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Received: 4 April 2022 | Accepted: 23 May 2022

DOI: 10.1002/jvc2.44

ORIGINAL ARTICLE

Characteristics of Riehl melanosis in an ethnic Asian

population: A comparative study according to age, sex,
and hair dye use

Myoung Eun Choi1 | Youngkyoung Lim2 | Woo Jin Lee1 |

Chong Hyun Won1 | Mi Woo Lee1 | Sung Eun Chang1

1
Department of Dermatology, Asan
Medical Center, University of Ulsan
College of Medicine, Seoul, Republic of
Korea
2
Deparment of Dermatology, Seoul
National University, Seoul, Republic of
Korea
Correspondence
Sung Eun Chang, Department of
Dermatology, Asan Medical Center,
University of Ulsan College of Medicine,
88 Olympic‐ro 43 gil, Songpa‐gu,
Seoul 05505, Republic of Korea.
Email: changse2016@gmail.com
Funding information
None
Abstract
Background: Riehl melanosis, characterized by diffuse brown to grey
hyperpigmentation of the face and neck, affects middle‐aged women with
dark skin phototypes. Riehl melanosis prevalence has increased in Korea, and
a relationship with henna hair dye has been suspected. In this study, we aimed
to evaluate clinical features and patch test results of Riehl melanosis patients
and analyse them according to age, sex, and hair dye use.
Methods: We identified patients showing clinical and histopathological
manifestations consistent with Riehl melanosis between January 2009 and
December 2019 in our medical centre.
Results: Of 154 patients, 76.5% had positive patch‐test results, and the most
common sensitizing agents were nickel, cobalt, and benzyl salicylate. Patients ≥50
years old were more likely to have spotty hyperpigmentation and less likely to
have diffuse patterns, while lesions in the younger‐aged group were more
commonly accompanied by erythema. Preceding erythema was found more often
in female patients. Hair dye usage was more likely to be associated with
aggravation of symptoms in females. Patients who developed Riehl melanosis
after hair‐dye use more frequently had lesions on the forehead and were
diagnosed an average of 14.1 months earlier as compared with other patients.
Short disease duration, aggravation by hair dye (except henna), laser therapy, and
longer follow‐up periods were related to good treatment responses.
Conclusions: Detailed history taking regarding disease duration and
aggravating factors as well as the length of the period of laser therapy can
be important for the management of Riehl melanosis patients.

KEYWORDS
contact dermatitis, inflammatory disorders, pigmentary disorders

Myoung Eun Choi and Youngkyoung Lim contributed equally to this study.

[Correction added on 16 November 2022, after first online publication: Acknowledgement has been changed to Ethics Statement as appropriate.]

This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
© 2022 The Authors. JEADV Clinical Practice published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology.

