Riehl's Melanosis

ts & C por a e se R S l Chan and Ma, Med Rep Case Stud 2019, 4:1 t a u

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i DOI: 10.4172/2572-5130.1000174

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ISSN: 2572-5130 Medical Reports and Case Studies

Case Report Open Access

A Case of an Elderly Women Presented with Severe Pigmented Contact Dermatitis (Riehl's melanosis) Effectively Treated with Topical Lignin Peroxidase Cream Kam Tim Michael Chan1* and Matthew Ming Wai Ma2 1Department of Dermatology, Hong Kong Academy of Medicine, Hong Kong 2Diagnostix Pathology Laboratories Ltd., Histopathology Unit, Canossa Hospital, 1 Old Peak Road, Hong Kong *Corresponding author: Kam Tim Michael Chan, Department of Dermatology, Hong Kong Academy of Medicine, Hong Kong, Tel: +85221282129; E-mail: [email protected] Received Date: Nov 19, 2018; Accepted Date: Jan 31, 2019; Published Date: Feb 07, 2019 Copyright: © 2019 Chan KTM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Pigmented Contact Dermatitis is an acquired allergic contact dermatitis secondary to certain cosmetics or airborne allergens. Although it is rarely reported in fair skin types and in western countries, it is a significant disease with major psychological burden to patients with dark skinned types. Its exact relationship to Riehl melanosis remains controversial. While its exact aetiology and pathogenesis are still unknown, advances in treatment including oral tranexamic acid, glycyrrhizin compound and laser have been proposed. We report a case of an elderly female histologically confirmed to have Pigmented Contact Dermatitis secondary to hair dyes and hydrocarbon oils responded satisfactory to topical Lignin Peroxidase cream applied over six month duration.

Keywords Elderly Chinese women; Riehl’s melanosis; Topical lignin side effects. She did not take any systemic and topical medications peroxidase cream including herbal medicines. On examination, she was found to have severe generalized grey-black hyperpigmentation involving the face, Introduction neck, post-auricular region and part of the upper chest. Skin reticulated hyperpigmentation over the forehead was noted. Her Pigmented Contact Dermatitis (PCD); originally described by G. original white hair was tanned to a light grey colour. On further Riehl in World War II, is a contact allergic dermatitis of the face enquiry, she reported to have repeatedly used an over the counter complicated by severe hyperpigmentation [1-4]. It’s exact aetiology and preparation of natural hair dye and conditioner consisted of the pathogenesis is unknown. Contact allergy is believed to be secondary following ingredients: Indigofera tinctoria Leaf Powder (Indigo), to cosmetics, fragrances, textiles, hair dyes, coal tar and azo dyes, Cassia auriculata Leaf Powder (Senna), Lawsonia inermis Leaf Powder metallic jewelleries and possibly others like airborne allergies resulted (Henna). She denied any irritation after each application. In addition, in an asymptomatic presentation of severe dyschromia [5-13]. The she had also been applied a moisturizer over the face, neck and body condition impacted a significant physical and psychological burden to which contained Camellia seed oil (tea polyphenols). the patient and their families. Till now, no well proven effective treatment is known [14]. We report a severe case of PCD in an elderly At this juncture, the differential diagnosis are exogenous ochronosis, 70 years old woman presented with clinically and histologically Riehl’s post-inflammatory hyperpigmentation secondary to inflammatory melanosis after using topical hair dyes and moisturizers containing dermatosis, maturational dyschromia, melasma, acquired nevus of hydrocarbon oils effectively managed by topical Lignin Peroxidase Ota, Addision’s diseases and PCD or Riehl melanosis. The clinical (LiP) cream. history suggested the latter. A diagnostic skin biopsy was performed after careful explanation and counselling to the patient with her consent. The histology reported a piece of skin with scattered isolated Case Report and small clusters of melanophages and small lymphocytes in the A 70 year old Chinese lady visited our dermatology clinic on papillary dermis. The overlying epidermis appears unremarkable. November 9, 2017 presented with a severe hyperpigmentation over the Scantly pigmented melanocytes are seen at the dermo-epidermal face. She also noticed increased pigmentation over the neck, post- junction, no melanocytic proliferation is seen. There is mild superficial auricular regions, chest and axillae. She denied any pruritus and perivascular lymphocytic infiltrate. Solar elastosis is seen. The features discomfort. There is no significant past medical and allergy history. She are compatible with post inflammatory hyperpigmentation due to reported to have frequent applications of hair dyes but without any previous contact dermatitis to topical application (Figure 1).

