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Lactic Acid as a New Therapeutic Peeling Agent in the Treatment of Lifa

Disease (Frictional Dermal Melanosis)

Article in Indian Journal of Dermatology · November 2012

DOI: 10.4103/0019-5154.103063 · Source: PubMed

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 Efficacy and Safety of 532-nm and 1,064-nm Q-switched
Nd:YAG Laser Treatment of Frictional Dermal Melanosis
Over Bony Prominences (Lifa Disease)
Muhsin A. Al-Dhalimi, MD,* Azar H. Maluki, MD,* and Amir Tauma, MD†

BACKGROUND Frictional dermal melanosis over bony prominences (Lifa disease) is a common pigmentary
skin disorder in Iraqi patients. Q-switched lasers are the gold standard treatment of correcting pigmentation;
among them are the 532-nm and 1,064-nm lasers.

OBJECTIVE To evaluate the efficacy of these lasers in the treatment of hyperpigmentation due to Lifa disease.

PATIENTS AND METHODS A prospective, comparative, controlled, split-lesion clinical trial study was
designed. Nineteen female patients with clinical diagnosis of Lifa disease were enrolled. Each patient was
treated for 3 sessions at 2-week intervals. A 532-nm Q-switched Nd:YAG laser was used on the left side and
1,064-nm on the right side of each lesion. Both objective and subjective parameters were assessed 1 and 3
months after the last treatment session. Darkness score, photographic assessment and patient satisfaction,
and improvement of itch were recorded, respectively.

RESULTS Seventeen patients completed the study. The color score changes of both sides demonstrated that
although both lasers were effective in reducing the pigmentation, the 1,064-nm wavelength had a more sig-
nificant response. Similar results were obtained for the photographic evaluations and patient satisfaction
scores. These changes were sustained throughout the 3 month follow-up.

CONCLUSION Both lasers were effective in the treatment of pigmentation abnormalities caused by Lifa
disease. However, the efficacy was greater with the 1,064-nm wavelength.

The authors have indicated no significant interest with commercial supporters.

P igmentary skin disorders present a difficult clinical

challenge among Iraqi and other Asian populations,
as they can result in negative cosmetic appearances and
can be associated with disfiguring diseases that have few
curative remedies.1,2 The term “frictional melanosis”
refers to the localized hyperpigmentation that develops
at sites of repeated friction.3 Frictional dermal
melanosis over bony prominences (Lifa disease) was
initially described in Iraq as a new distinctive condition
that followed chronic rubbing and friction with
a washing brush (Lifa).4,5 Clinically, the disease is
typically observed in slim females, with bilateral and
symmetrical distribution of pigmentation over bony
prominences, such as clavicular areas, upper back,
upper arms, and shins.4,5 This represents a common
problem especially in Iraq and other Asian countries,
such as Japan, Korea, India, and Jordan.6–9 Sharquie
speculated that the mechanism of pigmentation is due
to repeated damage to the basal cell layer as a result of
epidermal pressure between the underlying bone and
the offending washing brush.4,5,10,11 This explanation
was supported by the observed histopathologic features
of many melanophages in the papillary and reticular
dermis.4–8,11
Unfortunately, there is no curative or uniformly
effective therapy for this entity, although there have
been a few reports of clinical trials.12–14 The use of
Q-switched Nd:YAG laser (1,064 nm and 532 nm)
treatment was previously shown to be effective for

*Department of Dermatology, Faculty of Medicine, University of Kufa, Kufa, Iraq; †Department of Dermatology, Al-Sadir
Medical City, Najaf Health Directorate, Najaf, Iraq

· · ·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins
ISSN: 1076-0512 Dermatol Surg 2015;41:136–141 DOI: 10.1097/DSS.0000000000000238
·
136

Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.