JEADV Clin Pract. 2022;1:219–228. wileyonlinelibrary.com/journal/jvc2 | 219


220 | CHOI
I N T R O D U C TI O N
Riehl melanosis, also known as pigmented contact
dermatitis, was first described by Riehl in 1917.1 It is
characterized by brown to grey discolouration of the face
and neck affecting Asian women with dark skin
phototypes.2 Strikingly, the prevalence of Riehl melano-
sis shows an upward trend in Korea, and the possibility
of a relationship with henna hair dye has been
suspected.3,4 However, the increase in the use of
irritating cosmetics, exposure to hot baths, scrubbing
with flannel, as well as laser procedures also parallels the
increase in Riehl melanosis patients.
Korean patients with Riehl melanosis had clinical
differences from the original description of Riehl
melanosis in that in these patients it tended to present
initially with ill‐defined erythematous patches before the
development of brown to grey pigmentation. Moreover,
the majority of Korean Riehl melanosis patients had
concurrent impairment of skin barrier function accom-
panied by various degrees of symptoms such as itching,
dryness, burning, and hot sensations with the initiation
and aggravation of Riehl melanosis lesions. Currently, it
is not uncommon to see Riehl melanosis patients
younger than 40 and even male Riehl melanosis patients
despite the fact that the disorder mostly affects middle‐ to
older‐aged women. However, there has been limited
clinical analysis according to age and sex because of the
rarity of disease in these groups (<40 years old and male
patients) in the past.
The treatment of Riehl melanosis includes topical
blanching agents, topical steroids, topical calcineurin
inhibitors, oral steroids, and laser therapy. However,
the results of treatment have had variable degrees of
success, and some patients have complained of
aggravation during the course of treatment.5 Because
the factors that affect the treatment response of Riehl
melanosis have not been studied, it is difficult to
predict prognosis.
In this study, we evaluated clinical features and
patch‐test results of Riehl melanosis patients and
analysed them according to age, sex, and hair dye use.
In addition, we investigated factors associated with
treatment response.
MATERIALS A ND METHODS
Subjects
We identified a total of 154 patients with Riehl melanosis
evaluated in the Dermatology Department between
January 2009 and December 2019. This study was
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ET AL.
approved by the Institutional Review Board (IRB) (IRB
approval no. 2019‐0920). The medical records of these
patients were reviewed to gather clinical data, patch‐test
results, and follow‐up data. We included the patients
only if their skin biopsy results and clinical manifesta-
tions supported the diagnosis of Riehl melanosis. We
excluded patients who had other possible causes of
hyperpigmentation such as Addison's disease, hyper-
thyroidism, and hemochromatosis. Patients with hyper-
pigmentation in sites other than the face and neck were
also excluded.
Variables of interest
The clinical features of the primary lesions, such as age at
diagnosis, sex, anatomical location of the lesion, mor-
phology, multiplicity, clinical course, symptoms, time to
diagnosis, and causative agents were identified through
medical records and clinical photographs. Histopatho-
logical slides of all patients were reviewed by two
dermatopathologists.
Patch test
Standard patch‐test kits (Korean Standard Series [KOR‐
1000] and Cosmetic Series [C‐1000]), as well as several
suspected products brought in by patients, were used for
patch testing in 34 patients. The patch tests were applied
on the back for 2 days. The interpretation of the results
was based on the International Contact Dermatitis
Research Group scoring scale (ICDRG) guideline at 48
and 96 h after application. Delayed reactions were
recorded as needed.
Clinical outcome measures
Clinical outcomes were evaluated based on clinical
photographs obtained at baseline and at the last time
medical photographs were taken. Two dermatologists
compared the initial photographs with the final follow‐
up photographs in a blind manner and assessed the
treatment response according to the percentage pigment
clearing as follows: none to fair (0%–25%, score = 0),
moderate (26%–50%, score = 1), good (51%–75%, score =
2), or excellent (76%–100%, score = 3). Global assessment
scale (GAS) scores (0 [no pigmentation] to 4 [severe
pigmentation]) were used to measure pigmentation
severity. Treatment response was defined as pigment
clearing ≧26% (a grade of moderate to excellent) in
evaluating prognostic factors.
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CHARACTERISTICS OF RIEHL MELANOSIS | 221

Statistical analysis TABLE 1 Clinical features of Riehl melanosis

Clinical parameters Number of patients (%)
All data were statistically analysed using SPSS version Number of patients 154
18.0 (SPSS Inc.). p Values < 0.05 were considered to be
Male 15 (9.7%)
statistically significant. Comparisons between subgroups
of patients according to age and sex were performed Female 139 (90.3%)
using a χ2 test or Fisher exact test for categorical variables Mean age (range, years) 56.0 (18–86)
and a t test for continuous variables. Logistic regression Mean time to diagnosis (range, months) 24.1 (1–180)
analyses were performed in sequence to determine the
Preceding symptoms and signs
independent prognostic factors associated with treatment
response. Erythema 62 (40.3%)
Itching 84 (54.5%)
Facial flushing 32 (20.8%)
RESU LTS
Associated symptoms and signs

Clinical manifestations Photosensitivity 15 (9.7%)

