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IJD SYMPOSIUM
Year : 2010  |  Volume : 55  |  Issue : 3  |  Page : 255-258
Chemical leukoderma: What's new on etiopathological and clinical aspects?


Department of Dermatology, Venereology and Leprology, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India

Date of Web Publication25-Sep-2010

Correspondence Address:
Sanjay Ghosh
27/2 C Bakultala Lane, Kasba, Kolkata 700042, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.70680

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   Abstract 

Chemical leukoderma denotes an acquired hypopigmentation caused by repeated exposure to specific chemical compounds simulating clinically idiopathic vitiligo. The ailment has been increasing in developing countries like India in recent years. Etiologically, a lot of chemicals, especially phenolic group, have been identified in various countries including India. The term, "chemical leukoderma syndrome" has been described to encompass all the various manifestations of chemical leukoderma. Clinical diagnostic criteria have been proposed to diagnose chemical leukoderma clinically more confidently.


Keywords: Chemical leukoderma, contact leukoderma, occupational leukoderma, vitiligo


How to cite this article:
Ghosh S. Chemical leukoderma: What's new on etiopathological and clinical aspects?. Indian J Dermatol 2010;55:255-8

How to cite this URL:
Ghosh S. Chemical leukoderma: What's new on etiopathological and clinical aspects?. Indian J Dermatol [serial online] 2010 [cited 2020 Apr 8];55:255-8. Available from: http://www.e-ijd.org/text.asp?2010/55/3/255/70680



   Introduction Top


Chemical leukoderma represents an acquired vitiligo-like hypomelanosis induced by repeated exposure to specific chemical compounds. This chemical effect, independent of their sensitizing potential, is distinctly separate from post-inflammatory depigmentation and Koebner in vitiligo. [1]

Chemical leukoderma is also designated as contact leukoderma or occupational leukoderma. Chemical leukoderma has been reported from many countries of the world, developing as well as developed, induced probably by "globalization processes."

Chemical leukoderma remains an under-diagnosed common condition often inducing clinical dilemma with idiopathic vitiligo in dermatological practice. This ailment has been increasing rapidly in incidence in recent decades in developing countries like India. [2]


   Etiological Aspects Top


The contributory chemicals are mostly aromatic or aliphatic derivatives of phenols and catechols. [3] Other responsible toxins are sulfhydryls, cinnamic aldehyde, p-phenylenediamine, mercurials, arsenics, azelaic acid, corticosteroids, tretinoin, otic preparations such as eserine and thiotepa as well as systemic medications such as chloroquine and fluphenazine (prolixin). [1],[3],[4] However, these chemicals are lethal for melanocytes only in persons having specific inherent susceptibility. [2],[3]

Oliver et al. in 1939 [5] first identified chemical leukoderma in a leather manufacturing company in workers who used "acid-cured" rubber gloves. Monobenzylether of hydroquinone (MBH), an antioxidant used in the rubber industry, was the culprit agent. In later decades, several reports of occupational leukoderma caused by phenolic compounds were published from various countries. [6] Para-tertiary butylphenol (PTBP) and p-tertiary octylphenol (PTOP) were reported offending chemicals from Japan, [7] whereas from Russia PTBP and p-tertiary butylphenolformaldehyde (PTBPF) resins were reported. [8] Occupational depigmentation in tappet assembly workers exposed to p-tertiary butylcatechol (PTBC) was mentioned by Gellin et al. [9] Depigmentation from certain phenolic detergent germicides such as PTBP and p-tertiary amylphenol (PTAP) was reported by Kahn. [10] Vitiligo caused by PTBP and homologues has been reported by Malten et al. [11] Chemical leukoderma from semipermanent and permanent hair colors and rinses was first published in 1993 by Taylor et al. [12] Offending chemicals were para-phenylenediamine (PPD) and benzyl alcohol. From India, chemical leukoderma was first reported by Pandhi and Kumar [13] induced by adhesive "bindi" (decorative color used on the forehead by Asian females) and "footwear." [13] Bajaj et al. were the first to report chemical leukoderma from free PTBP in "bindi" adhesive, [14] from MBH in synthetic wallets causing depigmentation of the breast from the habit of keeping wallets inside blouses, [15] from MBH causing footwear depigmentation, [16] from PPD in hair dye, [17] from azo dye in "alta" (a decorative color used by Asian females on their feet) [18] and from solvent yellow 3, an azo dye, used in "alta," and other domestic objects such as watch straps, spectacles, and hearing aids. [19]

