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Chemical leukoderma induced by colored strings

2009; Elsevier BV; Volume: 61; Issue: 5 Linguagem: Inglês

10.1016/j.jaad.2009.01.016

1097-6787

Sudip Kumar Ghosh, Debabrata Bandyopadhyay,

Acne and Rosacea Treatments and Effects

To the Editor: In India, it is a fairly common cultural and religious practice to wear colored strings with or without various forms of amulets round the neck, arms, or waist. We report a case series of 11 patients from eastern India who developed linear leukoderma at the sites of contact with these strings.We evaluated 11 consecutive patients with linear leukoderma associated with wearing colored strings who presented to the dermatology clinic of a tertiary care hospital over a 2-year period. None of the patients had a personal or family history of vitiligo. There was no history of symptoms, such as itching, redness, or any other lesions at the sites of depigmentation in any of the patients. No signs of inflammation or any change in texture of the skin was noticed at the sites of the pigmentary changes. There were eight men and three women. Six patients were under 2 years of age. Most (6 patients) of the lesions were located over the waist (Fig 1) followed by the neck (3), groin (2), buttocks (2), and chest (1). Depigmentation in remote areas of the body (back) was noticed in only one patient. The strings were either black (7 strings) or red (5 strings) in color. One patient had worn multiple strings. The mean duration of lesions in our patients was 9.9 months. Some of our patients had metallic (3), plastic (1), or wooden (1) amulets attached to the strings. Confetti macules around the lesions were noticed in five patients. Chemical analysis of the strings was not done, but personal communications with several manufacturers revealed that paraphenylenediamine (PPD) and Congo red were used in dying the black and red strings, respectively. Patch tests were done in six patients using the Indian standard battery of allergens, but none of them had positive patch test reaction at 48 or 72 hours. One of the patients showed depigmentation at the site of PPD testing at 1-month of follow-up. In the remainder of the patients, we could not perform patch tests, because the patients or their parents did not give consent for the same, for fear of developing depigmentation at the patch test sites.Chemical leukoderma (CL) refers to an acquired vitiligo-like depigmentation induced by exposure to specific chemical compounds. Depigmented areas may continue to appear even after discontinuation of contact with the suspected chemicals. Repigmentation may or may not occur despite discontinuation of the offending agents and treatment. CL is often difficult to distinguish from idiopathic vitiligo. Although depigmentation may occur at remote sites, CL is generally restricted to the sites of contact and usually spreads by the coalescence of small macules.1Lapeere H. Boone B. Schepper S.D. Verhaeghe E. Ongenae K. Geel N.V. et al.Hypomelanosis and hypermelanosis.in: Wolf K. Goldsmith L.A. Katz S.I. Gilchrest B.A. Paller A.S. Leffell D.J. Fitzpatrick's dermatology in general medicine. 7th ed. McGraw Hill, New York2008: 622-640Google Scholar Confetti macules, thought to be an important marker of CL, were found in five (45.45%) of our patients. CL to strings may be suspected from their distinctive linear patterns without any signs of inflammation, occurring along the line of contact with the strings.2Banerjee K. Banerjee R. Mandal B. Amulet string contact leukoderma and its differentiation from vitiligo.Indian J Dermatol Venereol Leprol. 2004; 70: 180-181PubMed Google Scholar In developed countries, CL is mostly an industrial hazard. In developing countries, such as India, this has mainly been reported to occur from exposure to consumer products. The strings may contain a variety of chemicals, such as dyes and chemical additives such as formaldehyde. PPD or azo dyes, which are well known causes of CL,3Bajaj A.K. Pandey R.K. Misra K. Chatterji A.K. Tiwari A. Basu S. Contact depigmentation caused by an azo dye in alta.Contact Dermatitis. 