pigmentation reduction of macular amyloidosis
patches,15 a disease with many similarities to Lifa
disease.6
Melanin absorbs and localizes the high-intensity irra-
diation from Q-switched Nd:YAG laser leading to
a rapid heating of melanosomes, thereby creating
a sharp temperature gradient between the melano-
somes and the surrounding structures. This gradient
leads to thermal expansion, leading to generation and
propagation of acoustic waves, which damage the
melanosome-laden cells, thus the mechanism of action
of Q-switched Nd:YAG laser is based on photo-
thermal and photomechanical effects, resulting in
pigmentation reduction of the treated area. Use of this
ultrashort pulsed laser can theoretically eliminate or
reduce melanin in the upper dermis as demonstrated
by histopathologic analyses.5–11
Based on this therapeutic success, this study was
designed to evaluate the efficacy and safety of 532-nm
and 1,064-nm Q-switched Nd:YAG laser treatment of
hyperpigmentation due to Lifa disease.
Patients and Methods
This is a prospective, comparative, clinical study per-
formed at the Laser Research Unit, College of Medi-
cine, University of Kufa, between October 2011 and
December 2012.
Nineteen patients who were clinically diagnosed with
frictional dermal melanosis over bony prominences
(Lifa disease) were enrolled in this study. These
patients did not receive any systemic or topical treat-
ment in the preceding 6 months. Exclusion criteria
were the presence of chronic systemic disease, personal
history of hypertrophic scar and keloid formation,
melanoma or other skin cancer, immunosuppression,
pregnancy, and lactation.
A full medical history was taken from each patient
including name, age, sex, lesion site(s), age of onset
and duration, presence and degree of itching, history
of friction (duration and agent), history of topical
medication, and family history and history of any
associated skin or systemic diseases. Careful physical
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
AL-DHALIMI ET AL
examination was performed for each patient to iden-
tify the lesion site(s), color, pigmentation pattern,
distribution, lesion symmetry, and skin phototype.
Wood’s light (Waldmann Medizintechnik, Berlin,
Germany) examination was completed for all patients
to assess the depth of pigmentation.
The treatment procedure was fully described to each
patient, and informed consent was obtained from all
participants. Furthermore, this study was approved by
the Ethical Scientific Committee of Dermatology and
Venereology of the Iraqi Board for Medical
Specializations.
Nineteen female patients, aged 20 to 48 years, with
disease duration ranging between 2 and 27 years were
included. A 532-nm Q-switched Nd:YAG laser was
used on the left side and 1,064-nm on the right side of
each lesion. Symmetrical regions of the back measur-
ing approximately 10 · 5 cm2 were treated. The
parameters of the laser used in this study were chosen
according to personal experience with treatment of
pigmented lesions on the trunk with Q-switched Nd:
YAG using the same laser system (Ultralight Q-
switched Nd:YAG laser; Quanta System SPA, Milan,
Italy). These parameters were modified to achieve the
blanching or whitening of the treated area, which
represent the desired immediate response to laser
treatment. Thus, in this study, the left side was treated
with a Q-switched Nd:YAG 532-nm laser with the
following parameters: spot size, 3 mm and fluence,
2.5 J/cm2 at a repetition rate of 5 Hz. The right side
was treated with the same laser type of 1,064-nm
wavelength with the following parameters: spot size,
3 mm and fluence, 9 J/cm2 at the same repetition rate.
No local anesthetic was used during laser therapy,
and patients were questioned regarding the level of
pain from the 2 of laser treatments by a visual analog
scale (VAS) (0: no pain to 10: intolerable pain). At the
end of each session, the treated sites were observed,
and the early skin reactions to the laser treatment
were recorded. Each patient was treated for 3 sessions
at 2-week intervals.
All participants were instructed to avoid any rubbing
or friction of skin with a washing agent (Lifa). The
patients were also asked to avoid additional therapy
41:1:JANUARY 2015 137
 LASER TREATMENT OF FRICTIONAL DERMAL MELANOSIS
during the study period. Patients who complained of
discomfort and erythema were given 2.5% hydro-
cortisone skin cream twice daily until discomfort
ceased.
Follow-up
The patients were examined every 2 weeks during the
treatment period, side effects were recorded, and pho-
tographs were taken before and after each session. The
assessment of the improvement was performed 1 month
after the last treatment session. Monthly follow-up
examinations were completed for 3 months after the
last treatment session to determine any complications
or signs of relapse.
Evaluation
All treated patients were evaluated objectively and
subjectively regarding their response to treatment by
the following methods.
Color Score (Darkness Score)
The darkness of the hyperpigmentation was assessed
by the same clinician according to a specific color score
chart established by Sharquie and colleagues, 2005.16
According to this score, the darkness or the color of
pigmentation is graded from 0 to 4 as follows:
Score 0: no pigmentation;
Score 1: light brown;
Score 2: brown;
Score 3: dark brown;
Score 4: black.
Photographic Assessment
Color photographs for each patient were taken in the
same place with fixed illumination and distance at the
baseline, before and after each therapy session and at
each follow-up visit using a Sony digital, high sensi-
tivity, 9.1 mega pixel, DSC-HX1 still camera. The
digital photographs were blindly assessed by 2 inde-
pendent dermatologists for the degree of pigmentation
improvement using a VAS from 0 to 10 (0: no pig-
mentation to 10: severe black pigmentation) before
treatment and at the end of follow-up period.
138 DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
Subjective Methods
Patient Satisfaction. This method depended on
recording the degree of patient satisfaction regarding
the improvement of pigmentation during the course of
intervention and was graded from 0 to 3 as follows:
Grade 0: not satisfied;
Grade 1: moderately or partially satisfied;
Grade 2: greatly but not fully satisfied;
Grade 3: fully or completely satisfied.
Itching Improvement. All patients were asked
about the state of their itching (increased, decreased,
or disappeared) at each follow-up visit.
Statistical Analysis
All values were expressed as mean 6 SD. The data
were analyzed using SPSS version 17 and establishing
p < .05 as the lowest limit of significance. Paired
t-tests were used to assess the differences in param-
eters before and after treatment.
Results
Nineteen female patients were enrolled in this study.
Their ages ranged from 20 to 48 years with a mean 6
SD of 33.7 6 7.6 years. Itching was reported in 12
(63.15%) patients, although the main cause of pre-
sentation in all patients was cosmetic disfigurement.
According to Fitzpatrick classification for skin types,
2 patients (10.5%) were skin Type II, 10 patients
(52.6%) were skin Type III, and 7 patients (36.8%)
were skin Type IV. Wood’s light examination in all
patients showed no contrast, indicating that pig-
mentation was mainly dermal.
Two patients were defaulted from the study after the
first treatment session for unknown reasons, and the
remaining 17 patients completed the study. The baseline
color score was 3 (dark brown) for all patients before
initial treatment. The left side of the back was treated
with Q-switched Nd:YAG laser (532 nm), changing the
color score to 2 (brown) in 11 (64.7%) patients, to 1
(light brown) in 3 (17.6%) patients, and no change in 3
(17.6%) patients. On the right side of the back, which
was treated with 1,064-nm laser, the change of color
score to 2 (brown) was achieved in 5 (29.4%) patients
 AL-DHALIMI ET AL

