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KMID : 0363220150530020173
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Korean Journal of Dermatology
2015 Volume.53 No. 2 p.173 ~ p.175
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Pigmented Contact Dermatitis Caused by Hydroquinone: An Unusual Presentation and Allergen
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Jung Joon-Min
Han Ji-Su
Won Chong-Hyun
Chang Sung-Eun
Lee Mi-Woo
Choi Jee-Ho
Moon Kee-Chan
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Abstract
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Sir, Hydroquinone, which is a hydroxyphenolic chemical, has been the gold standard for the treatment of hyperpigmentation for over 50 years. Hydroquinone is generally considered a safe agent, but it can cause irritant and allergic contact dermatitis, and while some case reports describe contact dermatitis caused by hydroquinone1, none of these have described a pigmented type of contact dermatitis. Here, we report the first case of pigmented contact dermatitis caused by hydroquinone. A 59-year-old woman who had melasma on her face was treated topically with a 4% hydroquinone cream. After applying the cream once-a-day for 2 weeks, an itchy erythema developed on the treated area, then symmetrical and well demarcated hyperpigmentation progressively appeared on the whole face (Fig. 1A, B). A biopsy showed pigmentary incontinence and subacute lichenoiddermatitis with a perivascular lymphocytic infiltration (Fig. 1C). Laboratory tests that included a complete blood count, the serum zinc level, the blood chemistry, the antinuclear antibody titer, the thyroid-stimulating hormone level, the free thyroxine level, the adrenocorticotropic hormone level, the cortisol level, and the total immunoglobulin (Ig) E level revealed no abnormalities, except that the total IgE level was elevated to 1,050 IU/mL (reference range 0∼120 IU/mL). Patch tests were performed using the cosmetic series and the patient’s own product. Patch-test readings were performed on days 2 and 4 according to the International Contact Dermatitis Research Group guidelines. The patch tests showed positive reactions to octyl gallate (＋), bronopol (＋), cocamidopropyl betaine (＋), and her own product (＋), which contained 4% hydroquinone, on days 2 and 4 (Fig. 2A). The patient was asked to avoid the 4%hydroquinone cream and to only use moisturizing cream that did not contain any of the ingredients that showed positive patch-test reactions. She was also asked to take tranexamic acid and oral antihistamine for a while. Five months after she had stopped using the cream, she reported the partial clearance of her facial pigmentation (Fig. 2B). Although her own product also contained squalane (1 mg/g), L-ascorbic acid, 6-palmitate (5 mg/g), and tocopherol acetate (2 mg/g), the concentrations of these components were much lower than that of the hydroquinone, and given that there had been no reports of these components causing contact dermatitis, it was much less likely that they would cause contact dermatitis in this case. Pigmented contact dermatitis was first reported byOsmundsen in Denmark in 1969, who described an epidemic of melanosis in Copenhagen2. While the same mechanism underlies pigmented cosmetic dermatitis and pigmented contact dermatitis, the causative allergens are quite different, and a number of cosmetic allergens are involved in pigmented cosmetic dermatitis. Patch testing using the cosmetic series of allergens is recommended, and the continual and exclusive use of allergen-controlled cosmetics and soaps cures the disease3. Exogenous ochronosis associated with the use of hydroquinone has been reported in dark-skinned patients, particularly in South African women who frequently use very high concentrations of hydroquinone on large areas of skin4. A case of exogenous ochronosis with allergic contact dermatitisas a consequence of hydroquinone use has been reported5. We performed a skin biopsy on the current case to exclude exogenous ochronosis, and the results were consistent with pigmented contact dermatitis. To the best of our knowledge, pigmented contact dermatitis because of hydroquinone use has not been described previously. The findings presented in this important first report show that it is necessary for dermatologists to recognize the role of cosmetic allergens in the development of hyperpigmentation.
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KEYWORD
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Hydroquinone , Pigmented contact dermatitis , Hyperpigmentation
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