1998; 38: 189-193Crossref PubMed Scopus (29) Google Scholar are important constituents of the dyeing agents used in the manufacture of black and red strings, respectively. CL may occur at patch test sites, and patch test results may not always be positive in cases of CL. We speculate that the combined effects of the chemical agents and friction with the strings might have been responsible for causing the linear patterns of depigmentation in our patients. To the Editor: In India, it is a fairly common cultural and religious practice to wear colored strings with or without various forms of amulets round the neck, arms, or waist. We report a case series of 11 patients from eastern India who developed linear leukoderma at the sites of contact with these strings. We evaluated 11 consecutive patients with linear leukoderma associated with wearing colored strings who presented to the dermatology clinic of a tertiary care hospital over a 2-year period. None of the patients had a personal or family history of vitiligo. There was no history of symptoms, such as itching, redness, or any other lesions at the sites of depigmentation in any of the patients. No signs of inflammation or any change in texture of the skin was noticed at the sites of the pigmentary changes. There were eight men and three women. Six patients were under 2 years of age. Most (6 patients) of the lesions were located over the waist (Fig 1) followed by the neck (3), groin (2), buttocks (2), and chest (1). Depigmentation in remote areas of the body (back) was noticed in only one patient. The strings were either black (7 strings) or red (5 strings) in color. One patient had worn multiple strings. The mean duration of lesions in our patients was 9.9 months. Some of our patients had metallic (3), plastic (1), or wooden (1) amulets attached to the strings. Confetti macules around the lesions were noticed in five patients. Chemical analysis of the strings was not done, but personal communications with several manufacturers revealed that paraphenylenediamine (PPD) and Congo red were used in dying the black and red strings, respectively. Patch tests were done in six patients using the Indian standard battery of allergens, but none of them had positive patch test reaction at 48 or 72 hours. One of the patients showed depigmentation at the site of PPD testing at 1-month of follow-up. In the remainder of the patients, we could not perform patch tests, because the patients or their parents did not give consent for the same, for fear of developing depigmentation at the patch test sites. Chemical leukoderma (CL) refers to an acquired vitiligo-like depigmentation induced by exposure to specific chemical compounds. Depigmented areas may continue to appear even after discontinuation of contact with the suspected chemicals. Repigmentation may or may not occur despite discontinuation of the offending agents and treatment. CL is often difficult to distinguish from idiopathic vitiligo. Although depigmentation may occur at remote sites, CL is generally restricted to the sites of contact and usually spreads by the coalescence of small macules.1Lapeere H. Boone B. Schepper S.D. Verhaeghe E. Ongenae K. Geel N.V. et al.Hypomelanosis and hypermelanosis.in: Wolf K. Goldsmith L.A. Katz S.I. Gilchrest B.A. Paller A.S. Leffell D.J. Fitzpatrick's dermatology in general medicine. 7th ed. McGraw Hill, New York2008: 622-640Google Scholar Confetti macules, thought to be an important marker of CL, were found in five (45.45%) of our patients. CL to strings may be suspected from their distinctive linear patterns without any signs of inflammation, occurring along the line of contact with the strings.2Banerjee K. Banerjee R. Mandal B. Amulet string contact leukoderma and its differentiation from vitiligo.Indian J Dermatol Venereol Leprol. 2004; 70: 180-181PubMed Google Scholar In developed countries, CL is mostly an industrial hazard. In developing countries, such as India, this has mainly been reported to occur from exposure to consumer products. The strings may contain a variety of chemicals, such as dyes and chemical additives such as formaldehyde. PPD or azo dyes, which are well known causes of CL,3Bajaj A.K. Pandey R.K. Misra K. Chatterji A.K. Tiwari A. Basu S. Contact depigmentation caused by an azo dye in alta.Contact Dermatitis. 1998; 38: 189-193Crossref PubMed Scopus (29) Google Scholar are important constituents of the dyeing agents used in the manufacture of black and red strings, respectively. CL may occur at patch test sites, and patch test results may not always be positive in cases of CL. We speculate that the combined effects of the chemical agents and friction with the strings might have been responsible for causing the linear patterns of depigmentation in our patients.