FIGURA 3 - uploaded by Fabio Francesconi
Content may be subject to copyright.
Caso 2 – Paciente com mancha hipercrômicas, em região malar e zigomática, contendo pápulas enegrecidas, em permeio às áreas de leucodermia e pápulas eritematosas
Source publication
Exogenous ochronosis consists of chronic hyperpigmentation of areas previously treated with topical agents such as hydroquinone, resorcinol, antimalarials and phenol. Early diagnosis allows to promptly suspend the causative agent and it is imperative since the available therapeutic options are scarce and have presented so far unsatisfactory results...
Similar publications
Dermatoscopy is a non-invasive, handy tool, which is increasingly being used in diagnosis and prognostication of pigmentary dermatoses. Dermatoscopic changes in pigmentary pattern, scaling, and vasculature help us to differentiate among the myriad of hypo and hyper pigmentary diseases. This review gives a brief overview of the dermatoscopic feature...
Citations
... The homogentisic acid then polymerizes, forming an ocher pigment in the papillary dermis, as occurs in other tissues in cases of endogenous ochronosis due to a primary structural defect of this enzyme. 18 Exogenous ochronosis lesions observed in dermoscopy were initially described in 2008 19,20 as sites of blue-gray or brown to black, amorphous globules, with follicular obliteration areas. It contrasts with melasma cases where dermoscopy demonstrates a pattern of reticular pigmentation, pseudonet accentuation, and brownish granules and globules, sparing the follicles. ...
Exogenous ochronosis is a cutaneous hyperpigmentation condition caused by the accumulation of substances derived from phenol on the skin or mucous membranes without affecting other tissues. It occurs mainly due to the use of bleaching agents, most frequently hydroquinone. The lesions are difficult to treat, being resistant to several approaches. Sometimes it’s necessary to use laser technologies or intense pulsed light to achieve some degree of improvement. The present work consists of a literature review of publications on these technologies in exogenous ochronosis from January 1990 to July 2020.
... Focal white areas and interostial pigmentary structures (including brown/grey globules, circles and semi-circles), corresponding to showing focal loss of melanin and ocher pigment arranged in different patterns in the dermis, respectively, were found to be characteristic of exogenous ochronosis. These findings have already been reported in the literature under various "metaphoric" terms ("confetti-like" depigmentation, caviar-like structures, worm-like pattern, etc.) [28,29]. Although, similar to previous studies, we also observed pigmented (brown and grey) areas with follicular openings obliteration [28,29], such findings were not absolutely specific to exogenous ochronosis as they were also seen in nevus of Ota. ...
... These findings have already been reported in the literature under various "metaphoric" terms ("confetti-like" depigmentation, caviar-like structures, worm-like pattern, etc.) [28,29]. Although, similar to previous studies, we also observed pigmented (brown and grey) areas with follicular openings obliteration [28,29], such findings were not absolutely specific to exogenous ochronosis as they were also seen in nevus of Ota. Notably, this condition also commonly displayed both a brown and grey pseudonetwork, although a statistical association was found only for the latter. ...
Background: Dermoscopy has been shown to be a useful supportive tool to assist the diagnosis of several non-neoplastic dermatoses (i.e. inflammatory, infiltrative and infectious skin diseases), yet data on skin of colour is still limited.
Objectives: To characterize dermoscopic features of non-neoplastic dermatoses in dark-skinned patients in order to identify possible clues that may facilitate the differential diagnosis of clinically similar conditions.
Materials & methods: Members of the International Dermoscopy Society were invited to submit cases of any non-neoplastic dermatosis developing in patients with Fitzpatrick phototypes V-VI whose diagnosis had been confirmed by the corresponding gold standard diagnostic test. A standardized assessment of the dermoscopic images and a comparative analysis according to clinical presentation were performed. Seven clinical categories were identified: (I) papulosquamous dermatoses; (II) facial hyperpigmented dermatoses; (III) extra-facial hyperpigmented dermatoses; (IV) hypopigmented dermatoses; (V) granulomatous dermatoses; (VI) sclerotic dermatoses; and (VII) facial inflammatory dermatoses.
