CLINICAL CASES

RIEHL TRIGGERED BY CLEANING AGENTS

MONICA COSTESCU*, RALUCA GHIORGHISCAN**, RALUCA MIULESCU***, MARIA GRIGORE****, OANA ANDREIA COMAN*****, SIMONA ROXANA GEORGESCU*

Summary Hypermelanases are defined as hyperpigmentative skin disorders resulting from quantitative abnormalities ( excess) or qualitative melanin pigments. Hypermelanosis can be determined by genetic and acquired factors. Some melanosis occur by increasing melanogenesis under the influence of genetic factors. Other melanosis occur by increasing the number of (Mongoloida patch, Ota nevita, Ito nevul). Other melanomas occur under the influence of hormonal factors, UV, chemical compounds and cosmetics. Riehl’s melanosis (cosmetic pigmentary dermatitis or facial melanoma of women) is a skin disorder that is manifested by the appearance of a pigmentation in the cephalic extremity encountered especially in women and in the appearance of which cosmetics, detergents and sunlight appear to play a role important. We present the case of a 43-year- old patient presenting in our clinic for a dramatic facial melanoma with a major negative impact on the emotional state of the patient. Diagnosis based on clinical examination, history, challenge tests and histological examination is Riehl’s melanosis. Keywords: melanosis, Riehl, cosmetics, detergents, .

Received: 11.09.2017 Accepted: 3.11.2017

Introduction neurological, systemic, post-inflammatory, cosmetic or idiopathic [1]. Melanosis is a common disorder in It is well known in hyperpigmentation that dermatological medical practice and in the major trigger factor is exposure to ultraviolet. dermatocosmetics, with a major impact in the vast majority of cases, with a negative impact on Ultraviolet have the ability to trigger and social life, especially for women. We speak of aggravate the evolution of any melanosis [2]. hypermelaninases when activity is Ultraviolet stimulates the proliferation and increased and hypermelanocytosis when melano- migration of melanocytes but also melano- cytes are excessively elevated [1]. genesis. The influence of the sun is proven by the The etiology of melanosis is still quite fact that the onset of the disease is usually unclear, and there are a number of factors that summer and later it is always aggravated during can trigger the condition. Melanosis can be the warm season. But in the case of Riehl’s related to the nature of the triggering process: melanosis there are other factors that are more genetic, metabolic, endocrine, deficiency, prominent in triggering hyperpigmentation, physical, toxic, parasitic, infectious, tumor, namely cosmetics and detergents [3].

* Dermatology Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest. ** Dermatology Department ,“Victor Babes” Clinical Hospital, , Bucharest.. *** Dermatology Department, Elias University Emergency Hospital, Bucharest. **** Department of Histopathology, Clinical Hospital “Prof. Dr. Victor Babeº“, Bucharest.. ***** Department of Pharmacology, “Carol Davila” University of Medicine and Pharmacy, Bucharest.

