Journal of Cosmetic and Laser Therapy, 2013; 15: 4245

CASE REPORTS AND SHORT REPORTS

Effect of combination of 1064 nm Q-switched Nd:YAG and fractional

carbon dioxide lasers for treating exogenous ochronosis

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PINYAPAT KANECHORN-NA-AYUTHAYA, NUCHA NIUMPHRADIT,

KOBKUL AUNHACHOKE, ARTIT NAKAKES, RANGSIT SITTIWANGKUL &
CHUTIKA SRISUTTIYAKORN
Phramongkutklao Hospital, Dermatology, Bangkok, Thailand
Abstract
We describe three cases of exogenous ochronosis of the malar areas due to long-term application of skin-lightening agents
for melasma, effectively treated by combination of Q-switched Nd:YAG and the fractional carbon dioxide lasers. None of
these lasers has been reported to be used to effectively treat ochronosis before. The Q-switched Nd:YAG laser is capable
of disintegrating dermal ochronotic fibers, thereby facilitating their phagocytosis and elimination via lymphatics.
The fractional carbon dioxide laser is believed to assist transepidermal elimination of the onchronotic material. We believe
successful treatment of ochronosis is possible when both mechanisms are applied.
Key Words: lasers and light sources, ochronosis, transepidermal elimination

Introduction
Ochronosis is the bluish black discoloration of certain tissues such as the skin, ear cartilage and the
ocular tissue, and can be classified as either endogenous, e.g., alkaptonuria, or exogenous from mainly
topical products. Clinically, ochronosis is known to
be cosmetically disfiguring and involves the malar
eminences, temples, inferior cheeks, neck, back, and
the extensor surfaces of the extremities (1,2).
Exogenous ochronosis most commonly results from
exposure to various substances such as phenol, trinitrophenol, resorcinol, mercury, picric acid, benzene,
hydroquinone, and antimalarials (36). Often, however, ochronosis is a result of topical application of
hydroquinone as a skin-bleaching agent for a prolonged
period of time or in high concentrations. The highest
reported incidence of this syndrome occurs in South
African Blacks wherein prevalence can be as high as
2835% although prevalence is still unknown in
Asians. The mechanism of hyperpigmentation is
speculated to involve effects on tyrosinase or alternatively by inhibiting homogentisic acid oxidase locally
resulting in deposition (5,7,8).
Ochronosis is very recalcitrant to treatment and
has no cure. A number of treatments had been tried

with variable efficacy. Treatments with tretinoin, cryotherapy, trichloroacetic acid, sunscreens, oral tetracycline, corticosteroids dermabrasion, and CO2 laser
were variable and reports have been limited
(6,9,10,11). The Q-switched Alexandrite 755-nm
laser was reported to improve the appearance of
hydroquinone-induced ochronosis; however, there
had been no reported outcome of the Q-switched
1064-nm Nd:YAG laser for this disorder despite an
attempt made (9,12).
Ochronotic fiber degeneration can be progressive,
forming the banana-shaped pigment fibers histologically in the dermis, reflecting the brownish hyperpigmentation with minute dark brown to black papules
similar to a colloid milia seen on the affected skin.
Previously colloid milia have been successfully treated
using the fractional CO2 laser (12). Because transepidermal elimination of pigment has also been described
in ochronosis (6,7,1315), we believe that the fractional CO2 laser might accelerate transepidermal
elimination of ochronotic material as well. Applying
both the fractional CO2 and the Q-switched Nd:YAG
lasers in order to implement both strategies in eliminating the abnormal pigmentation have not been
reported before. We report three cases of exogenous

Correspondence: Dr Pinyapat Kanechorn Na Ayuthaya, Phramongkutklao Hospital, Dermatology, 315 Rajavithi Rd., Bangkok, Thailand. Tel: 6623540374.
Fax: 6623540375. E-mail: jewenator@gmail.com
(Received 10 February 2012 ; accepted 2 November 2012 )
ISSN 1476-4172 print/ISSN 1476-4180 online 2013 Informa UK, Ltd.
DOI: 10.3109/14764172.2012.748198

Combined lasers for ochronosis

ochronosis treated using dual lasers: Q-switched
Nd:YAG 1064-nm and the fractional CO2 lasers that
achieved satisfactory improvements.