TABLE 1. Mean 6 SD of Color Score and VAS Before and After Treatment With 532-nm and 1,046-nm Laser

Parameters Types of Laser Before Treatment After Treatment p

Color score 532 nm 360 1.45 6 0.82 <.001

1,046 nm 360 1.27 6 0.46 <.001
VAS 532 nm 7.6 6 0.92 6.54 6 1.1 <.01
1,046 nm 7.6 6 0.92 4.63 6 0.8 <.001

and to 1 (light brown) in 12 (70.6%) patients. These
color score changes were statistically significant (p <
.001; Table 1). The change of color score after treat-
ment with the 1,064-nm laser was significantly greater
compared with the 532-nm laser treatment (p < .027)
(Figures 1 and 2). The improvement that was estab-
lished after the last treatment session for both sides in
each patient was sustained without any obvious relapse
throughout the 3 months follow-up period.
by computer view of their digital photographs by 2
independent dermatologists before treatment and at
the end of follow-up period (Table 1). The change in
the VAS score from the baseline for the region treated
with the 1,064-nm laser was statistically more sig-
nificant than the 532-nm laser treatment (p < .001).
Furthermore, patients were more satisfied with the
1,064-nm laser treatment compared with 532-nm
laser treatment (p < .006; Table 2).

The VAS from 0 to 10 was used to assess the degree of The itching disappeared after the first treatment ses-
pigmentation of both treated regions for each patient sion for all patients, independent of treatment type.

Figure 1. Patient with Lifa disease. (A) Before treatment. (B) Figure 2. Patient with Lifa disease. (A) Before treatment. (B)
After treatment—L: treated with 532-nm laser; R: treated After treatment—L: treated with 532-nm laser; R: treated
with 1,064-nm laser. with 1,064-nm laser.