Results: A total of 653 patients (541 and 112 with Phototype V and VI, respectively) were recruited for the analysis. Thirty-six statistically significant dermoscopic features were identified for papulosquamous dermatoses, 24 for facial hyperpigmented disorders, 12 for extra-facial hyperpigmented disorders, 17 for hypopigmented disorders, eight for granulomatous dermatoses, four for sclerotic dermatoses and 17 for facial inflammatory diseases.
Conclusions: Our findings suggest that dermoscopy might be a useful tool in assisting the diagnosis of clinically similar non-neoplastic dermatoses in dark phototypes by revealing characteristic clues. Study limitations include the retrospective design, the lack of a direct dermoscopic-histological correlation analysis and the small sample size for less common diseases.
... In 1908, Garrod coined the term ′inborn error of metabolism′ and proposed that AKU resulted from the deficiency of an enzyme that normally splits the aromatic ring of homogentisic acid. The deficient enzyme was identified by La Du in 1958 [9]. Sixty-seven mutations of the Alkaptonuria gene have been identified up to date. ...
... The diagnosis is done through the clinical history and from changes in coloration of
urine in environmental or alkali air and confirmed by dosage of homogentisic acid in
urine, which is the gold standard.6 The description of dermoscopy in endogenous ochronosis was not found in any of these
articles; however, the description of dermoscopy of a lesion by exogenous ochronosis, in
which it is possible to visualize blackened blue dots obstructing hair follicles was
observed in an article.7 ...
Alkaptonuria, also called endogenous ochronosis, is a rare metabolic autosomal
recessive disorder. It occurs by complete inhibition of homogentisic acid oxidase
enzyme having its deposition in various tissues. Male patient, 52 years old, sought
medical help complaining about progressive appearance of hyperchromic papules on the
lateral edge of the second finger of both hands for 02 years. He also complained
about darkening of urine, sperm and underwear. Incisional biopsy of second hand
finger and test for homogentisic acid in the urine results were positive. The
findings are compatible with the diagnosis of alkaptonuria. Given these findings,
treatment was initiated, followed-up by other specialties and he was advised to avoid
certain foods.
As hipermelanoses são enfermidades que acometem os tecidos da derme e epiderme e se caracterizam pela capacidade de alteração na pigmentação da pele. Os recorrentes números dessas alterações levaram ao aumento da produção de cosméticos com funções clareadoras. A hidroquinona é um composto fenólico, amplamente utilizado na indústria alimentícia como antioxidante e na indústria cosmética e dermatológica, devido às suas propriedades despigmentantes. No entanto, diversos estudos têm levantado preocupações sobre sua segurança e efeitos adversos, como a ocronose exógena. A ocronose exógena é uma condição dermatológica caracterizada pela hiperpigmentação negro-azulada fuliginosa, localizada na região onde foi aplicado o agente causador, como o uso prolongado e inadequado da hidroquinona. A exposição crônica a altas concentrações dessa substância pode levar ao acúmulo desta nos tecidos, resultando em danos irreversíveis à pele e à cartilagem. Desta forma, ressalta-se a importância do controle referente ao uso sem acompanhamento profissional dessa substância.
Exogenous ochronosis is a potential side effect associated with hydroquinone, and treatment is often unsatisfactory. Our study objectives were to review data on hydroquinone-associated ochronosis to determine risk factors for patients experiencing this adverse event. On September 27, 2020 (MEDLINE/PubMed), and October 30, 2020 (Scopus and Web of Science), databases were searched for “ochronosis + hydroquinone” by both authors to reduce risk basis. PRISMA reporting guidelines were used to select 56 articles with a total of 126 patients with hydroquinone-associated ochronosis. Included articles described hydroquinone-associated ochronosis. Articles were excluded if they had irrelevant content, were non-English language text, and were non-case studies. Full text articles were assessed and recorded. Cross-tabulation analysis was performed on categorical data, and Fisher exact test was performed. Ochronosis was most often reported in middle-aged women (53.2%), of African descent (45.2%), Black races (55.5%), and Fitzpatrick skin types V–VI (52.4%). It was most frequently reported with unknown and hydroquinone concentrations greater than 4% (32.5 and 35.7% cases, respectively). Median duration of use was 5 years, with only four cases reported with courses 3 months or shorter and eight cases reported with use 1 year or less. All patients presented with facial blue-black or gray-blue macules in a reticulate, lace-like fashion. Histopathology consistently showed solar elastosis and brownish-yellow, ‘banana-shaped’ fibers between degenerated collagen fibers of the papillary dermis. Based on these findings, we conclude that hydroquinone in concentrations above 4% and in treatment courses longer than 3 months may be associated with new-onset ochronosis.