Case reports

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Case 1
A 67-year-old Thai female with skin type 5 presented
with 28 years history of melasma which later progressed to blue-black facial discoloration covering
almost the entire face, especially the malar areas and
nose. She has underlying diabetes and dyslipidemia
that is under control. She admitted to heavy use of
bleaching creams for melasma on her face over a
period of many years. Further topical bleaching
agents of unknown source did not improve her condition but actually worsened the pigmentation and
caused persistent and increased facial flushing when
exposed to sunlight, heat and spicy food. Physical
examination revealed diffuse, dark-brown patches on
the cheeks and numerous, grouped, pinpoint slategray colored macules on the forehead, infraorbital
regions, nose, and cheeks and generalized telangiectasia mostly confined to the nose and cheeks. Skin
biopsy demonstrating pathognomonic yellow-brown
dermal deposits confirmed the diagnosis of ochronosis (Figure 1).
The patient was treated with a QS Nd:YAG
1064-nm laser (Medlite; Medlite C2, Hoya Conbio,
CA, USA Candela Laser Corp., Wayland, WA) at
1.92.2 J/cm2 at multiple passes for 4 sessions spaced
2, 1 and 4 months apart, respectively. Topical anesthesia containing prilocaine and lidocaine (EMLA
cream) was applied for 1 hour prior to every procedure. Treatment endpoints were mainly purpura due
to the underlying numerous telangiectasia and immediate whitening in some areas. Transient but dark
post-inflammatory hyperpigmentation was evident
after the first treatment. However, progressively
noticeable lesional fading and smoother facial skin

Figure 1. Ochre pigment deposits seen in the dermis before

treatment (hematoxylin and eosin, 40 Magnification).

43

was apparent just before the 3rd Q-switched Nd:YAG

procedure. A single fractional CO2 laser was done
after the 3rd Q-switched Nd: YAG laser procedure.
Shown in Figures 2 and 3 are before and after photos post 3 Q-switched Nd:YAG (1064 nm) procedures and a single fractional CO2.
After each procedure 1% chloramphenicol ointment was applied twice daily for 1 week and the patient
was encouraged to avoid sun exposure. Sunscreen was
applied a week after each procedure throughout the
duration of treatment.
Case 2
A 58-year-old healthy female with skin type 3 suffered from long-standing recalcitrant melasma for 28
years. She had underlying diabetes and hypertension
which were under control by metformin, gliclazide;
propanolol, enalapril; and rosuvastatin, respectively.
She had been using a hydroquinone-containing
bleach to lighten her complexion, which was later
to exhibit a rebound persistent darkening of the
melasma. Physical examination revealed slate-gray,
hyperpigmented patches over the temples and malar
regions bilaterally. Eyebrows, eyelids and lip outline
showed cosmetic tattoos. Skin biopsy confirmed
the diagnosis of ochronosis. The patient received a
total of four Q-switched Nd:YAG (1064-nm) laser
treatments at 1-month intervals with increasing fluences from 1.9 J/cm2 in multiple passes to achieve
pinpoint petichiae and purpura. As with the first
case, marked lightening of the ochronotic skin lesions
and flushing were achieved at the end of the 3rd
treatment. Fractional CO2 laser was also done after
the 3rd Q-switched Nd:YAG laser. Improved facial
skin toning, texture and lightening were observed.
Post-inflammatory hyperpigmentation was noted
after each procedure but was short-lived. She underwent the exact post-procedural treatment as in the
first case. Our patient was very satisfied with the
results and gave feedback to us that improvement

Figure 2. Slate-gray onchronotic patches on central forehead and

malar areas before (left) and after three Q-switched Nd:YAG
1064-nm laser plus single fractional carbon dioxide laser (right).

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44

P. Kanechorn-Na-Ayuthaya et al.

Figure 3. Before (left) and after three sessions of Q-switched

Nd:YAG 1064-nm laser plus single fractional carbon dioxide laser
(right).

was better seen when the procedure produced immediate laser purpura. Three months after the last ablative laser she had pulse-dye laser treatment for the
underlying telangiectasia. Unfortunately, no photographs were taken.