Dryness 18 (11.7%)
The clinical features of the patients are presented in Aggravating factors
Table 1. The mean patient age was 56 years (range: 18–86
Henna hair dye 34 (22.1%)
years). There were 15 male patients and 139 females.
Hair dye other than henna 47 (30.5%)
Mean time to diagnosis was 24.1 months, ranging from 1
to 180 months. Of the patients, 40.3% had preceding Laser treatment 10 (6.5%)
erythema. More than half of patients (54.5%) had itching Peeling 7 (4.5%)
before initiation of hyperpigmentation. Facial flushing Friction 14 (9.1%)
was noted in 20.8% of patients. Photosensitivity and
Cosmetics 22 (14.3%)
dryness were symptoms seen in 9.7% and 11.7% of Riehl
melanosis patients, respectively. A variety of factors were Exercise 7 (4.5%)

reported to be related to the aggravation of Riehl Sunlight 21 (13.6%)

melanosis, and more than one factor could be associated Heat 16 (10.4%)
with the aggravation. Henna hair dyes as well as other Others 24 (15.6%)
hair dyes were most commonly reported by patients as
Fitzpatrick skin type
aggravating factors, followed by cosmetics, sunlight, heat,
friction, and laser procedures. Other factors included Mean (range) 3.7 (3–5)
hormonal treatment, herbal medications, and mental III 48 (31.2%)
stress. In classification by the Fitzpatrick skin type, 48 IV 105 (68.2%)
patients (31.2%) were Type III, 105 patients were (68.2%)
V 1 (0.6%)
were Type IV, and 1 patient (0.6%) was Type V. The face
was involved in 89.6% of patients, and the neck was Location
involved in 72.7% of patients. Among those with facial Face 138 (89.6%)
involvement, the lateral sides of both cheeks, followed by Forehead 97 (63.0%)
the chin and forehead, were most commonly involved. A
Periocular area 79 (51.3%)
wide range of clinical manifestations of hyperpigmenta-
Cheek 115 (74.7%)
tion, as well as mixed types of hyperpigmentation, was
noticed. Although diffuse hyperpigmentation over the Nose 55 (35.7%)
face and neck (71.4%) was the most commonly observed Perioral area 83 (53.9%)
pattern, spotty (37.0%) and reticulated (9.1%) hyperpig- Chin 111 (72.1%)
mentation were also found.
Neck 112 (72.7%)

Clinical manifestation
Patch‐test results Spotty 57 (37.0%)
Reticulated 14 (9.1%)
Patch tests were performed on 34 patients and the results
Diffuse 110 (71.4%)
are listed in Table 2. Twenty‐six cases showed positive
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222 | CHOI ET AL.

T A B L E 2 Frequency of allergen detection in patch tests in TABLE 3 Histopathological features of Riehl melanosis
Riehl melanosis Histopathological features Patients (%)
Results of % of Epidermis
patch test Detected agents patients
Acanthosis 17 (11.0%)
Positive (n = 26) Fragrance mix 3
Atrophy 15 (9.7%)
4‐Phenylendiamine 1.5% 3
Spongiosis 7 (4.5%)
Colophony 1
Apoptotic body 84 (54.5%)
Cl+ Me‐isothiazolinone 1
Vacuolar degeneration 103 (66.9%)
Imidazolidinyl urea 1
Basal hyperpigmentation 22 (14.3%)
p‐Phenylenediamine (PPD) 1
Dermis
Benzyl salicylate 5
Perivascular inflammation 97 (63.0%)
Formaldehyde 1
Lichenoid infiltration 35 (22.7%)
Nickel sulphate hexahydrate 12
Telangiectasia and capillary hyperplasia 44 (28.5%)
Cobalt chloride hexahydrate 5
Dermal melanophages 145 (94.2%)
Potassium dichromate 3
Prominent solar elastosis 12 (7.8%)
Octyl gallate 2
Abitol 1
2‐Phenoxyethanol 1 acanthosis, atrophy, and spongiosis were observed in
Dimethylaminopropylamine 1 11.0%, 9.7%, and 4.5%, respectively. Apoptotic bodies
Benzophenone‐3 1 were found in 54.5% of patients, and vacuolar degenera-
tion was found in 66.9% of patients. Basal hyperpigmen-
Tert‐butylhydroquinone 1
tation was observed in 14.3% of cases. In the dermis,
Methyldibromo 1 prominent perivascular inflammation and lichenoid
glutaronitrile (MDBGN) inflammation were observed in 63.0% and 22.7%,
Henna 1 respectively. Telangiectasia and capillary hyperplasia
Others a
4 were found in 28.5%, and dermal melanophages in the
upper dermis were observed in 94.2%. Severe solar
Negative (n = 8)
elastosis was found in 7.8% of patients.
a
Sunblock, Lodien tab, Meladopa peeling agent, spot cream.