41:1:JANUARY 2015 139

Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
 LASER TREATMENT OF FRICTIONAL DERMAL MELANOSIS
TABLE 2. Patients Satisfaction After Treatment With 532-nm and 1,064-nm Lasers
Grading of Patient Satisfaction
Types of Grade 0 (Not Grade 1 (Partially
Laser Satisfied) Satisfied)
532 nm 2 (18.1%) 3 (27.2%)
1,064 nm 0 3 (27.2%)
p value statistically significant (.006).
Surprisingly, itching even ceased on the untreated
sites. This effect persisted throughout the treatment
sessions and the follow-up period. Recurrence of
itching was reported in 3 patients after the second
treatment session. After laser treatment, burning sen-
sation and erythema persisted for 2 to 3 days for all
patients. Generally, at the time of therapy, patients
believed that 532-nm laser was more painful than the
1,064-nm laser at the time of therapy (mean 6 SD,
6.7 6 1.0 for 532 nm and 4.3 6 0.9 for the 1,064 nm
based on a 1–10 analogical scale). Urticarial lesions
disappeared after few hours. Petechiae lesions per-
sisted for 5 to 7 days and then disappeared without
any sequel. Desquamation was persisting for 1 to
2 days.
Discussion
Frictional dermal melanosis over bony prominences
(Lifa disease) was described in many countries, includ-
ing Iraq. It was an extremely disfiguring pigmentary
disease, especially among females.3–11 Generally, dermal
hyperpigmentation was resistant to many therapeutic
interventions.13 The treatment of Lifa disease was often
challenging, especially when the patient continues to
experience friction and Lifa usage.5 This malady has no
satisfactory topical bleaching or peeling treatment,
although if the patient stops the use of the Lifa or gains
weight, the melanosis may disappear spontaneously
over long time.10 However, many patients seek treat-
ment of this chronic and disfiguring disease.
Topical steroid and etretinate treatment have positive
ameliorating effects,17–19 although the condition soon
relapses after the etretinate is discontinued.19 Derm-
abrasion could be a useful approach in dermal
140 DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
Grade 2 (Greatly Grade 3 (Fully
Satisfied) Satisfied)
4 (36.3%) 2 (18.1%)
4 (36.3%) 4 (36.3%)
melanosis,20 although it may be associated with high
risk for postinflammatory hyperpigmentation. In
a recent study, a full-strength lactic acid (92%, pH 3.5)
was used as a chemical peeling agent in the treatment
of this entity and was shown to be an effective and safe
option for the treatment of Lifa disease.12
Lasers have revolutionized the treatment of many
dermatological conditions, such as pigmentary dis-
orders.21 Several types of lasers were developed specif-
ically for the treatment of pigmented skin lesions.22 The
Q-switched Nd:YAG laser (1,064 nm and 532 nm) has
yielded promising results in the treatment of many
epidermal and dermal pigmented lesions.15,23
Based on the positive results, the authors aimed to test
the efficacy of this type of laser therapy for the treat-
ment of Lifa disease in Iraq. Both color score and
objective assessment of patches reveal a positive effect
for both wavelengths of laser treatment for improved
pigmentation. The degree of response was significant
for both wavelengths but was more effective for the
regions treated with the longer wavelength laser
(Figure 1). The improvement was sustained without
any obvious relapse throughout the follow-up period.
These response rates were also accompanied by
strong patient satisfaction scores. Moreover, no side
effects were observed, and the pain created by lasers
at the time of treatment was tolerable.
Additionally, itching subsided after first treatment
session in all patients who experienced itching ini-
tially. This was true for either treatment type. Sur-
prisingly, this response was recorded in untreated
regions as well. The exact mechanism behind this
specific response is unclear and may be related to

psychological aspects or release of certain anti-
inflammatory cytokines. The efficacy and safety of
therapy were not affected by the age of patients,
duration of disease, or skin phototype of patients.
All results of this study support the use of the 1,064-
nm wavelength over 532-nm wavelength. This may be
explained by the fact that melanin pigments may reach
deeper layers of the dermis,11 and the 1,064-nm laser
was more effective in the middle to deep dermal
pigmentations of skin. This was supported by the
general fact that the Q-switched Nd:YAG at 1,064-
nm was best for treating darkly pigmented skin
because of the lower risk of subsequent induction of
pigmentary changes.24 In conclusion, the 1,064-nm
Q-switched Nd:YAG laser is a suitable and effective
mode of therapy for treating dermal melanosis in
patients with Lifa disease.
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Address correspondence and reprint requests to: Muhsin A.
Al-Dhalimi, MD, Department of Dermatology, Faculty of
Medicine, University of Kufa, PO Box 21, Kufa Post Office,
12224, Najaf, Iraq, or e-mail: muhsin.aldhalimi@uokufa.
edu.iq
41:1:JANUARY 2015 141