Treatment of Exogenous Ochronosis With a Q-Switched Alexandrite (755 nm) Laser

Skin Lightening Causes and Complications

Skin bleaching, also known as skin lightening, is the deliberate lightening of an individual's skin tone outside of medical supervision. The causes are complex, multifactorial and often intertwined although the unifying themes centre around a belief that lighter skin denotes an individual of higher status, be that economic or physical beauty, than their darker skinned counterpart. Skin lightening is achieved using agents that block the production of melanin and often contain drugs such as Hydroquinone, super potent topical steroid and Mercury. These drugs can cause serious local and systemic complication. Skin lightening compounds are illegal in most countries throughout the world however the industry is worth billions of dollars annually and the agents can be easily obtained by individuals seeking to lightening their skin. Dermatologists are in a unique position to identify those at risk of using skin bleaching agents, manage complications and give advice on how to avoid using skin lightening agents to treat dermatological conditions and physiological variation in pigmentation. In order to manage the belief that lighter skin is better, societal level change is required in order to ensure that people of all skin tones are represented in the media.

Exogenous ochronosis associated with hydroquinone: a systematic review

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.

Exogenous Ochronosis (EO): Skin lightening cream causing rare caviar-like lesion with banana-like pigments; review of literature and histological comparison with endogenous counterpart

Ochronosis is a cutaneous disorder caused by the accumulation of phenols, either endogenously as homogentisic acid in patients with alkaptonuria (autosomal recessive disorder with deficiency of the enzyme homogentisic acid oxidase), or exogenously in patients using phenol products such as topical creams containing hydroquinone or the intramuscular application of antimalarial drugs. Exogenous ochronosis (EO) typically affects the face and was reported in patients with dark skin such as Black South Africans or Hispanics who use skin-lightening products containing hydroquinone for extended periods. Recently more cases have been reported worldwide even in patients with lighter skin tones, to include Eastern Indians, Asians, and Europeans. However, just 39 cases of EO have been reported in the US literature from 1983 to 2020. Here we present two cases; a 69 and a 45-year-old female who were seen for melasma, given hydroquinone 4% cream daily and tretinoin 0.05%. Both patients noticed brown spots on their cheeks, which progressively enlarged and darkened in color. The diagnosis of ochronosis was confirmed by characteristic histopathological features on the punch biopsy. Unfortunately, neither patient responded to multiple treatments (to include, tazarotene 0.1% gel and pimecrolimus ointment, topical corticosteroids, and avoidance of hydroquinone containing products). We also present a case of classic (endogenous) ochronosis in a patient with alkaptonuria to picture the histological similarities of these two entities. EO is an important clinical consideration because early diagnosis and treatment may offer the best outcome for this notoriously refractory clinical diagnosis.

A case of ochronosis successfully treated with the picosecond laser

Exogenous ochronosis is a cutaneous condition characterized by blue-black pigmentation resulting as a complication of long-term application of skin-lightening creams containing hydroquinone and other substances such as quinine, phenol and mercury derivatives. We report a case of a 55-year-old woman who developed exogenous ochronosis as a result of prolonged use of topical hydroquinone for 5 years, characterized by greyish hyperpigmented patches on the nose and cheeks. The diagnosis was confirmed histologically. Treatment with picosecond laser resulted in marked clinical improvement together with improvement in overall texture and quality of the skin.

Fifty Shades of African Lightness: A Bio-psychosocial Review of the Global Phenomenon of Skin Lightening Practices

Skin-lightening is an aesthetic practice of global concern. By adopting a biopsycho-social approach, we consider the interplay between the biological, psychological and social factors that underpin the circulation and consumption of skin lighteners in South Africa. This paper reflects on biological aspects of skin lightening, interpersonal relationships, individual beliefs and expectations about the maintenance of health and well being that informs cosmetic practices. The paper seeks to examine claims made by historians (Thomas) and political philosophers and activists (Biko) that colonialism and apartheid in South Africa historically reinforced the use of skin lightening products in the country. The paper also investigates the role of media in staking out the boundaries of beauty. We argue that men and women practice skin-lightening not only as a complex result of the internalization of global standards of beauty, but meshed with a national politics of race and colorism. Banning skin lightening products without understanding the biological effects but also the social forces that underlie their increased popularity will prove futile. Moreover, we must consider the immeasurable pleasures associated with lightening, and the feelings with achieving visibility in South Africa, a country that continues to wrestle with blackness.

Exogenous Ochronosis

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.

Exogenous ochronosis in a Chinese patient: use of dermoscopy aids early diagnosis and selection of biopsy site

The diagnosis of exogenous ochronosis is often challenging and requires a high index of suspicion. Herein, we report a case of exogenous ochronosis in a Chinese patient. The condition was caused by the use of bleaching agents, including creams containing hydroquinone. We demonstrate the use of dermoscopy as an invaluable tool for the early recognition of the condition, as well as in the selection of an appropriate site for a skin biopsy.