Clinical analysis according to age

results, while in 8 cases there was no reaction to the
agents in the patch test. Nickel sulphate hexahydrate was
the most common sensitizing agent (12 cases), followed
by cobalt chloride hexahydrate (5 cases) and benzyl
salicylate (5 cases). Fragrance mix, 4‐phenylendiamine,
and potassium dichromate were detected in three
patients each. Some patients had positive results with
products they brought in marked as “as is,” which
included henna hair dye, cosmetics such as sunblock,
spot cream, peeling agents (Meladopa®), and medications
such as S‐amlodipine nicotinate (Lodien®) tablet.
Histopathological features
The histopathological features of the patients are
presented in Table 3. In the epidermis, noticeable
Clinical features were analysed according to age
(Table 4). There were 114 patients 50 or more years old
and 40 patients were less than 50 years of age. The use of
henna as well as other types of hair dye was a statistically
significant aggravating factor according to age (p = 0.026
for henna hair dye and p = 0.002 for other types of hair
dye). Moreover, older patients were more likely to show
spotty hyperpigmentation while less likely to manifest
diffuse hyperpigmentation (p = 0.003 and p = 0.009,
respectively). Accompanying erythema was found signif-
icantly more often in the younger‐aged group (p = 0.016).
Other variables including sex, time to diagnosis, preced-
ing and associated symptoms, aggravating factors
other than hair dye, Fitzpatrick skin type, and location
of hyperpigmentation did not show any significant
differences.
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CHARACTERISTICS OF RIEHL MELANOSIS | 223

TABLE 4 Clinical characteristics of Riehl melanosis patients according to age and sex
Age ≥ 50 Age < 50 Male Female
(n = 114) (n = 40) p Value (n = 15) (n = 139) p Value
Sex 0.494 0.000*
Male 10 5 15 0
Female 104 35 0 139
Age of diagnosis (years) 61 43 0.000* 56 58 0.571
Time to diagnosis (months) 22.7 28.1 0.306 28.0 23.7 0.598
Preceding symptoms and signs
Erythema 45 17 0.737 2 60 0.025*
Itching 63 21 0.763 5 79 0.082
Facial flushing 28 4 0.051 1 31 0.156
Associated symptoms and signs
Photosensitivity 13 2 0.240 2 13 0.621
Dryness 13 5 0.853 0 18 0.138
Aggravating factors
Henna hair dye 30 4 0.026* 0 34 0.027*
Other hair dye 42 5 0.002* 0 47 0.005*
Laser treatment 9 1 0.147 0 10 0.236
Peeling 5 2 0.873 1 6 0.678
Friction 11 2 0.363 0 13 0.216
Cosmetics 16 5 0.881 1 20 0.375
Exercise 4 3 0.280 2 5 0.087
Fitzpatrick skin type 0.694 0.268
3 37 11 2 46
4 76 29 13 92
5 1 0 0 1
Location
Face 102 36 0.925 14 124 0.619
Forehead 73 25 0.862 11 87 0.411
Periocular area 60 19 0.543 8 71 0.890
Cheek 87 28 0.429 13 102 0.261
Nose 42 13 0.548 5 50 0.793
Perioral area 60 23 0.595 6 77 0.286
Chin 82 29 0.994 11 100 0.943
Neck 85 27 0.388 15 103 0.244
Clinical manifestations
Spotty 50 7 0.003* 7 50 0.415
Reticulated 12 2 0.296 1 13 0.731
Diffuse 75 35 0.009* 12 98 0.439
Presence of erythema 17 13 0.016* 4 26 0.527
Presence of hypopigmentation 28 10 0.956 2 36 0.851
*p < 0.05.