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Initially, the pigmentation is punctual, but clinic for the appearance of a pigmentation in the later it extends, including the whole of the cephalic extremity, limbs and thorax with cephalic extremity as well as the limbs and the evolution over two months without significant chest. pathological personal history. Also, the patient Pigmentation has different shades, so it can accuses facial pruritus and especially at the level be yellow-brown, dark-brown and even black, of the decolletage. Initially, before hyper- with the net limit of the banner. The skin is pigmentation, the patient said that face and generally normal, rarely slightly atrophic, and neckline areas were pruritic and erythematous. occasionally there are lichenoid papules and The clinical examination describes an rarely follicular hyperkeratosis. eruption consisting of hyperpigmented plaques Skin color can be constitutional (native, located at the face, neckline, neck and superior influenced by genetic factors), or induced (under upper limb area, which began about two months the action of solar rays or other factors). ago. The entire face and the decollete are covered Melanosis occurs more frequently in certain by a diffuse stretched, discreetly cross-linked, ethnic groups, such as hispanic, oriental or asian melanodermic plaque, with a significant diffe- individuals [2,4]. rence in color from normal skin (the patient has Skin pigmentation is fairly common in both constitutively hyperpigmented skin, phenotype males and females, irrespective of race, and is IV). Hyperpigmentation is also evident in the characterized by brown or black, circumscribed upper limbs, in the upper 1/3 and the dorsal lesions (in which case the skin between the faces of the hand. healthy and diseased skin is clearly visible), The patient is employed by a company that diffuse or generalized. provides cleanliness by being in contact with a Women are more affected, especially during variety of detergents and cleaning agents, and the reproductive period, with a peak between 20- cleaning products are often changed during the 30 years [2,3,4]. It has been noticed that cleaning process. He states that the exposure to melanoses are much rare before puberty. Skin the cleaning products he works with generates a hyperpigmentation is common in both men and generalized pruritus, respiratory discomfort, women, but women are those who, through the even the simple odor causes a state of illness. All perceptions that define „beauty, perfect skin,“ are these accusations disappear when they leave more emotionally affected, with a negative their jobs. This awareness appears to have impact on the quality of life. No matter how small occurred more than 10 years ago when working the affected or intense area is pigmentation, most in this environment. The introduction of new affected people feel the disease intense and have detergents a few months ago triggered this state a relatively high degree of frustration over this of affairs, which is why he presented himself to aesthetic problem. Melanoses can be limited, the dermatologist. circumscribed, and become broad, diffuse in Insisting on the anamnesis, we found out that evolution. she does not use facial cosmetics (creams, lotions, There are varying degrees of pigmentation in serums), only soap with which she washes twice various regions of the body but the most a day on the face. Decorative cosmetics are rarely unpleasant aspect experienced by the patient is used occasionally. She also uses deodorant spray, when the extremity of the head and the decollete a deodorant that has no contact with the face. are affected areas. She was not particularly exposed to the sun, Melanosis is in most cases a problem of her work being mostly at night, and rests during aesthetics, more of a „social visiting card“ felt by the day. The period in which she presents is the the affected individual, within well-defined disorders that cause skin hyperpigmentation. late autumn at the end of October, but we are still thinking about an unintended sun exposure during the summer. She says she never used Material and methods: case presentation sunscreen creams. We present the case of a 43-year-old smoker The patient is not pregnant and does not use from the urban environment presenting in our estro-progestative contraceptives or any other

