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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 78-83

Facial frictional melanosis in Indian patients: Defining the entity


1 Department of Dermatotherapy and Cosmetology, Maharashtra Medical Foundation's Joshi Hospital, Pune, Maharashtra, India
2 Dr. Suresh Pethe Skin Clinic, Consultant Dermatologist, Pune, Maharashtra, India
3 Department of Dermatology, Krishna Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication14-Feb-2019

Correspondence Address:
Sharad D Mutalik
Planet Skin, 1st Floor, Samruddhi Apartments, 95/a/2, Shivaji Nagar, Near PMC Bus Terminus, Near Shramik Bhavan, Pune - 411 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_6_18

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  Abstract 


Background: Facial melanosis in tropics presents as a diagnostic and therapeutic challenge. We report characteristic patterns of facial pigmentation following vigorous rubbing or cleaning of the face in Indian patients. Awareness of the condition shall guide the clinician to a specific diagnosis. Objective: To study clinicohistopathological profile and patterns of facial frictional melanosis (FFM). Materials and Methods: A multicenter clinicohistopathological hospital-based cross-sectional case descriptive study of sixty patients with characteristic patterned facial melanosis underwent a detailed history taking and clinical examination over a period of 5 years. Biopsy specimens of thirty patients were analyzed for histopathology with hematoxylin-eosin stain. Ten biopsy specimens were also processed for both Fontana Mason and Congo red staining. Results: Sixty patients (males n = 48, females n = 12) with typical clinical features of FFM were studied. Ages of patients varied from 16 to 68 years. Patients on direct questioning confirmed history of vigorous rubbing with hand/handkerchief to clear the face of sweat and grime. Pigmentation was distributed symmetrically over the bony prominences with several characteristic patterns. Histology showed epidermal hypermelanosis, dermal melanin incontinence, and consistent absence of amyloid deposits. Conclusion: We present characteristic facial melanosis in Indian patients due to friction as a specific type of benign friction melanosis. We aim to bring to notice; friction as a distinct etiology of patterned facial hyperpigmentation.

Keywords: Amyloid, facial melanosis, friction


How to cite this article:
Mutalik SD, Pethe SV, Nikam BP, Rasal YD. Facial frictional melanosis in Indian patients: Defining the entity. Clin Dermatol Rev 2019;3:78-83

How to cite this URL:
Mutalik SD, Pethe SV, Nikam BP, Rasal YD. Facial frictional melanosis in Indian patients: Defining the entity. Clin Dermatol Rev [serial online] 2019 [cited 2019 Jul 15];3:78-83. Available from: http://www.cdriadvlkn.org/text.asp?2019/3/1/78/252318




  Introduction Top


In a tropical country like India, a fair skin is prized above a healthy, even-toned facial skin, with facial pigmentation translating into a significant psychosocial problem and a frequent cause of dermatologic consultation.[1],[2] In the Indian context, common causes of facial melanosis include melasma, Riehl's Melanosis, Lichen planus pigmentosus, facial acanthosis nigricans, pigmentary demarcation lines, postinflammatory hyperpigmentation, and as the present observation indicates friction.

Friction melanosis is an acquired pigmentary disorder due to habit of rubbing. Facial frictional melanosis (FFM) is hardly uncommon, but it often goes undiagnosed or misdiagnosed and remains largely underreported and undefined. It is postulated that squeezing of melanocytes against the underlying bony structures releases melanosomes to the dermis seen as melanophages after engulfment by macrophages resulting in the pigmentation seen clinically at sites of friction.[3]

As part of our clinical experience, the presentation of facial hyperpigmentation with a peculiar pattern overlying bony prominences of the face led us to consider external factor such as friction as the underlying causative factor.

We report varied patterns of FFM presenting as characteristic pigmentation over the face on the bony prominences associated with a history of vigorous rubbing or cleaning of the face.


  Materials and Methods Top


Sixty Indian patients (males n = 48, females n = 12) of facial pigmentation were included in this multicenter clinicopathological hospital-based cross-sectional case descriptive study conducted in Maharashtra state, India, between January 2012 and January 2017.

Patients of all ages and both sexes with characteristic facial hyperpigmentation giving a history of cleaning or rubbing the face frequently and/or vigorously with or without a handkerchief/hand towel, and those willing to undergo a diagnostic biopsy post a written informed consent were included in the study.