224 | CHOI
Clinical analysis according to sex
Clinical characteristics were analysed according to sex
(Table 4). Fifteen patients were male and 139 patients were
female. Among preceding and associated symptoms,
preceding erythema was statistically more frequent in
women (p = 0.025). Henna hair dyes and other types of
hair dyes were more likely to be associated with aggravation
in female patients (p = 0.027 and p = 0.005, respectively).
Other clinical variables such as the age of diagnosis, time to
diagnosis, aggravating factors other than hair dye, Fitzpa-
trick skin type, location of hyperpigmentation, and clinical
manifestations did not show any significant differences
between the two groups.
Clinical analysis according to hair dye use
Supporting Information: Table 1 presents clinical
features analysed according to hair dye use. There were
61 patients who reported using hair dye before Riehl
melanosis development. Thirty‐four patients reported
using henna hair dye, 47 patients reported using hair dye
other than henna, and 20 patients used both products.
The age and sex are both statistically related to the hair
dye use (p = 0.001 for both). Among various locations,
involvement of the forehead was significantly related to
hair dye use (p < 0.001). Time to diagnosis was signifi-
cantly shorter in those who used hair dye (p = 0.001).
Other clinical variables such as preceding and associated
symptoms, aggravating factors other than hair dye,
location of hyperpigmentation other than the forehead,
and clinical manifestations did not show any significant
differences between the two groups.
Treatment and prognosis
Follow‐up data were available in 110 patients. The
mean follow‐up period was 11.4 months (range 2–48
months). Global assessment scale scores decreased
from 2.7 ± 0.6 to 1.8 ± 0.8 on average after treatment.
The average treatment response score according to the
percentage of pigment clearing was 0.9. There were 38
patients who showed a fair response (0%–25%),
50 patients had a moderate response (26%−50%), 17
patients showed a good response (51%–75%), and 5
patients had an excellent response (76%–100%)
(Figure 1). The overall cumulative response rate of
≥26% pigment clearing was 65.5%. According to
logistical regression analysis, a longer disease duration
(>3 months, p = 0.002) was a statistically significant
factor associated with poorer treatment response
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ET AL.
(Table 5). On the other hand, aggravation by hair
dye other than henna, use of laser therapy, and a
longer follow‐up period were found to be statistically
significant factors positively associated with treatment
response (p = 0.006, p = 0.015, and p = 0.021, respec-
tively). Patients received a wide range of treatments.
Topical agents including steroids (49.1%), calcineurin
inhibitors (40.9%), blanching creams (41.8%), and
polydeoxyribonucleotide (PDRN) (29.1%) were used.
Oral medication such as systemic steroids (49.1%),
antihistamines (73.6%), and tranexamic acid (87.3%)
were prescribed. Laser therapy was performed in
63.6% of patients, including low fluence 1064‐nm
Nd:YAG laser toning (22.7%), 1064‐nm picosecond
laser therapy (7.3%), and needle radiofrequency laser
therapy (17.3%). However, no single therapy proved to
be a statistically significant factor in the treatment
response.
D I S C U S S IO N
Riehl melanosis is a cosmetically debilitating disorder
with significant psychosocial impacts on affected
patients because it manifests as hyperpigmentation
on exposed areas such as the face and neck. All
patients enrolled in this study had hyperpigmentation
limited to the face and neck to exclude lichen planus
pigmentosus (LPP) or ashy dermatosis, which can also
involve the trunk and limbs. However, it is difficult to
make a differential diagnosis among Riehl melanosis,
LPP, and ashy dermatosis. Generally, ashy dermatosis
develops at a younger age and more commonly
involves sun‐protected areas such as the trunk and
proximal extremities and presents with an erythema-
tous border in early lesions. 6 LPP can present with
past or current evidence of lichen planus, can manifest
in intertriginous sites, and may present erythematous
borders; it mostly affects the forehead and temporal
area and shows dense band‐like lichenoid infiltra-
tion.6,7 Whether these three diseases are distinct
entities or variants of the same disease has been a
topic of debate.7,8
Another descriptive diagnosis to take into account is
erythrose peribuccale pigmentaire of Brocq, also referred
to as erythrosis pigmentosa faciei.9 This syndrome occurs
predominantly in middle‐aged women, and a photo-
dynamic substance in cosmetics is probably responsi-
ble.10,11 Diffuse, brownish‐red pigmentation develops
more or less symmetrically around the mouth but spares
a narrow perioral ring. It may extend to the centre of the
face and the forehead, and in some cases there are well‐
defined patches of pigmentation over the angles of the
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CHARACTERISTICS OF RIEHL MELANOSIS | 225

