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Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 297-299  

Dermoscopy negates the need for biopsy in cases of confetti-like leukoderma and exogenous ochronosis

Department of Dermatology and Venereology, Universitas Indonesia/Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

Date of Web Publication20-Jun-2018

Correspondence Address:
Nahla Shihab
Jl. Diponegoro No 71 Salemba, Jakarta Pusat, DKI Jakarta 10430
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsbm.JNSBM_205_17

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Confetti-like leukoderma and exogenous ochronosis are two of the rarest side effects of a long-term use of hydroquinone (HQ). HQ is the first choice of topical bleaching agents used in the treatment of melasma. Confetti-like leukoderma is characterized as mottled depigmented spots, whereas exogenous ochronosis presents as gray-brown or blue-black hyperpigmentation. Both disorders are especially found in the area where HQ is applied. We report two cases of women with these two rare pigment disorders, who had a history of using HQ for more than 8 years. The dermoscopic examinations show dark-brown globular-like structures on a diffuse fine brown reticular patterns background, multiple guttate depigmented macules, and prominent telangiectasias which are characteristics for melasma, ochronosis, and confetti-like leukoderma. Both patients were advised to stop HQ and treated with sunscreen, 0.05% retinoic acid cream, 2% kojic acid cream, and 20%–35% glycolic acid chemical peel.

Keywords: Confetti-like leukoderma, dermoscopy, hydroquinone, ochronosis

How to cite this article:
Shihab N, Suseno LS, Legiawati L, Simbolon Sitohang IB. Dermoscopy negates the need for biopsy in cases of confetti-like leukoderma and exogenous ochronosis. J Nat Sc Biol Med 2018;9:297-9

How to cite this URL:
Shihab N, Suseno LS, Legiawati L, Simbolon Sitohang IB. Dermoscopy negates the need for biopsy in cases of confetti-like leukoderma and exogenous ochronosis. J Nat Sc Biol Med [serial online] 2018 [cited 2021 Feb 27];9:297-9. Available from:

   Introduction Top

Hydroquinone (HQ) is the most common topical whitening agent used in Indonesia. It is widely available over the counter with varied concentration ranging from 2% to 6%. The most common adverse effects of HQ are irritant dermatitis, contact dermatitis, postinflammatory pigmentation, and nail bleaching.[1] Confetti-like leukoderma and exogenous ochronosis are two of the rarest side effects of HQ.[2],[3] Confetti-like leukoderma is characterized by mottled depigmented spots that develop on the macules of melasma,[4] while exogenous ochronosis manifests clinically as gray-brown or blue-black hyperpigmentation.[5] Both disorders have a characteristic dermoscopic appearance.[6]

   Case Report Top

We report two cases of a skin Type IV Indonesian woman presented with dark and white patches on the face. They were both on their 60s, generally in good health, not taking any medication, had an indoor occupation, and no personal or family history of other pigmentation disorders. In previous years, both women had used hormonal contraception, which was promoted by the government through the National Family Planning Program. They had a history of using 4% HQ cream for more than 8 years to treat their melasma, with no history of procedural treatment. They initially saw appreciable improvement of the melasma with topical HQ. However, after several years, they noticed darkening spots on their cheeks, which triggered them to use the HQ more vigorously. They slowly noted white spots forming on the dark patches.

On physical examination, there were confetti-sized depigmented macules, and black-to-bluish macules overlap the dark-brown hyperpigmented macules, with prominent erythematous cheeks [Figure 1] and [Figure 2]. There were no other areas of hyperpigmentation and depigmentation found on a complete physical examination. Both patients refused to perform a biopsy. Dermoscopic examinations showed prominent telangiectasias, dark-brown globular-like structures on a diffuse fine brown reticular patterns background, and multiple guttate depigmented macules, which are characteristics for melasma, ochronosis, and confetti-like leukoderma [Figure 3] and [Figure 4]. Both patients were advised to stop using HQ and treated with sunscreen, 0.05% retinoic acid cream, 2% kojic acid cream, and 20%–35% glycolic acid chemical peels for every 2 weeks.
Figure 1: Multiple whitish macules covering the dark-brownish hyperpigmented macules on both cheeks with prominent erythematous cheeks

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Figure 2: Brown to grayish macules and small depigmented macules on both cheeks

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Figure 3: Dermoscopy features of confetti-like depigmentation, some fine brown reticular patterns, and a rough dark globular pattern with prominent telangiectasia

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Figure 4: Dermoscopy: fine brown reticular pattern with dark brown globules, confetti-like leukoderma, and telangiectasia

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   Discussion Top

Melasma is a common acquired symmetrical hyperpigmentation disorder caused by increased melanin production by melanocytes, found on sun-exposed areas.[2] The main treatments for melasma are sun protection, avoidance of predisposing factors, and the use of depigmenting agents.[1] HQ is considered the gold standard depigmenting agent for melasma, that works by blocking the conversion of dihydroxyphenylalanine to melanin, as well as blocking DNA and RNA synthesis leading to melanosome degradation and melanocyte destruction.[7] HQ is widely available over the counter in Indonesia. Long-term use of HQ may cause severe and cosmetically disfiguring pigmentation disorder, such as confetti-like leukoderma and exogenous ochronosis.[2],[3]

Confetti-like leukoderma is a part of chemical leukoderma, which indicates an acquired hypopigmented dermatosis induced by repeated exposure to specific chemical compounds.[8]