Common offending agents responsible for chemical leukoderma are shown in [Table 1]. In a recent Indian publication etiological agents for chemical leukoderma identified were hair dye 27.4% (21% self-use; 6.4% not self-use), deodorant and spray perfume 21.6%, detergent and cleansers 15.4%, adhesive bindi 12%, rubber chappal 9.4%, black socks and shoes 9.1%, eyeliner 8.2%, lipliner 4.8%, rubber condoms 3.5%, lipstick 3.3%, fur toys 3.1%, toothpaste 1.9%, insecticides 1.7%, "alta" 1.2%, and amulet string color 0.9%. [2]
Table 1: Chemical leukoderma: contributory chemicals

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In contrast to the western literature, in the above study, household chemical exposure was a much more common inducing agent than occupational chemical exposure. Nontechnical or nonindustrial occupations had more involvement than those in technical or industrial occupations. The probable reasons for these discrepancies of data between developed and developing countries could be: (1) lack of quality control in consumer products in developing countries (cheaper ingredients to compete in market even by multinational companies), (2) lack of reporting from industrial set up: (a) from owner's view: fear of compensation, (b) from worker's view: fear of loosing job, (c) from doctor's view: lack of awareness, and (3) lack of industrialization.


   Etiopathogenesis Top


Predisposing factors for the development of chemical leukoderma predominantly constitutes genetic factors which render the melanocytes more fragile. Precipitating factors, which in comparison to idiopathic vitiligo are evident in chemical leukoderma, initiate programmed cell death, or apoptosis of melanocytes [Table 2]. [3]
Table 2: Precipitating factors: Chemical leukoderma and vitiligo compared

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Tyrosinase-related protein-1 (Tyrp1), by catalytic conversion of chemicals, produces radical oxygen species. This oxidative stress triggers activation of cellular free-radical scavenging pathway to prevent cell death. Genetic inability of melanocytes to tolerate and/or respond to oxidative stress may underlie etiology of chemical leukoderma. [4]

Elevated tumor necrosis factor related apoptosis-inducing ligands (TRAIL) death receptor expression and heat shock protein (HSP) play important role in onset of chemical leukoderma and later its generalization by systemic auto-immunity. Melanocyte exposed to 4-tertiary butyl phenol (TBP) induces elevated TRAIL expression. TRAIL expression is strongly positive even in peri-leukoderma skin.

Dendritic cells (DC) effector functions also take pivotal role in spreading of leukoderma. Stressed melanocytes mediate DC inactivation by releasing heat shock protein (HSP70). DC function is partially inhibited by antibody to TRAIL [Figure 1]. [20]
Figure 1: Pathogenesis of chemical leukoderma: elevated TRAIL and HSP[20]

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   Clinical Features Top


Chemical leukoderma should be considered in the differential diagnosis of every case of idiopathic vitiligo or leukomelanoderma. Chemical leukoderma develops not only at the site of chemical contact, but also remotely. The mechanism responsible for this distant spread of the disease could be: (i) sensitization, [21] (ii) autotransfer, or heterotransfer of the chemical from patients themselves and people close to them.

Chemical leukoderma, such as vitiligo, lacks definitive diagnostic features. Clinico-histopathologically, no absolute criteria can differentiate chemical leukoderma from vitiligo. However, chemical leukoderma can be diagnosed clinically by a history of repeated exposure to a known or suspected depigmenting agent at the primary site, distribution of macules corresponding to chemical exposure, and the presence of numerous acquired confetti or pea-sized macules [Table 3]. [21]
Table 3: Chemical leukoderma: Clinical comparison with vitiligo (Mosher[21] and Ortonne[1])

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Chemical leukoderma can be differentiated from post-inflammatory leukoderma by the clinical features of the latter: (1) primary rash always limited to the original area and (2) no confetti or remote macules. [21] Similarly, chemical leukoderma can be compared with "Koebner in vitiligo" by the following features in the latter: (1) history of single chemical exposure or trauma, (2) usually linear, and (3) pre-existing vitiligo. [21]