26 DermatoVenerol. (Buc.), 62: 25-33 medication taken as a chronic medication. She pneumological examination. The local exam also does not suffer from osteoporosis, she does reveals dark-brown macules, with a clear gray not use hormonal therapies that would be tendency, with a tendency to confluence in indicated in the therapy of this disease. We have plaques, located on the face, chest, upper limbs insisted in this direction because the immediate and thighs, moderately pruritic, painless. The diagnosis was . This is all the more so entire face and neckline are covered with a since melasma is more common in people with a stretched, melanodermic diffuse plaque, finely hyperpigmented native constitution, our patient cored, with extremely significant color difference fits into this phenotype IV. to the healthy skin. On the periphery of melantic It seems that estrogen induces melasma by plaques there are hyperpigmentation spots that stimulating the estrogen receptor present on stand out from the normally colored skin around. melanocytes, resulting in increased melanin We mention that the patient has a hyper- production. Also, pelvic inflammatory diseases pigmented constitutional skin (fig. 1, fig. 2, fig. 3). in women, dysfunction and inflammation of the Excisional biopsy was performed with a ovary and its annexes, strongly suggest histopathological examination of epidermal skin involvement in the appearance of melasma / fragments with moderate hyperorthokeratosis facial hyperpigmentation. [Kim and Sawhney]. and epithelial basal hyperpigmentation that Therefore, the patient was investigated on this interest the malpighian inferior portion, with no line and no pelvic inflammation was found, the cavities, discrete infiltrated focal perivascular echography showing normal appearance and the lymphocytic infiltration and moderate macro- inflammatory specimens (VSH, C-reactive phages loaded with brown pigment present. protein, fibrinogen) being normal. Histopathological aspects support the diagnosis Another direction that was followed was that of melanoderma. Histologically, the first stages of endocrine hormonal investigations, describe a lichenification of the basal layer of the performing tests to detect thyroid and adrenal epidermis and the appearance of a perivascular dysfunction. Thyroid hormones TSH, T3, T4 as dermal infiltrate. These define pigment well as ATPOs were in normal limits. Also, there incontinence. Afterwards the epidermis appears was neither Addison’s disease nor Cushing’s to be normal, but more melanophores appear in syndrome, with ACTH being normal. the upper dermis. The histological aspects The UV test was negative, both immediate observed by us correspond to those described in reading and 24 hours. the speciality literature. Epicutan standard tests and environmental Ultrastructural studies show intra and antigen testing were performed. The patient was intercellular edema of keratinocytes and negative in all environmental antigen tests but multilateralisation of basal lamina, as well as the epicutaneous tests at 24 and 72 hours were migraine melanoma in the dermis (Fig. 4, Fig. 5). positive for mercapto mix, fragrance mix II and Corroborating all the aspects described, the potassium dichromate. The components in these diagnosis of Riehl melanosis triggered by contact mixes, like potassium dichromate, are used with detergents or their components is industrially in the manufacture of cleaning established and melasma is excluded as the main agents, detergents and cosmetics. diagnosis. These positive tests have greatly focused our Topical depigmented treatment is initiated, attention on awareness of detergents and / or applied oo the lesions presented. During cosmetics. Because the patient says she uses very hospitalization, there is a slight attenuation of the little cosmetics but uses various detergents and lesions. workplace cleaners daily, we tend to think of an The therapeutic indication is to definitely awareness of detergents or their components. avoid contact with substances that could trigger The objective exam identify a asthenic melanosis. The patient is also rigorously normoponderal patient with a TA of 110/80 instructed to use depigmenting and photo- mmHg, compensated hemodynamic and protective creams. Dermatocosmetic therapies respiratory. The ECG is in normal limits, as is the (laser, peeling, etc.) had no place to be indicated,

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Fig. 1. Facial hypergimentation, cleavage and arms Fig. 2. Facial grey-brown accentuated hyperpigmentation

Fig. 3. Spotted and diffuse pigmentation Fig. 4. Atrophic epidermis, hyperpigmentation of the basal layer. Derm - moderately inflamed and melanogenic pigment (4x col.HE)

reported strictly to the patient’s material condition, although it would probably have led to the improvement of the present hyper- pigmentation. In addition, these dermato- cosmetic therapies should have been carefully followed by the specialist to avoid some adverse effects such as exacerbation of pigmentation if the patient did not strictly follow the post-thera- peutic protocols of the procedures.

Discussions Skin pigmentation is a process that involves Fig. 5. Atrophy of the epidermis. Pigmentation of basal cell melanocyte melanogenesis, followed by the cells. derm - moderate lymphocytic infiltration, melanic transfer of melanosomes (containing melanin pigment disposed granular (10x col.HE) resulting from tyrosinase action) by cytokine