Background
Over the last few years, several articles on dermoscopy of non‐neoplastic dermatoses have been published, yet there is poor consistency in the terminology among different studies.
Objective
We aimed to standardize the dermoscopic terminology and identify basic parameters to evaluate in non‐neoplastic dermatoses through an expert consensus.
Methods
The modified Delphi method was followed, with two phases: (I) identification of a list of possible items based on a systematic literature review and (II) selection of parameters by a panel of experts through a three‐step iterative procedure (blinded email interaction in Round 1 and 3 and face‐to‐face meeting in Round 2). Initial panellists were recruited via email from all over the world based on their expertise on dermoscopy of non‐neoplastic dermatoses.
Results
Twenty‐four international experts took part in all the rounds of the consensus and 13 further international participants were also involved in Round 2. Five standardized basic parameters were identified: (I) vessels (including morphology and distribution); (II) scales (including colour and distribution); (III) follicular findings; (IV) “other structures” (including colour and morphology); and (V) “specific clues”. For each of them, possible variables were selected, with a total of 31 different sub‐items reaching the agreement at the end of the consensus (all the 29 proposed initially + 2 added in the course of the consensus procedure).
Conclusion
This expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This tool, if adopted by clinicians/researchers of the field, is likely to enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology.
This article is protected by copyright. All rights reserved.
Dermatoscopy is a non-invasive diagnostic tool currently used for neoplastic skin lesions, several inflammatory and infectious diseases, and skin appendage disorders. As the clinical applications of dermatoscopy beyond pigmented lesions are constantly increasing, the aim of this paper is to provide an update on this topic. This comprehensive review substantiates how several diseases may show peculiar dermatoscopy features so to enhance the diagnosis and to avoid in selected cases unnecessary histological confirmation. In other cases, dermatoscopy features may be shared with other conditions with the advantage of narrowing down the differential diagnosis by ruling out those dermatoses with similar clinical aspect but different dermatoscopy presentation.
Exogenous ochronosis (EO) is a cutaneous disorder characterized by blue-black pigmentation resulting as a complication of long-term application of skin-lightening creams containing hydroquinone but may also occur due to topical contact with phenol or resorcinol in dark-skinned individuals. It can also occur following the use of systemic antimalarials such as quinine. EO is clinically and histologically similar to its endogenous counterpart viz., alkaptonuria, which, however, exhibits systemic effects and is an inherited disorder. Dermoscopy and in vivo skin reflectance confocal microscopy are noninvasive in vivo diagnostic tools. It is very difficult to treat EO, a cosmetically disfiguring and troubling disorder with disappointing treatment options. © 2015 Indian Journal of Dermatology | Published by Wolters Kluwer - Medknow.
Exogenous ochronosis (EO) can be an unintended psychologically troubling condition for patients who are already being treated for longer-term hyperpigmentation disorders such as melasma. Early diagnosis is key in order that the offending agent can be stopped to prevent further disfiguring discoloration. EO can be diagnosed in the right clinical setting with the aid of dermatoscopy, which can assist in early diagnosis and may negate the need for a biopsy. Laser modalities using Q-switched lasers of longer wavelengths and combination laser dermabrasion treatments have shown the most significant results with minimal adverse events. However, further large-scale studies are needed to determine optimal treatment modalities. Although considered uncommon, the incidence of EO will likely continue to increase with the growth of immigrant populations and the use of skin-lightening agents above the FDA's recommended over-the-counter concentrations, without the guidance of a dermatologist.