All age groups from pediatric to geriatric including neonates may be affected by chemical leukoderma. Although adults have a much higher incidence of chemical leukoderma, a considerable number of children below the age of 12 years may also be affected, which has not been reported much in the western literature. This may indicate that exposure to household objects rather than to industrial chemicals has caused an important role in the pathogenesis of chemical leukoderma in Indian patients. Females suffered more than males probably due to more exposure to offending household objects and more offering of treatment due to the prevalent social stigma regarding vitiligo and any other depigmenting skin diseases in Asian countries. [2]

The presence of numerous acquired confetti or pea-sized macules is characteristic, although not diagnostic, of chemical leukoderma. In an Indian study, a considerable number of patients (88.4%) showed confetti macules, which thus represents an important diagnostic clue for chemical leukoderma. [2]

Contact dermatitis is not a prerequisite for the development of chemical leukoderma. [21] However, in some cases of concurrent contact dermatitis and chemical leukoderma the same offending chemical may cause contact dermatitis as well as chemical leukoderma in some patients but by a different pathomechanism.

The face and scalp were the commonest and least affected sites involved, respectively, in chemical leukoderma. Within the face the eyelids were a major area of involvement. This probably originates from greater penetration of the offending toxic chemicals through the thinner skin of the face (eyelids being the thinnest) compared with the thicker skin of the scalp. However, the hands and feet, although composed of much thicker skin, showed a high incidence of chemical leukoderma, probably due to a higher rate of exposure. [2]


   Chemical Leukoderma or Contact Leukoderma or Occupational Leukoderma? Top


There prevails some confusion regarding the varying terminology of chemical leukoderma or occupational leukoderma. The term "contact leukoderma" may be confusing as the adjective "contact" may indicate that leukoderma is confined only to the site of contact, which is baseless as shown in the various studies. [2],[21] The term "contact" may also signify that regarding pathogenesis this is similar to contact dermatitis, which again is not true. The term "occupational leukoderma" may be misleading as the majority of cases in the large study [2] were induced by nonoccupational household objects. Thus, "chemical leukoderma" remains as more rational and justified term to describe the disease.


   Chemical Vitiligo Top


Some patients who, despite the omission of all contributory toxic chemicals for more than 1 year, still develop vitiliginous patches in different parts of their body. These cases can be termed as "chemical vitiligo" to represent the vitiliginous process, which was switched on initially by the chemicals and continued even after stopping use of the chemicals. [2]


   Chemical Leukoderma Syndrome Top


A syndromic classification of chemical leukoderma similar to allergic contact dermatitis syndrome [22] has been described, [2] which can explain all the clinical features and patho-mechanisms adequately, which is termed as "chemical leukoderma syndrome (CLS)." The detail of this proposal is outlined in [Table 4].
Table 4: Chemical leukoderma syndrome[2]

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   Chemical Leukoderma: Clinical Diagnostic Criteria Top


Chemical leukoderma has to be excluded with certainty from every case of idiopathic vitiligo. [21] However, the differentiating factors between chemical leukoderma and vitiligo often remain clinically obscure, which often leads to misdiagnosis of chemical leukoderma syndrome (CLS) as vitiligo. The clinical criteria of diagnosis of chemical leukoderma have not yet been specifically outlined. The proposed clinical diagnostic criteria of chemical leukoderma has been outlined in [Table 5].
Table 5: Clinical diagnostic criteria of 'chemical leucoderma syndrome'[2]

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   Conclusion Top


As in developing countries like India the patent loads of chemical leukoderma have been increasing in recent years and this skin ailment resembles vitiligo very closely causing psycho-social reaction, the clinico-etiological diagnosis of this skin disorder is very much warranted. Further, clinico-etiological studies can refine the diagnostic pattern as well as pinpoint etiological factors.