Patients excluded from the study included those with facial hyperpigmentation of other known etiology, hyperpigmentation of other flexural areas, atopy or systemic diseases, having used topical or systemic drugs, and pregnant women.

In each patient, the diagnosis was made by history, clinical examination, and histopathological correlation. Detailed history taking, clinical photography, dermoscopy, and lesional skin biopsy using a two and half mm punch was performed in thirty patients for histopathological evaluation with hematoxylin and eosin staining (H and E). The intent of the biopsies, we also performed Fontana Masson stain to assess the location of the pigmentation and Congo red stain to detect amyloid deposits if any.


  Results Top


As a result, we identified a total of sixty patients with characteristic patterned frictional facial melanosis aged from 16 to 68 years. Males were more commonly affected with a male to female ratio of 80:20 (males n = 48, females n = 12). Patients had Fitzpatrick skin Type IV or V.

All patients gave a history of vigorous rubbing of their faces with hand or handkerchief, with some having a typical method of rubbing with a swipe on the right side and swipe on the left side of the face sparing the midline and sensitive nose tip. Hyperhidrosis was noted in 63.3% of patients (n = 38).

Lesions were specifically distributed over facial skin overlying bony prominences. The pigmentation was symmetric, uniform, confl uent, deep dark brown without accompanying skin textural changes.

Noting specific pigmentation patterns, we endeavored to name them descriptively according to their anatomic distribution as follows.

Six chief clinical patterns of pigmentation were observed.

  1. Zygomatico-supraorbitalis (n = 18)


    • The pigmentation overlies the zygomatic bone and temples [Figure 1].


  2. Metomelanosis (n = 8)


    • Pigmentation overlying the forehead with majority of patients demonstrating midline sparing and sparing of the nose tip [Figure 2].


  3. Panfacial melanosis (n = 5)


    • Pigmentation over entire face with sparing of apex of the nose [Figure 3].


  4. Paranasal melanosis (n = 6)


    • Pigmentation on the lateral sides of the nasal bridge [Figure 4].


  5. Perioral melanosis (n = 8)


    • Perioral type of FFM: Pigmentation around the mouth [Figure 5].


  6. Mixed melanosis (n = 15) [Figure 6].


    • Dermoscopy revealed black pigment dots, patchy pigment distribution on background of acanthotic skin, and patulous follicular openings with plugs [Figure 7].
Figure 1: Zygomatico-supraorbitalis type of facial frictional melanosis: Pigmentation overlying zygomatic bone and temples

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Figure 2: Metomelanosis type of facial frictional melanosis: Pigmentation over forehead. Note the midline sparing

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Figure 3: Panfacial type of facial frictional melanosis: Pigmenation over the entire face with sparing of apex of nose

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Figure 4: Paranasal type of facial frictional melanosis: Pigmentation on the lateral sides of the nasal bridge and nasolabial folds

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Figure 5: Perioral type of facial frictional melanosis: Pigmentation around the mouth

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Figure 6: Mixed type of facial frictional melanosis

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Figure 7: Dermoscopy showing black pigment dots and patchy pigment distribution on the background of acanthotic skin with patulous follicular openings with plugs

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Histopathology with H and E staining revealed irregular acanthosis of epidermis with antler such as projection of the rete ridges, hypermelanosis of the basal layer, patchy melanin incontinence, a superficial papillary perivascular lymphohistiocytic infiltrate, and vertical banding of the collagen fibers [Figure 8], [Figure 9], [Figure 10], [Figure 11]. Findings of basal melanosis and dermal melanosis were confirmed by Fontana Masson staining [Figure 12]. Congo red stain was negative for amyloid in all the examined 10 slides [Figure 13].
Figure 8: Irregular acanthosis of epidermis with antler-like projections of the rete ridges. Basal hypermelanosis and patchy melanin incontinence (H and E, ×10)

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Figure 9: Irregular acanthosis of epidermis with antler-like projections of rete ridges. Basal hypermelanosis and patchy melanin incontinence (H and E, ×40)

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Figure 10: Papillary thickening of collagen

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Figure 11: Patulous follicular openings, especially in seborrheic areas

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Figure 12: Fontana Masson stain confirming basal hypermelanosis and melanin incontinence in facial frictional melanosis

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Figure 13: Congo red stain negative for amyloid in facial frictional melanosis