The practice of skin-bleaching for a cosmetic purpose in immigrant communities

BACKGROUND

Using skin-lightening compounds for a cosmetic purpose that are normally restricted to medical use or forbidden has become a world-wide practice. Complications are numerous. Immigrant communities often import their practice from their original country.

METHODS

A review of the literature on the subject of complications of cosmetic skin-bleaching, with special focus on data concerning immigrants originating from highly endemic countries, was conducted.

RESULTS

Complications of cosmetic skin-bleaching are common, involving mainly the skin although some general complications are also reported with a growing incidence.

CONCLUSION

The high frequency of this practice, added to the frequency of various complications, suggests it might be considered as a genuine public health problem currently.

Effect of combination of 1064 nm Q-switched Nd:YAG and fractional carbon dioxide lasers for treating exogenous ochronosis

We describe three cases of exogenous ochronosis of the malar areas due to long-term application of skin-lightening agents for melasma, effectively treated by combination of Q-switched Nd:YAG and the fractional carbon dioxide lasers. None of these lasers has been reported to be used to effectively treat ochronosis before. The Q-switched Nd:YAG laser is capable of disintegrating dermal ochronotic fibers, thereby facilitating their phagocytosis and elimination via lymphatics. The fractional carbon dioxide laser is believed to assist transepidermal elimination of the onchronotic material. We believe successful treatment of ochronosis is possible when both mechanisms are applied.

Toxic Effects of Skin-Lightening Products in Canadian Immigrants

Background:

The cultural practice of skin bleaching is highly prevalent in Africa. Most reported cases of toxic effects of skin-lightening products occur in this region.

Objective:

To describe cases of misuse of over-the-counter (OTC) cosmetic skin-lightening products occurring in Canadian immigrants.

Methods:

Two cases of Canadian immigrants with severe complications from OTC skin-bleaching agents were identified in a community-based dermatology practice in Toronto. The case histories were reviewed and analyzed.

Results:

A 28-year-old African-Canadian woman developed extensive striae from long-term use of a topical cream containing clobetasol that she had purchased in a Caribbean health food store. A 55-year-old African-Canadian woman developed exogenous ochronosis from the use of a topical bleaching agent she had purchased in Ghana.

Conclusion:

Cosmetic skin lightening with unregulated topical products occurs in Canada. Dermatologists working in Canada need to be aware of this practice to provide appropriate directive care.

Hydroquinone for skin lightening: safety profile, duration of use and when should we stop?

Hydroquinone has been marketed in skin-lightening products for almost 50 years and remains as the most frequently used whitening constituent in the category. Issues and concerns have been raised regarding its potential dermatological and systemic side effects. These almost led to it being banned from the US market by the FDA in 2006. This article reviews its safety profile. The author also suggests on the duration of its use and advises on regular assessments by medical physicians.

Widespread use of toxic skin lightening compounds: medical and psychosocial aspects

Hyperpigmentation disorders and skin lightening treatments have a significant impact on the dermatologic, physiologic, psychologic, economic, social, and cultural aspects of life. Skin lightening compounds, such as hydroquinone and topical corticosteroids, are often used to treat hyperpigmentation disorders, such as melasma, or lighten skin for cosmetic purposes. Despite their established effectiveness, a multitude of dermatologic and systemic complications have been associated with these agents. Regulatory agencies have also recognized the adverse effects of skin lighteners and many countries around the world now forbid the production and sale of these compounds, although this prohibition has not significantly curtailed distribution. Dermatologists and users of cosmetic products should be aware of the various components in bleaching compounds, their potential adverse effects, and alternative options for skin lightening.

The safety of hydroquinone: A dermatologist's response to the 2006 Federal Register

Recently, the US Food and Drug Administration proposed a ban on over-the-counter hydroquinone mainly on the basis of high absorption, reports of exogenous ochronosis in humans, and murine hepatic adenomas, renal adenomas, and leukemia with large doses over extended time periods. Systemic exposure to hydroquinone from routine topical application is no greater than that from quantities present in common foods. While murine hepatic adenomas increased, murine hepatocellular carcinomas decreased, suggesting a protective effect. Renal tumors are sex, species, and age specific and therefore do not appear relevant to humans after decades of widespread use. Murine leukemia has not been reproducible and would not be expected from small topical doses. Finally, a literature review of exogenous ochronosis and clinical studies employing hydroquinone (involving over 10,000 exposures under careful clinical supervision) reveal an incidence of exogenous ochronosis in the United States of 22 cases in more than 50 years. Therefore, the proposed ban appears to be unnecessarily extreme.

Pigmentary Disorders in Latin America

Pigmentary disorders with hypopigmentation/depigmentation or hyperpigmentation may have special manifestations in Latin America. Most pigmentary disorders are commonly observed in all areas of Latin America, but a few are particularly seen in tropical and subtropical regions. In most pigmentary disorder ailments described, multiple factors involved in their pathogenesis are known, but etiology remains elusive. Some pigmentary disorders have peculiar clinical expressions and, in spite of being restricted to certain geographical areas, they may be observed in other world areas because of frequent traveling of affected patients. Therapy of most of these ailments is difficult or remains unknown.