Contact leukoderma due to cosmetic products

What is contact leukoderma?

Contact leukoderma is the loss of skin colour (hence white skin) following contact with a chemical known to kill the skin pigment cells (melanocytes). It is usually due to chemicals experienced in the workplace, but it can also follow use of cosmetic products. It is also known as chemical leukoderma and may be spelt leucoderma.

Who gets contact leukoderma from cosmetics and why?

Contact leukoderma due to cosmetics occurs most commonly in females.

Contact leukoderma may develop in the setting of pre-existing idiopathic vitiligo, suggesting a genetic predisposition. Liver and thyroid disease have been reported in some patients. However in the majority of patients there is neither a personal nor family history of vitiligo or other autoimmune disease.

The most common cause of contact leukoderma from cosmetics is para-phenylene diamine (PPD) in hair dyes. The hair dye may have been used by the patient or applied to someone else. As PPD can also be found in black socks and footwear, the leukoderma may also affect the feet. Sensitization to PPD may have followed the application of a temporary blakc henna tattoo, also leaving a white mark.

Contact leukoderma has been reported with the use of face cosmetics:

• Lipsticks
• Lipliner
• Eyeliners

and is due to the azo dyes present in these products.

Contact leukoderma can be caused by para-tertiary butyl phenol (PTBP) in deodorants and spray-on perfumes.

A series of cases followed the use of skin lightening cream containing monobenzyl ether of hydroquinone on the hands. Monobenzyl ether of hydroquinone has also been deliberately applied to pigmented areas to reduce the unsightliness of extensive vitiligo.

In addition it has been reported with cultural practices, particularly in India, related to the use of alta, a red dye painted on the feet, and bindi, the coloured spot applied to the forehead. The specific azo dye identified in alta was solvent yellow 3. The chemical associated with bindi leukoderma is PTBP in the adhesive.

Clinical features

Contact leukoderma presents as a white patch(es) of skin, initially at the site(s) of application but can spread beyond the area of known contact in approximately one quarter of patients. A single lesion occurs in approximately one third of patients; multiple patches are more common.

Contact leukoderma is never present at birth.

Contact leukoderma due to cosmetics occurs most frequently on the face. The eyelids are particularly involved. Contact leukoderma due to hair dyes applied to the patient usually affects the hair margin rather than the scalp skin.

Typically there are small confetti-sized flat spots of white skin with a sharply defined margin seen under magnification. The skin is not scaly.

Wood light examination shows an accentuation of the pigment loss although this is not always as clear as in vitiligo.

Preceding contact allergic dermatitis does not occur in the majority of cases. However itch is reported more commonly with contact leukoderma than with vitiligo.

How is contact leukoderma diagnosed?

Contact leukoderma must be distinguished from vitiligo. But both show the same features on histology of a skin biopsy with loss of melanocytes and melanin.

Suggested diagnostic criteria for contact leukoderma are three of the four following (Ghosh S, Mukhopadhyay S. 2009):

• Acquired vitiligo-like depigmented lesions
• History of repeated exposure to specific chemicals
• Pattern of flat vitiligo-like macules at the site of exposure to the chemical
• Confetti macules

Patch testing with the cosmetic product and the specific allergen may result in new patches of contact leukoderma and so is not usually performed.

Treatment

Avoidance of the cosmetic product results in the recovery of skin colour in the majority of cases, particularly if there was no history of pre-existing vitiligo. However, further extension of the leukoderma has been reported despite strict avoidance of the chemical and this may indicate a genetic tendency to vitiligo. Topical and systemic corticosteroids have been reported to speed recovery of skin colour.

Draft 4 November 2010