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  Discussion Top


Frictional stress, as such has been documented as an etiologic factor for pigmentation overlying bony prominences in defined conditions such as lifa disease and Daveners dermatosis.[3],[4] Use of lifa made from plant or plastic during body bath is known to cause symmetric pigmentation over clavicular area, upper back, lateral aspect of arms, shins, and Adams apple.[3] Daveners dermatosis describes pigmentation on the lower back in Jewish Israeli yeshiva students resulting from the long hours of constant rocking or rhythmic motion of the upper torso while sitting on bare wooden or metal chairs.[4] Reactionary frictional hypermelanosis has been reported over joints as in Frictional Asymptomatic Darkening Of The Extensor Surfaces with hypermelanosis being reported over elbows at site of friction;[5] as are case reports of pigmentation postrubbing medial thighs in Iraqi women.[3],[4],[5],[6],[7],[8],[9] Hidano et al. have claimed that frictional melanosis is a unique entity and should be differentiated from other pigmentary disorders as well as macular amyloidosis.[9]

They first observed cases having pigmentation postfriction due to nylon towel or brush in 1977 and suggested the use of the term friction melanosis. Amyloid deposition was an exception being detected in 1 out of 23 studied cases.[10]

The present study characterizes features of FFM as follows:

  1. A positive history of rubbing the face aggressively with or without handkerchief
  2. Seen predominantly but not exclusively seen in males (n = 48)
  3. Hyperhidrosis (n = 38) was notable feature
  4. Characteristic symmetric distribution with uniform deep dark brown pigmentation corresponding to the site of friction over the bony prominences of the face
  5. In majority of cases, there was a distinct vertical linear band of sparing in the middle of the forehead and sparing of the apex of the nose which stood out in contrast to the surrounding hypermelanosis. We observed that the support of the underlying facial bones, gingiva, and teeth made it easier to rub the overlying skin resulting in pigmentation while the apex of the nose being a sensitive area with soft cartilage underneath was usually not scrubbed
  6. Resultant pigmentation leads to a paradoxical increase in the vigorous rubbing exacerbating the pigmentation and setting up a vicious cycle of friction and reactionary hypermelanosis
  7. The histological picture was of both epidermal hypermelanosis as well as dermal melanosis. No amyloid deposits were noted in our patients after Congo Red stain evaluation
  8. Effective treatment would entail removal of friction by habit change to gentle mopping, use of photo block, and an array of exfoliating and depigmenting agents.


The differential diagnosis includes well-defined conditions such as melasma, facial macular amyloidosis and facial acanthosis nigricans, lichen planus pigmentosus, pigmented contact dermatitis, sebomelanosis, pigmentary demarcation lines, postinflammatory hyperpigmentation.[8],[9],[10],[11],[12]

Although a history of friction is often the clincher in the diagnosis of frictional melanosis, the varied presentations can mimic various other known cause of facial melanosis as can other causes of facial melanosis coexist.

Macular amyloid is often equated with frictional melanosis. Localized facial macular amyloidosis is less common tending to occur more in females with possible familial tendency. However, it has been observed in several case reports that not all patients gave a history of friction and in those that did, the perceived excessive friction did not correlate with the sites having pigmentary lesions.[13] While there is a paucity of studies on dermoscopic findings of friction melanosis, it is observed to reveal brownish structureless areas arranged in a reticular fashion whereas macular amyloidosis shows a white or brown central hub surrounded by various configurations of brownish pigmentation including fine radiating streaks, dots, leaf such as projections, and bulbous projections. Histopathology shows amyloid deposition and slow or negligible spontaneous resolution in cases of macular amyloidosis. Facial acanthosis nigricans or metabolic melanosis shows pigmented band usually over zygomatic, malar areas, and over the forehead with a velvety skin textural change. It is usually associated with a “obese face” with classical AN on the neck and other anatomical site in predominantly obese patient with insulin resistance. Dermoscopy of acanthosis nigricans shows linear crista cutis and sulcus cutis with focal hyperpigmented dots in the crista cutis. Histopathology in FAN shows acanthosis with or without papillomatoses together with dermoepidermal melanosis accounting for the pigmented velvety features of the skin. Prognostically facial acanthosis nigricans may persist indefinitely.[14],[15],[16] Postinflammatory hyperpigmentation due to conditions such as photo-dermatitis and air borne-contact dermatitis shows a similar distribution of the pigmentation; however, both conditions are preceded by subjective complaints of pruritus and burning sensation or discomfort. Clinically, changes due to inflammatory process such as erythema, scaling, or lichenified plaques help to distinguish from frictional melanosis easily. On dermoscopy, an eczematous dermatitis shows dotted vessels in a patchy distribution and yellow serocrustsor scaling. Histopathology further aids a correct diagnosis.[16]

A limitation of this study is the lack of histopathological correlation with skin biopsy and special stains for each of the 60 patients due to cosmetic concerns and economic constraints.