Figure 4. Ochronotic pigmentation before treatment (top), after 2

Q-switched Nd:YAG 1064nm laser and Single fractional carbon
dioxide laser (bottom).

Case 3
A 66-year-old healthy female with skin type IV had
history of melasma for 20 years. She had underlying
hypertension and dyslipidemia and was currently on
nifedipine, indapamide, rosuvastatin and telmisartan. Once in a while she received celecoxib for
osteoarthritis of the knees. She admitted applying
various bleaching agents for melasma, which were
not helpful and worsened the melasma. Physical
examination revealed bilateral slate-gray, hyperpigmented patches with background of marked telangiectasia at the malar regions. Close inspection revealed
numerous minute grayish-black caviar-like papules
over the hyperpigmented areas. Skin biopsy confirmed the diagnosis of ochronosis. Q-switched
Nd:YAG laser was done only twice, each 1 month
apart, with resulting purpura immediately after each
procedure. Post-inflammatory hyperpigmentation
occurred the least of all 3 cases. Fractional CO2 laser
was done at the third visit. She was very satisfied on
follow-up visits at 2 weeks and 5 months post laser.
Skin lightening was observed and mild skin rejuvenation was attained (Figure 4).

Discussion
Exogenous ochronosis is a cosmetically and psychologically distressing pigmentary condition recalcitrant to treatment. We demonstrated three cases
treated with combination of Q-switched 1064 nm
Nd:YAG and fractional CO2 lasers resulting in successful lightening of ochronosis together with
improvement of skin texture and tone within a few
sessions. Despite purpura and post-inflammatory

hyperpigmentation being present during the first two

treatments, significant lightening of ochronotic pigmentation was observed in case 1 and case 2 after
the third procedure, and case 3 after the second.
Abnormal mottled pigmentation or post-inflammatory hyperpigmentation beyond the third treatment
from the 1064-nm Q-switch Nd:YAG laser or the
fractional CO2 laser did not occur. Improved skin
texture and tone was appreciated in both patients,
and a decrease in fine wrinkles was observed in case
1 and after the fourth treatment. Case 3 was content
with the outcome after the third procedure and
discontinued treatment.
The origin of ochronotic pigment fibers is suppositional. They may represent abnormal elastic
fibers, or collagen fibers producing the ochronotic
pigment (16,17). Penneys (18) suggested that hydroquinone might cause local inhibition of homogentisic
acid oxidase, causing pigment implanting in the
dermis. Exogenous ochronosis also results from
dermal pigment accumulation of homogentisic acid,
which subsequently polymerizes to form pigment
(19). Findlay et al. hypothesized that after the hydroquinone casts its effect on melanocytes, it or its
metabolites are subsequently engulfed by fibroblasts
that excrete the pigmented material (19).
We used the the1064-nm Nd:YAG laser for its less
absorption by epidermal melanin and deeper tissue
penetration due to longer wavelengths, being less vulnerable to iatrogenic permanent hypopigmentation or
scarring especially in patients with higher skin types.
The laser is capable of delivering high energy in ultra
short pulses, subsequently shattering dermal ochronotic pigment fibers, which await to be phagocytized

Combined lasers for ochronosis

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and removed through lymphatic drainage or transepidermal elimination (6,9,1315). For this reason we
believe that the fractional carbon dioxide laser would
assist transepidermal elimination of the ochronotic
materials and pigment.
Since cases diagnosed with ochronosis are uncommon, we have limited patients and therefore were not
able to compare the efficacy of ochronosis treatment
of each laser individually. Thus we do not know if
both lasers account to an additive or synergistic
effect, or how much benefit would be achieved
cosmetically if more sessions of lasers were done.
Further studies on a larger scale are needed to investigate various treatment options for ochronosis and
establish a treatment protocol.

4.
5.

6.
7.

8.

9.

10.

Conclusion
Combination of the 1064-nm Q-switched Nd:YAG
and fractional CO2 lasers can be used to treat exogenous ochronosis effectively without untoward effects
while simultaneously achieving skin rejuvenation.

11.

12.

13.
14.

Declaration of interest: The authors state no

conflicts of interest. The authors alone are responsible for the content and writing of the paper.

15.
16.

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