 | 64 | 137 |
| 2021 Marzo | 60 | 24 | 84 |
| 2021 Febrero | 59 | 29 | 88 |
| 2021 Enero | 42 | 22 | 64 |
| 2020 Diciembre | 35 | 17 | 52 |
| 2020 Noviembre | 33 | 31 | 64 |
| 2020 Octubre | 19 | 10 | 29 |
| 2020 Septiembre | 32 | 10 | 42 |
| 2020 Agosto | 28 | 13 | 41 |
| 2020 Julio | 30 | 13 | 43 |
| 2020 Junio | 44 | 23 | 67 |
| 2020 Mayo | 26 | 25 | 51 |
| 2020 Abril | 32 | 21 | 53 |
| 2020 Marzo | 33 | 22 | 55 |
| 2020 Febrero | 2 | 10 | 12 |
| 2020 Enero | 0 | 11 | 11 |
| 2019 Diciembre | 4 | 3 | 7 |
| 2019 Noviembre | 0 | 2 | 2 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 4 | 6 | 10 |
| 2019 Agosto | 0 | 4 | 4 |
| 2019 Julio | 0 | 9 | 9 |
| 2019 Junio | 2 | 22 | 24 |
| 2019 Mayo | 2 | 13 | 15 |
| 2019 Abril | 0 | 21 | 21 |
| 2019 Marzo | 2 | 9 | 11 |
| 2019 Febrero | 0 | 4 | 4 |
| 2019 Enero | 4 | 3 | 7 |
| 2018 Diciembre | 1 | 4 | 5 |
| 2018 Noviembre | 1 | 3 | 4 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 6 | 1 | 7 |
| 2018 Agosto | 0 | 5 | 5 |
| 2018 Julio | 0 | 6 | 6 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Mayo | 0 | 6 | 6 |
| 2018 Abril | 0 | 2 | 2 |
| 2018 Marzo | 9 | 3 | 12 |
| 2018 Febrero | 12 | 6 | 18 |
| 2018 Enero | 39 | 5 | 44 |
| 2017 Diciembre | 39 | 10 | 49 |
| 2017 Noviembre | 24 | 3 | 27 |
| 2017 Octubre | 22 | 4 | 26 |
| 2017 Septiembre | 14 | 13 | 27 |
| 2017 Agosto | 14 | 17 | 31 |
| 2017 Julio | 16 | 7 | 23 |
| 2017 Junio | 22 | 49 | 71 |
| 2017 Mayo | 21 | 16 | 37 |
| 2017 Abril | 16 | 18 | 34 |
| 2017 Marzo | 24 | 16 | 40 |
| 2017 Febrero | 19 | 17 | 36 |
| 2017 Enero | 15 | 4 | 19 |
| 2016 Diciembre | 30 | 13 | 43 |
| 2016 Noviembre | 41 | 9 | 50 |
| 2016 Octubre | 34 | 13 | 47 |
| 2016 Septiembre | 0 | 1 | 1 |
| 2016 Agosto | 0 | 1 | 1 |
| 2016 Julio | 10 | 1 | 11 |
| 2016 Junio | 12 | 3 | 15 |
| 2016 Mayo | 11 | 3 | 14 |
| 2016 Abril | 13 | 7 | 20 |
| 2016 Marzo | 6 | 5 | 11 |
| 2016 Febrero | 12 | 1 | 13 |
| 2016 Enero | 12 | 1 | 13 |
| 2015 Diciembre | 12 | 0 | 12 |
| 2015 Noviembre | 8 | 2 | 10 |
| 2015 Septiembre | 0 | 1 | 1 |
| 2015 Agosto | 0 | 1 | 1 |
| 2015 Julio | 5 | 2 | 7 |
| 2015 Junio | 5 | 2 | 7 |
| 2015 Mayo | 7 | 3 | 10 |
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