Med Rep Case Stud, an open access journal Volume 4 • Issue 1 • 1000174 ISSN: 2572-5130 Citation: Chan KTM, Ma MMW (2019) A Case of an Elderly Women Presented with Severe Pigmented Contact Dermatitis (Riehl's melanosis) Effectively Treated with Topical Lignin Peroxidase Cream. Med Rep Case Stud 4: 174. doi:10.4172/2572-5130.1000174

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Figure 1: Histological slides from post-inflammatory hyperpigmentation featuring melanophages and small lymphocytes in superficial perivascular location in the papillary dermis. Also the epidermis show mild atrophy with mild vacuolar interface dermatitis compatible with pigmented contact dermatitis.

The histology and clinical history ruled out ochronosis, melasma, post inflammatory hyperpigmentation secondary to inflammatory dermatosis but pigmented contact dermatitis or allergic melanosis. Subsequent, investigation included complete blood picture, liver function test, thyroid function test, renal function test, occult systemic and gynaecological malignancy screens, serum cortisol and ACTH level were performed and reported negative. A standard patch testing was performed but failed to provide further clues of the culprits of the contact dyschromia. A provisional diagnosis of PCD or Riehl melanosis was made. In view of the severe disfigurement associated with the condition, management was started alongside with the investigations. The patient was carefully counselled, explained and reassured about the nature and course of the hyperpigmentation. Salient points were emphasized particularly on total abstinence of cosmetic products, inappropriate sunscreens, moisturizers, hair dyes and fragrances on the skin. The patient was instructed on the importance of sun protection with hats, umbrella, appropriate hypoallergenic sunscreen of a sun protective factor of 50++ and excessive sun avoidance. Hypoallergenic moisturizers were recommended. For the treatment, as no well proven effective medications are documented in the literature and tyrosinase inhibitors and laser therapy are relative contra-indicated and risky, topical cystamine cream was tried but refused by the patient due to stinging sensation and odour. The patient refused to take oral medication including tranexamic acid. Topical LiP cream was prescribed, accepted and well tolerated by the patient applied twice daily over the affected areas of the skin. A gradual improvement of the hyperpigmentation, skin texture and roughness of the patients were observed over a period of six months treatment duration (Figure 2). PCD is considered by some authorities a form of allergic contact dermatitis with resultant severe hyperpigmentation [5,6,14]. The allergic contact dermatitis is believed to be due to a variety of topical Figure 2: Gradual clinical improvement over time of the reported and airborne allergens or a lichenoid immune reaction that may be subject after daily twice application of Topical LiP cream with caused by intrinsic or extrinsic factors. Strictly speaking, the original lightening of skin hyperpigmentation, skin roughness and texture. cases described by Riehl seventy years ago may represent a separate disease entity; at least the nutritional factors seem to play a predominant role in the classical reported cases of Riehl melanosis. Nonetheless, PCD especially in the recently reported cases in the literature has a cause and effect relationship secondary to allergic sensitization to applied cosmetics, fragrances, textiles, hair dyes, metallic jewelleries allergens and hydrocarbon oils. Nakayama has suggested that the PCD is possibly a type IV allergy due to repeat small