jaw and the temples.9 The erythematous component and
the intensity of the pigmentation may fluctuate over
short periods.10,11 The pigmentation is usually persistent
but tends to fade gradually if the cause is eliminated.
Although only a few cases have been described, we
suspect that this entity can be included in the spectrum
of Riehl melanosis.
Unlike allergic contact dermatitis, Riehl melanosis is
usually preceded by either mechanical or chemical
stimulation and frequently accompanies barrier impair-
ment, resulting in enhanced penetration of causative
agents. In our study, dryness, which is a sign of damaged
barrier function, was found in 11.7% of patients, and
preceding erythema and itching were observed in about
half of the patients. Although various mechanical stresses
such as laser treatment, peeling, friction, exercise, and
overheating were aggravating factors, chemical stimuli
such as hair dyes and cosmetics were most commonly
found aggravating factors. In regard to the distribution of
the hyperpigmentation, the U‐zone of the face (cheek,
perioral area, and chin) was more likely to be affected than
the T‐zone (forehead and nose). This distribution is
probably related to the fact that the T‐zone has a stronger
barrier function with a higher sebum level and lower

F I G U R E 1 Clinical and histopathological features of a Riehl melanosis patient. (a−c) A 61‐year‐old woman who used hair dye every
6 months developed diffuse brownish maculopatches on her forehead, both cheeks, perioral area, and neck. The patient complained of an
itching sensation and previously had erythema. (d−f) The patient was prescribed transamine 250 mg three times a day and the
antihistamine ebastine 10 mg as well as a topical calcineurin inhibitor. A nanosecond 1064‐nm Nd:YAG laser (Tri‐Beam; Jeisys Corp.) was
used with a zoom handpiece with a spot size of 7 mm, fluence of 1.5−3.0 J/cm2, a repetition rate of 10 Hz, and six passes. After 15 laser
treatments, the hyperpigmented lesions improved significantly. (g, h) The histopathological features of the lesions suggested interface
dermatitis with dermal melanophages and mild perivascular inflammation (g: Hematoxylin−eosin stain; magnification: ×100,
h: Hematoxylin−eosin stain; magnification: ×400).
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226 | CHOI ET AL.

TABLE 5 Prognostic factors influencing the treatment response in the patients with Riehl melanosis
95% confidence
Variables Category Odds ratio interval p Value
Gender Female Reference
Male 6.224 0.613–63.238 0.122
Age (years) >50 Reference
≤50 0.201 0.039–1.041 0.056
Duration (mo) ≤3 Reference
>3 0.104 0.024–0.451 0.002*
Fitzpatrick skin type III Reference
IV 0.617 0.115–3.316 0.574
Preceding symptoms Erythema 5.247 0.850–32.379 0.074
Itching 0.583 0.139–2.444 0.460
Facial flushing 1.203 0.170–8.488 0.853
Associated symptoms and signs Photosens‐itivity 4.635 0.319–67.420 0.262
Dryness 0.230 0.022–2.455 0.224
Aggravating factors Henna hair dye 0.233 0.027–2.004 0.184
Other hair dye 5.033 1.578–16.056 0.006*
Laser treatment 24.793 0.186–3297.618 0.198
Friction 3.537 0.244–51.250 0.354
Cosmetics 1.703 0.221–13.136 0.609
Exercise 0.205 0.008–5.319 0.340
Sunlight 0.823 0.095–7.154 0.860
Treatment Topical steroid 2.145 0.567–8.109 0.261
Topical calcineurin inhibitor 0.457 0.057–3.655 0.461
Topical blanching cream 0.813 0.186–3.557 0.784
Systemic steroid 1.084 0.240–4.900 0.916
Antihista‐mine 0.408 0.062–2.678 0.350
Tranexamic acid 1.190 0.168–8.452 0.862
PDRN 3.179 0.307–32.924 0.332
Laser treatment 4.397 1.331–14.523 0.015*
Nd‐YAG 0.286 0.080–1.017 0.053
Pico 1064 0.094 0.003–3.210 0.190
Needle RF 0.668 0.053–8.464 0.756
Follow‐up period ≤3 Reference
>3 3.399 1.09–11.450 0.021*
*p < 0.05.