28 DermatoVenerol. (Buc.), 62: 25-33 mechanism to the neighboring keratinocytes. In phagocytized by leukocytes, it can circulate in humans pigmentation of the skin involves a the body. Thus, melanin due to the ability to double mechanism: 1) the production of pigment circulate through the body can influence cellular by melanocytes- Melanogenesis and 2) the metabolism. Starting with this premise, melanin distribution and transfer of the pigment to may even be considered a hormone [3]. surrounding epidermal keratinocytes. Each The skin’s color varies according to race and epidermal melanocyte is surrounded by a group ethnicity, as we mentioned above, being of keratiocytes, with which it maintains close determined by the melanosome characteristics functional contact, constituting the melanic unit. produced by melanocytes and then transferred to Although the number of melanic units varies neighboring keratinocytes (their number, shape, depending on the topographic cutaneous size, and way of organizing). In the white race, disposition in the various regions of the body, the melanosomes are small and are organized into number of keratinocytes in the melanic unit is membrane-adhering complexes containing three constant, around 36 [5,6]. or more keratinocytes, being degraded from the The main fact that is involved in the color of basal layer of the epidermis under the action of the skin is definitely the epidermal distribution of lysosomal enzymes, while in the black race or melanin and its quantity. Variation in the number, arboriens, the melanosomes are large, having 1 distribution and size of melanosomes, along with micrometer length, not organized into melanocytes and keratinocytes, determines aggregates, being intact in the stratum corneum. differences in race and ethnicity, relative to skin Melanin concentration in melanosomes in the color. basal layer of the epidermis is double in the black But it seems that along with melanin there is race. In addition, melanosome degradation, a mixture of biopolymers located in the basal along with keratinocytes, is slower in darker- layer of the epidermis, biopolymers synthesized haired races [6]. by melanocytes. It is known that melanin is Women are usually less pigmented than men. classified according to the chemical composition Pigmentation is non-homogeneous in different in eumelanin and feomelanin. It is also known areas of the body, with a variable distribution that darker-skinned individuals have more total depending on race (in the white race, the upper melanin and eumelanine is found in a higher portion of the thigh is the most pigmented and proportion than lighter skin [5]. the most hypopigmented lumbar area, while in Melanocytes form at the basal layer a the black race the abdomen is much more dendritic network that has the role of transferring pigmented than the lumbar region). melanosomes through cytoplasmic filaments In some breeds (Japanese or African- (more obvious to albinos and those with white Americans, there is a clear delimitation between and efelid skin) to the neighboring keratinocytes the shades of different anatomical regions (for [3,7]. The neighboring melanocyte-keratinocyte example, the lateral side of the arm (darker) and complex (averaging 36) is the melanic epidermal the medial (lighter)). Skin pigmentation is also unit with a structural and functional role, varying influenced by the geographic region, being more in different areas of the body. Melanocytes intense in people living in the tropics than those occupy a volume of 1.0-1.5 cm cubic, having a in the temperate zone. Hyperpigmentation offers higher density in the face and the genital area many advantages, such as protection against than in the chest[5,6]. Their number increases intense solar radiation, elimination of phototoxic after exposure to the sun and decreases with age, degraded cancer cells, protection against malaria decreasing by about 6-8% in every decade of life. or other parasites as well as malnutrition. There are also melanocytes that make a Melanin appears to have an important role in transfer of melanosomes from the perinuclear reducing free radicals by absorbing and diffusing area to dendrite and vice versa, they are called sunlight absorbed into the skin. As a melanophores. Melanin from melanosomes disadvantage, people with pigmented skin causes an increase in their electrons. It is absorb more heat in warmer climates and lose recirculated in the body. Because melanin is more heat than those with white skin in cold