Page 3 of 4 amount of contact sensitization to the skin immune system with the hydroquinone with no reported adverse side effects but with results of pigmentary incontinence and engulfing of melanin by superiority in skin texture and roughness [27]. Our case report also melanocytes [5,6,8,14]. Our reported case also illustrated this clinical demonstrates the overall improvement in discoloration, texture and history. In addition, our patient gender, dark skin type (Fitzpatrick III) skin roughness as commonly seen in solar elastotic skin patient come and late middle age are in consistent with the described from an intensely pigmented ethnicity. However, as the cost of LiP epidemiological data of the documented cases of PCD [14,15]. Further cream is not inexpensive and the duration of treatment maybe long confirmation of the diagnosis can be aided by dermoscopy, confocal and extensive; this may impede the patient’s compliance to the microscopy and sophisticated extended patch and photo patch testing management. Patient should be fully explained, counselled on the series [15,16]. different alternative regimes for the treatment of PCD and followed up regularly and continuously with a team care approach. Currently, no double blinded control trial has been performed for evidence-based therapy of PCD [14] Avoidance of the cosmetics, use of hypoallergenic skin care products, sun-protection and use of topical tyrosinase inhibitor, azelaic acid, retinoids, lasers have been attempted but may not be effective and acceptable to the patients due to its irritancy and unpredictable results [17,18]. A small study of 10 patients suffered from PCD were treated with oral tranexamic acid combined with glycyrrhizin acid topical preparations for three months followed by further three months of tranexamic acid orally alone were reported to be efficacious [19]. Although the number of recruited subjects were small, but the action of tranexamic acid in inhibiting the transfer of melanin is a plausible mechanism. Another small pilot study used a triple combination therapy with a low - fluence 1064 nm Q-switched Nd: YAG laser, hydroquinone cream and oral tranexamic acid for recalcitrant Riehl’s melanosis was reported to complete clear the melanosis in the majority of patients; albeit tyrosinase inhibitor may not be available in some countries [20]. In our current report, topical LiP cream is shown to be an efficacious, well tolerated treatment option with a high patient’s acceptability. Topical LiP may provide an Figure 3: Mechanism of action of lignin peroxidase as cosmetic alternative treatment modality to this severely disfiguring, still lightening agent. Step 1: oxidation of action of LiP by hydrogen pathogenetically unresolved pigmentary disorders in the female who peroxide, Step 2: reduction of oxidized LiP by one molecule of frequently applied cosmetics. We previously also reported another case Veratryl Alcohol (VA), Step 3: oxidation of melanin, Step 4: of a 40 years old male presented with unilateral asymptomatic Riehl inactivation of LiP by change in pH to become a simple melanosis after applying expired topical sunscreen treated satisfactorily glycoprotein, Step 5: hydrolysis of glycoprotein into amino acids by managed by topical LiP cream [21]. proteases and other glycosidases naturally present in the skin [24]. LiP was discovered in the extracellular medium of the white-rot fungus; Phanerochaete chrysosporium [22,23] Since then, at least six other isoforms of the ligninolytic enzymes were characterized from Conclusion various fungal organisms, namely: Tramates versicolor, Phlebia radiata We report a case of an elderly female who clinical and and Phanerochaeta sordida but not bacterium. Each has a different histopathological presentation compatible with a diagnosis of PCD isoelectric point, sugar content, substrate specificity and stability effectively managed with lifestyle modifications, sunscreen advices, [23,24]. Melanin; expressed as eulmelanin and phaeomelanin; abstinence of irritant allergic skin care products together with topical produced by the process of melanogenesis are physiologically stored in application of twice daily LiP cream for duration of six months melanosomes and transferred to the keratinocytes in the epidermis interval. The treatment regime is well tolerated, without adverse which serves its role of protection against ultraviolet radiation and reactions and efficacious. Large scale, better designed, double blind environmental stress [23]. However, aberrant or uncurbed transfer of study should be performed to investigate the feasibility of using LiP melanin to the dermis and epidermis may result in the frequently seen cream to effectively treat PCD. clinically condition of skin hyperpigmentation and dyschromia due to various pathophysiological mechanisms. Lignin and coal in the polymers form are made up of indole and phenolic subunits have a References close structural resemblance to melanin [23]. Hence, naturally 1. Riehl G (1917) uber eine eigenartige melanose. Wien Klin Wochensschr occurred ligninolytic enzymes like LiP is a good organic candidate 30: 280-281. endowed by nature to oxidize and denature abnormal melanin in the 2. Rorsman H (1982) Riehl’s melanosis. Int J Dermatol 21: 75-78. skin which biologically resemble lignin. The biochemical pathway and 3. Findlay GH (1952) Some observations on melanosis of Riehl. S Afr Med J mechanism of LiP is illustrated in Figure 3. Clinically, crude LiP was 26: 373-375. demonstrated to decolorize synthetic melanin [22-25]. This is further 4. Osmundsen PE (1970) Pigmented contact dermatitis. Br J Dermatol 83: illustrated in another study that LiP act as a melanolytic enzyme 296-301. capable of degrading human skin melanin [23]. The application of the 5. Nakayama H, Harada R, Toda M (1976) Pigmented cosmetic dermatitis. LiP cream provided a significant faster skin lightening effect than the Int J Dermatol 15: 673-675. tyrosinase inhibitor; 2% hydroquinone cream [26]. Draelos 6. Nakayama H, Matsuo S, Hayakawa K, Takhashi K, Shigematsu T, et al. demonstrated LiP has a skin lightening effect comparable to (1984) Pigmented cosmetic dermatitis. Int J Dermatol 23: 299-305.

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Med Rep Case Stud, an open access journal Volume 4 • Issue 1 • 1000174 ISSN: 2572-5130