In our case, HQ caused injury to melanocytes in our patients, which most likely have specific genetic susceptibility.[9] Delayed onset of leukoderma is a well-recognized effect of monobenzone, the monobenzyl ether form of HQ, but it is an unwanted effect of HQ. In 2014, Jow and Hantash published two cases of HQ-induced depigmentation and reviewed 8 other similar cases with documented exposures of HQ ranged from weeks to 9 months.[10] Confetti-like leukoderma lacks of definitive diagnostic features. Histopathologically, it is difficult to differentiate it from vitiligo. Both have a low number or even a total absence of melanocytes in epidermis. Nonetheless, confetti-like leukoderma can be easily diagnosed clinically by a history of repeated exposure to a known or suspected depigmenting agent and its distribution that are corresponding to the chemical exposure.[11] The findings of numerous confetti or pea-sized depigmented macules are characteristic of chemical leukoderma.[8] With the help of dermoscopy, this features of confetti-sized depigmented macules are more easily recognized.

Exogenous ochronosis is an uncommon disorder characterized by a blue-black or gray-blue pigmentation, caused by a long-term application of skin-lightening creams containing HQ.[12] The cause of exogenous ochronosis is unknown. One of the most acceptable hypotheses was put forth by Penneys which stated that HQ inhibits the enzyme homogentisic oxidase which leads to local accumulation of homogentisic acid that polymerizes to form typical ochronotic pigment in the papillary dermis.[13] Genetic predisposition is also considered to have a role.[14] The pathognomonic histopathological feature of exogenous ochronosis is the brownish-yellow or ochre-colored, banana-shaped fibers in the papillary dermis, known as the ochre bodies.[5],[6],[14] However, many patients reluctant to have biopsy on their faces, like these two women. This is where dermoscopy can be really helpful, where such a characteristic feature of dark-brown globules and globular-like structures on a diffuse brown background can be seen. In contrast, melasma will show a fine brown reticular pattern on a background of a faint light brown.[6],[12] The findings of coarse texture of the skin, telangiectasia, and speckled or reticulated hyperchromia should alert dermatologist about exogenous ochronosis.[15]

The treatment of these two pigmentations can potentially be really challenging. Although a lot of modalities of treatments are now available, the results are often still far from satisfying. The most important treatment is to stop further use of HQ. Physical and chemical sunscreens, topical retinoid acid, glycolic acid, and a low-potency corticosteroid cream used judiciously often lead to considerable improvement of both pigmentations. Procedural treatments need to be done cautiously, especially in darker skin type, to avoid further hypo- and hyper-pigmentation.[12],[16]

   Conclusion Top

Confetti-like leukoderma and exogenous ochronosis can be diagnosed with a thorough history taking, clinical examination, and biopsy to provide histopathologic evaluation. Dermoscopy may negate the need for biopsy, which is much appreciated by cosmetic patients. Early diagnosis and discontinuation of the offending agent are the principal treatments.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Rendon M, Berneburg M, Arellano I, Picardo M. Treatment of melasma. J Am Acad Dermatol 2006;54:S272-81.  Back to cited text no. 1
Goldstein BG, Goldstein AO, Callender V. Melasma. UpToDate; 2017. Available from: https://www. [Last updated on 2017 Jun 13].  Back to cited text no. 2
Lartey M, Krampa FD, Abdul-Rahman M, Quarcoo NL, Yamson P, Hagan PG, et al. Use of skin-lightening products among selected urban communities in Accra, Ghana. Int J Dermatol 2017;56:32-9.  Back to cited text no. 3
Ennes SB, Paschoalick RC. A double-blind, comparative, placebo-controlled study of the efficacy and tolerability of 4% hydroquinone as a depigmenting agent in melasma. J Dermatol Treat 2000;11:173-9.  Back to cited text no. 4
Martins VM, Sousa AR, Portela Nde C, Tigre CA, Gonçalves LM, Castro Filho RJ, et al. Exogenous ochronosis: Case report and literature review. An Bras Dermatol 2012;87:633-6.  Back to cited text no. 5
Charlín R, Barcaui CB, Kac BK, Soares DB, Rabello-Fonseca R, Azulay-Abulafia L, et al. Hydroquinone-induced exogenous ochronosis: A report of four cases and usefulness of dermoscopy. Int J Dermatol 2008;47:19-23.  Back to cited text no. 6
Bandyopadhyay D. Topical treatment of melasma. Indian J Dermatol 2009;54:303-9.  Back to cited text no. 7
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Ghosh S, Mukhopadhyay S. Chemical leucoderma: A clinico-aetiological study of 864 cases in the perspective of a developing country. Br J Dermatol 2009;160:40-7.  Back to cited text no. 8
Boissy RE, Manga P. On the etiology of contact/occupational vitiligo. Pigment Cell Res 2004;17:208-14.  Back to cited text no. 9
Jow T, Hantash BM. Hydroquinone-induced depigmentation: Case report and review of the literature. Dermatitis 2014;25:e1-5.  Back to cited text no. 10
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Penneys NS. Ochronosislike pigmentation from hydroquinone bleaching creams. Arch Dermatol 1985;121:1239-40.  Back to cited text no. 13
Nagler A, Hale CS, Meehan SA, Leger M. Exogenous ochronosis. Dermatol Online J 2015;20:e1-5.  Back to cited text no. 14
Khunger N, Kandhari R. Dermoscopic criteria for differentiating exogenous ochronosis from melasma. Indian J Dermatol Venereol Leprol 2013;79:819-21.  Back to cited text no. 15
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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