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climates. Also, hyperpigmentation inhibits the Types of facial hyperpigmentation (adapted synthesis of vitamin D, thus favoring the after Vashi NA, Kundu RV. Facial hyper- development of rickets. pigmentation: causes and treatment. British Journal of Dermatology 2013, 169 (suppl. 3) pp 41-56) [2] Pathology of melanie disorders Melasma Symmetrical, centrofacial Pigmentation disorders occur through pigmentation, color variation from mechanisms that may involve: melanosomes in light brown to dark. Historic use of melanocyte melanosis of melanosomes, melano- anticonvulsants / pregnancy and exposure to sunlight somal secretion in keratinocytes or their transport at this level with or without their degradation. Ephelides Small, hyperpigmented round, oval macules, accentuated after exposure Three mechanisms appear to be involved in to the sun determining the skin’s color: Lentigines Well defined, round, oval or irregular a) cellular pigment can act as an lesions, tan to dark brown appearance independent executor and is stimulated to Hyperpigmentation A history of inflammation with act directly by light radiation; post inflammatory erythema and / or scales b) melanic pigment movement within the Maturity More frequent in black race, dark melanophore may be under nervous color of cheekbones and forehead to control; (maturational mature skin c) melanic pigment activity can be dyschromia) influenced by hormones. Periorbicular hyper- Hyperpigmentation around From here, the interesting idea that melanin pigmentation the eyes pigment acts itself as a hormone but at the same Melanoza Riehl Favored by contact with cosmetics, time is influenced by other hormones in the body brown-gray color, pruritus and [3]. erythema before pigmentation in the network, diffuse Melanogenesis is controlled by alpha MSH (melanocyte stimulating hormone alpha), having Brocq pigmented The variant of Riehl melanoma peribucal erythema triggered by cosmetics the proopiocortin precursor. Some endocrine disorders may be associated with hyper- Exogenous The use of hydroquinone ochronosis pigmentation (Addison syndrome, Nelson’s (exogenous syndrome) [7]. Also, estrogens can amplify skin ochronosis) pigmentation. Acantoza nigricans Symmetrical hyperpigmentation, soft Increasing the quantity of melanin in the neck and shoulder plates epidermis is expressed by the inconsistent Dermatosis Pigment papules in the cheekbones appearance of a brown color, whereas the papuloasa nigra and forehead accumulation of melanin in the dermis causes a Nevul Ota Congenital hyperpigmented, gray or blue color. Etiology of this pathology unilateral, black-blue congenital involves genetic, hormonal and environmental macula on the first branch of the factors (UV radiation and chemical factors). It can trigeminal be generalized (malignant melanoma with Nevul Hori Especially in Asian women, brown- metastases, including mucous), diffuse, localized gray or gray-blue macula, on the zygomatic area, rarely on forehead, (segmental) or circumscribed. Large pigment tample, eyelids, nose wing granules are observed in the skin of patients with Lichen plan Oval macules, irregular gray-brown lentigineosis, spilus nev and neurofibromatosis. pigment spots in sun-exposed areas Some white patients with diffuse hypermelanosis Eritema Gray, brownish-blue macules, in the may have unaggregated melanosomes within the discromicum inflammatory phase with keratinocytes, similar to those of the black race or perstans (erythema erythematous ring those treated with trimethylsoralen and subjected dyscromicum to UVA radiation. perstans)