transepidermal water loss.12 Riehl melanosis is known to
present as diffuse pigmentation but reticulated or spotty
lesions are also observed.6,13,14 Most of our study patients
had a diffuse pattern but spotty or reticulated lesions were
also found as a single pattern or combined with other types.
The common allergens observed in Riehl melanosis
patients include aniline dyes, bactericides, fragrances,
and fixatives such as benzyl salicylate.15–17 Despite the
fact that the exact pathogenesis and aetiology of Riehl
melanosis still remain controversial, previous studies

CHARACTERISTICS OF RIEHL MELANOSIS
have suggested that allergic sensitization induced by
repeated exposure to low concentrations of particular
chemicals, including fragrance or dye, could be the
major cause.14,18 In this study, 76.5% of patients
revealed positive patch tests, which is consistent with
previous studies.3,17,19,20 However, the clinical rele-
vance of positive test results is doubtful in most cases.
Despite the fact that half of the patients recalled that
their lesions were related to hair dye use, p‐
phenylenediamine and henna hair dye showed
reactive patch tests in only one patient each. More-
over, a recent study on Riehl melanosis suggested that
elevated transient receptor potential vanilloid 1
(TRPV1) linked the symptoms of Riehl melanosis
patients to inflammation‐related hyperpigmentation
through Ca2+/protein kinase C/tyrosinase activity,
which implies that irritation is important in the
development and aggravation of Riehl melanosis.21
In this study, Riehl melanosis in older patients was
related to hair dye use and more likely to manifest as
spotty hyperpigmentation, while in younger patients the
disorder tended to show erythema. Since the barrier
functions of skin decrease with age, a young patient who
develops Riehl melanosis may have been exposed to
preceding stimuli that damaged the skin barrier, result-
ing in erythema. In regard to sex, female patients are
more likely to have had preceding erythema and hair dye
use than male patients. Lastly, patients who developed
Riehl melanosis after hair dye use developed lesions
more frequently on the forehead and that were diagnosed
more quickly. This is probably because hair dyes can
result in the relatively rapid development of Riehl
melanosis or because dyspigmentation after henna hair
dye has been a social issue in Korea, resulting in
enhanced awareness.
Among a wide range of factors, long disease
duration was associated with poor treatment response,
while aggravation by hair dye other than henna, laser
therapy, and longer follow‐up periods was related to
good treatment response. In this study, tranexamic
acid and antihistamine were the most frequently
prescribed drugs, and laser therapy was used in
63.6% of patients. Despite the fact that no single
treatment proved to be a statistically significant factor
in the treatment response, laser therapy was associ-
ated with better outcomes. Although standardization
of laser therapy has not been established in Riehl
melanosis patients, two previous studies demonstrated
the efficacy of intense pulsed light therapy (IPL) and
dual pulsed Q‐switched Nd:YAG laser therapy for
Riehl melanosis.20,22 More studies are needed to
compare the efficiency of various laser therapies in
Riehl melanosis patients.
27686566, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jvc2.44 by Cochrane Malaysia, Wiley Online Library on [20/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 227
In summary, we investigated clinical characteristics
of recent Korean Riehl melanosis patients and found that
clinical manifestations of Riehl melanosis differ to some
extent according to age, sex, and hair dye use. Moreover,
detailed history taking in regard to disease duration and
aggravating factors, as well as the use of extended laser
therapy, can be important for the management of Riehl
melanosis.
C O NF L I C T O F I N T E R E S T
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are
available on request from the corresponding author, Sun
Eun Chang.
ETHICS STATEMENT
The patients in this manuscript have given written
informed consent to the publication of their case details.
ORC ID
Myoung Eun Choi http://orcid.org/0000-0001-
7514-7873
Youngkyoung Lim http://orcid.org/0000-0002-
6409-2704
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SU PPOR T ING INF OR MATI ON
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.
How to cite this article: Choi ME, Lim Y, Lee
WJ, Won CH, Lee MW, Chang SE. Characteristics
of Riehl melanosis in an ethnic Asian population: a
comparative study according to age, sex, and hair
dye use. JEADV Clin Pract. 2022;1:219–228.
https://doi.org/10.1002/jvc2.44