Further studies on the same lines would help to support our findings.

Despite perceived overlaps, FFM remains a distinct clinicopathological entity with many characteristic features.

Vitally, frictional melanosis tends to be self-limited where if the patient stops the habitual rubbing the pigmentation eventually fades away.


  Conclusion Top


We propose frictional facial melanosis to be a characteristic entity defined as a benign acquired frictional melanosis secondary to vigorous rubbing due to a constant compulsive urge to wipe off the sweat and grime leading to pigmentation overlying bony prominences sparing the nose tip.

The knowledge of typical clinical clues and alert history taking will aid the clinician to arrive at the diagnosis of FFM leading to its appropriate management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) have given their consent for 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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dominguez-Soto L, Hojyo-Tomoka T, Vega-Memije E, Arenas R, Cores-Franco R. Pigmentary problems in the tropics. Dermatol Clin 1994;12:777-84.  Back to cited text no. 1
    
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Khanna N, Rasool S. Facial melanoses: Indian perspective. Indian J Dermatol Venereol Leprol 2011;77:552-63.  Back to cited text no. 2
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Sharquie KE. Frictional dermal melanosis (Lifa disease) over bony prominences. J Fac Med (Baghdad) 1993;35:83-7.  Back to cited text no. 3
    
4.
Naimer SA, Trattner A, Biton A, Avinoach I, Vardy D. Davener's dermatosis: A variant of friction hypermelanosis. J Am Acad Dermatol 2000;42:442-5.  Back to cited text no. 4
    
5.
Krishnamurthy S, Sigdel S, Brodell RT. Frictional asymptomatic darkening of the extensor surfaces. Cutis 2005;75:349-55.  Back to cited text no. 5
    
6.
Sharquie KE, Noaimi AA, Hajji AA. Frictional melanosis of rubbing thighs in Iraqi patients. J Cosmet Dermatol Sci Appl 2014;4:203-11.  Back to cited text no. 6
    
7.
Al-Aboosi M, Abalkhail A, Kasim O, Al-Khatib A, Qarqaz F, Todd D, et al. Friction melanosis: A clinical, histologic, and ultrastructural study in Jordanian patients. Int J Dermatol 2004;43:261-4.  Back to cited text no. 7
    
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Sharquie KE, Al-Dhalimi MA, Noaimi AA. Frictional dermal melanosis over bony prominences (Clinicopathological study). J Cosmet Dermatol Sci Appl 2012;2:196-200.  Back to cited text no. 8
    
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Somani VK, Hari S, Sita VN, Razvi F. Nylon friction dermatitis: A distinct subset of macular amyloidosis. Indian J Dermatol Venereol Leprol 1995;61:145-7.  Back to cited text no. 9
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Hidano A, Mizuguchi M, Higaki Y. Friction melanosis. Ann Dermatol Venereol 1984;111:1063-71.  Back to cited text no. 10
    
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Ghosh A, Coondoo A. Lichen planus pigmentosus: The controversial consensus. Indian J Dermatol 2016;61:482-6.  Back to cited text no. 11
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Prabhakara VG, Chandra S, Shankar KD. Frictional pigmentary dermatoses: A clinical and histopathological study of 27 cases. Indian J Dermatol Venereol Leprol 1997;63:99-100.  Back to cited text no. 12
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Bandhlish A, Aggarwal A, Koranne RV. A clinico-epidemiological study of macular amyloidosis from North India. Indian J Dermatol 2012;57:269-74.  Back to cited text no. 13
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Verma S, Vasani R, Joshi R, Phiske M, Punjabi P, Toprani T, et al. A descriptive study of facial acanthosis nigricans and its association with body mass index, waist circumference and insulin resistance using HOMA2 IR. Indian Dermatol Online J 2016;7:498-503.  Back to cited text no. 14
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Higgins SP, Freemark M, Prose NS. Acanthosis nigricans: A practical approach to evaluation and management. Dermatol Online J 2008;14:2.  Back to cited text no. 15
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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