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Lichen plan actinic The network is fine over the violet localization responding better to therapy than a (actinic lichen lesions, on exposed photo areas profound dermal localization of melanin. Also, planus) the concentration and vehicle of hydroxy- chloroquine is important in therapeutic success, Follicular Erythema, hyperpigmentative erythromelanosis follicular papules, fever and the hydroalcoholic solution is more effective of the face and neck association than cream [9]. In order to obtain results, the (erythromelanosis therapy should last for 4-12 months, with results folliculis faciei averaging about 6 weeks on average. The adverse et colli) reactions that occur (irritation, erythema, confeti- Post-chikungunya Small brownish-black macules or like , oc- nosis) are directly pigmentation slices in the central area of the face, dependent on the duration and concentration of history of fever, polyarthritis the product with hydroquinone. Pokilodermia Brown-brown macules, cross-linked Current topical therapies include the use of Civatte paternity, atrophy, telangiectasia retinoids, Kojic acid, azelaic acid, ascorbic acid (Vit C), soy extracts, niacinamide, mequinol (a hydroxychloroquine derivative), glycolic acid Treatment of melanosis [10,11]. Treatment still continues to be a challenge for The physical, dermatocosmetic therapies that melanosis. The treatment includes the elimi- can be used for melanos are laser therapy, nation of trigger factors when they are chemical peeling or dermabrasion but with great discovered, mandatory photoprotection, the care, among the frequent side effects, even the topical application of various formulations to accentuation of post-procedure hyperpigmen- ensure the depigmentation of the lesions, the tation [12]. decorative cosmetic to camouflage the pigmen- tation, if there is no major contraindication, as is Proposed Treatments for Facial Melanosis the case with Riehl’s melanosis [8]. (adapted after Damevska Katerina. New aspects of melasma. Serbian Journal of Dermatology and In the case of identifying the triggering agent, Venereology, 2014;6 (1):5-18) [5]). removing it results in a net improvement in hyperpigmentation. Re-exposure to the causative agent, however, leads to the recurrence of Phenolic hydroquinone components 4-hydroxyanisole (Mequinol) melanosis. This therapeutically method is the N acetyl 4 scistaminylphenol most convenient, with minimal costs for the Non-phenolic Azelaic acid success of the treatment of the condition [9]. components Topical retinoids Also, photoprotection is indicated in all cases Kojic acid of hyperpigmentation, as it is known that Ascorbic acid (Vit C) exposure to UV triggers/accentuates facial adapalene hyperpigmentation. Chemical Alpha hydroxy acids (AHA) Hydroquinone (1,4-dihydroxybenzene) was peeling Beta hydroxy acids (BHA) Jessner solution the gold standard for the treatment of facial Trichloroacetic acid hyperpigmentation. However, undesirable side Glycolic acid effects have made it banned in Europe. Hydro- Physical Intense pulse light quinone inhibits tyrosinase activity, thereby therapies lasers reducing the production of melanin by microdermabrasion melanosomes. It seems that even melanosome Plant extracts Arbutin, licorice extract, soy, green tea, destruction and even inhibition of AND oregonin, orchid extract, comoric acid, synthesis and RNA occurs. The hydroquinone gentisic acid, niacinamide, arbutin efficiency depends on the location of the melanin Others Indomethacin, mercury, ZnSO4, topical pigment, the more superficial epidermal corticoids, lignin peroxidase

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Conclusions The main trigger factor appears to be expo- sure to cosmetics or some ingredients in the Melanoses are hyperpigmentative skin detergent industry. Also, professional exposure disorders with incompletely elucidated etiology, but with many trigger factors: solar radiation, to cleaning products and bituminous derivatives food deficiency, environmental and occupational and tar seems very likely to trigger melanosis. factors. However, other factors, including food, may be Riehl melanosis is also called cosmetic involved, as cases of Riehl melanosis are noted in pigment dermatitis or facial melanosis of women. children and people who have denied any Little is known in the literature about this contact with cosmetics, tar or detergents. Where condition. It seems to be more common in there is contact with a trigger agent, its removal women than there are men affected. Initially, it and interruption of exposure to the allergen led appears to have been described in Vienna during to the improvement of melanosis, after a slow the First World War, when the incriminating evolution, for several months. trigger factor was its coal and derivatives, and Wherever possible, the patches of incriminat- women were affected because the situation ing agents, cosmetics, detergents, specific required them to handle the procurement and personal use products used by the patient, tend handling of coal. Nowadays, Affection occurs to orientate the diagnosis relatively easily. Even almost exclusively in women aged 30-50 years. It photopatch can be considered as a diagnostic test. often debuts suddenly in the form of an erythema Suspected allergen challenge tests or repeated accompanied by pruritus, which is then followed applications with the incriminated agent can be by pigmentation in a brown-gray network, in many cases pigmentation being the only used to clearly identify the etiology of hyper- manifestation of the disease. pigmentation. Evolution of the disease is extended for many Riehl melanosis is not very common and the years and it is recommended to avoid sun trigger agent’s detection remains a challenge. exposure as well as the application of photo- At the same time treatment is difficult, with sensitising substances, the mandatory appli- aesthetic results inconsistent, with high costs in cation of SPF 50 photoprotective cream. many cases.

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Conflict of interest NONE DECLARED

Correspondance address: Monica Costescu [email protected], Dermatology Department, “Carol Davila” University of Medicine and Pharmacy, “Victor Babeº” Clinical Hospital, Bucharest

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