 
   References Top

1.Ortonne JP, Bahadoran P, Fitzpatrick TB, Mosher DM, Hori Y. Hypomelanosis and hypermelanosis. In: Freddberg IM, Eisen AZ, Wolft K, Austen KF, Goldsmith LA, Katz SI, editors. Fitzpatricks' Dermatology in general medicine. New York: McGraw Hill; 2003. p. 836-81.  Back to cited text no. 1      
2.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. 2      
3.Boissy RE, Manga P. On the etiology of contact⁄occupational vitiligo. Pigment Cell Res 2004;17:208-14.  Back to cited text no. 3      
4.Miyamoto L, Taylor JS. Chemical leukoderma. In: Hann SK, Nordlund JJ, editors. Vitiligo: A Comprehensive Monograph on Basic and Clinical Science. London: Blackwell Science; 2000. p. 269-80.  Back to cited text no. 4      
5.Oliver EA, Schwartz L, Warren LH. Occupation leukoderma. J Am Med Assoc 1939;113:927-8.  Back to cited text no. 5      
6.Bajaj AK. Chemical leukoerma. In: Valia RG, Valia A, editors. What's New in Dermatology, STDs and Leprosy. Mumbai: Fulford; 2004. p. 3-5.  Back to cited text no. 6      
7.Okmura Y, Shirai T. Vitiliginous lesions occurring among workers in a phenol derivative factory. Jpn J Dermatol 1962;7:617-9.  Back to cited text no. 7      
8.Chumakov NN, Babanov GP, Simarov AG. Vitiliginoid dermatoses in workers of phenol formaldehyde resin workers. In: Chumakov NN, Babanov GP, Simarov AG, editors. Bulletin of Dermatology. Moscow: State Publishing Firm of Medical Literature; 1962. p. 14.3.  Back to cited text no. 8      
9.Gellin GA, Possick PA, Davis IH. Occupational depigmentation due to 4-tertiarybutyl catechol (TBC). J Occup Med 1970;12:386-9.  Back to cited text no. 9      
10.Kahn G. Depigmentation caused by phenolic detergent germicides. Arch Dermatol 1970;102:177-87.  Back to cited text no. 10      
11.Malten KE, Seutter E, Hara I, Nakajima T. Occupational vitiligo due to paratertiary butylphenol and homologues. Trans St Johns Hosp Dermatol Soc 1971;57:115-34.  Back to cited text no. 11      
12.Taylor JS, Maibach HJ, Fisher AA, Bergfeld WF. Contact leukoderma associated with the use of hair colors. Cutis 1993;52:273-80.  Back to cited text no. 12      
13.Pandhi RK, Kumar AS. Contact leukoderma due to 'bindi' and footwear. Dermatologica 1985;170:260-2.  Back to cited text no. 13      
14.Bajaj AK, Gupta SC, Chatterjee AK. Contact depigmentation from free para-tertiary-butylphenol in bindi adhesive. Contact Dermatitis 1990;22:99-102.  Back to cited text no. 14      
15.Bajaj AK, Gupta SC, Chatterjee AK. Contact depigmentation of the breast. Contact Dermatitis 1991;24:58.  Back to cited text no. 15      
16.Bajaj AK, Gupta SC, Chatterjee AK. Footwear depigmentation. Contact Dermatitis 1996;35:17-8.  Back to cited text no. 16      
17.Bajaj AK, Gupta SC, Chatterjee AK, Singh KG, Basu S, Kant A. Hair dye depigmentation. Contact Dermatitis 1996;35:56-7.  Back to cited text no. 17      
18.Bajaj AK, Pandey RK, Misra K, Chatterji AK, Tiwari A, Basu S. Contact depigmentation caused by an azo dye in alta. Contact Dermatitis 1998;38:189-93.  Back to cited text no. 18      
19.Bajaj AK, Misra A, Misra K, Rastogi S. The azo dye solvent yellow 3 produces depigmentation. Contact Dermatitis 2000;42:237-8.  Back to cited text no. 19      
20.Kroll TM, Bommiasamy H, Boissy RE, Hernandez C, Nickoloff BJ, Mestril R, et al. 4-Tertiary butyl phenol exposure sensitizes human melanocytes to dendritic cell-mediated killing: relevance to vitiligo. J Invest Dermatol 2005;124:798-806.  Back to cited text no. 20      
21.Mosher DB, Fitizpatrick TB. Chemical leukoderma. In: Sober AJ, Fitzpatrick TB, editors. Yearbook of Dermatology. Boston: Mosby; 1994. p. 3-13.  Back to cited text no. 21      
22.Lachapelle JM. The spectrum of diseases for which patch testing is recommended. In: Lachapelle JM, Maibach HI, editors. Patch Testing, Prick Testing: A Practical Guide. Berlin: Springer; 2003. p. 7-26.  Back to cited text no. 22      


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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    Abstract
    Introduction
    Etiological Aspects
    Etiopathogenesis
    Clinical Features
    Chemical Leukode...
    Chemical Vitiligo
    Chemical Leukode...
    Chemical Leukode...
    Conclusion
    References
    Article Figures
    Article Tables

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