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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.80 no.4 Rio de Janeiro July/Aug. 2005
Depigmentation therapy for generalized vitiligo with topical 88% phenol solution*
Maurício ZaniniI; Carlos D' Apparecida Santos Machado FilhoII
in Dermatology, Tutor at Dermatocosmiatry and Dermatological Surgery Department
IIDoctor in Medicine, Efective Member of the Brazilian Society of Dermatology, Full Head of Dermatology Discipline at Faculdade de Medicina do ABC
Authors relate a case of generalized vitiligo with residual normochromic patches succesfully treated with 88% solution of phenol.
Keywords: Phenol; Vitiligo; Vitiligo/therapy
Sixty-two year-old female with generalized vitiligo, with residual normochromic patches in the anterior cervical region (Figure 1), stable for over eight years. Owing to the generalized affection, nearly universal, repigmentation options were not considered. A depigmentation therapy with topic aqueous 88% phenol solution was proposed. Before the application, skin was intensely hygienized with gauzes soaked with alcohol. The solution was applied with a swab in a single application, with the observation of formation of cutaneous frosting. After two sessions, 45 days apart, there was total elimination of residual pigmented areas (Figure 1).
Vitiligo is an acquired pigment disturbance which affects the melanocyte, a dendritic cell producing melanin pigment and which is derived from the neural crest. In the skin, it is located at the basal layer and follicular sheath.1,2 Depigmentation therapy is indicated for generalized vitiligo, particularly in instances in which repigmentation therapy failed. American specialized literature highlights the use of cream of monobenzyl ether of hydroquinone at 20% as the drug of choice for depigmentation.1 Even though it is often efficable, repigmentation and adverse effects are common (confetti-like dischromia).3,4 In Brazil, however, this drug is not available. As such, and based on the pharmacological/biological principles of phenol compounds, the authors have introduced in their clinical practice the use of 88% phenol solution as a depigmentation therapy for generalized vitiligo.
Phenol is a well established agent used in chemical peelings. When used at the concentration of 88%, an immediate proteic coagulation is observed in the epidermis.5 If phenol is re-applicated, depth will be greater, with the capacity of reaching upper reticular dermis.5,6 All phenol compounds have toxicity over melanocytes. Transient or definite hipopigmentation is a feature of phenol cauterizing, and this is due to the development of a melanocytic incapacity to normally synthesize melanin,7 i.e., phenol does not seem to determine melanocyte destruction, rather, it compromises its activity.
The use of a swab moisted with phenol is more proper to treat small areas. The patient feels a burning sensation for approximately 60 seconds, which returns after 10 minutes, with a smaller intensity and which lasts from minutes to hours. Following cares include delicate cleaning with saline, use of antibiotic ointment with steroids of mild to moderate potency and sun blocks. The use antivirals is indicated for patients with a history of herpes simplex. A non-occluded phenol application in a small area does not demand necessary cares with Baker-Gordon's phenol formula.5 A small area should be understood as an area extending up to 20% of face or neck area, as 88% phenol rapidly coagulates epidermis, thus stopping its percutaneous penetration; on the other hand, in Baker-Gordon's formula, phenol is concentrated at 40 to 50%, which enhances its penetration and consequently its systemic absorption.5
The goal of this correspondence was to bring a case to exemplify the atuthors' experience in phenol depigmentation therapy for vitiligo. In this case, the proposal to use phenol was made with the purpose of determining hipopigmentation in residual pigmented areas. Since the neck has a low follicular density, only two cauterizing sessions were needed for complete success. About one year and a half after the therapy there were no signs of repigmentation. Eighty-eight percent phenol can be considered as a therapeutical option for generalized vitiligo in order to eliminate residual normally pigmented areas. It is a cheap, practical product, normally with no complications in experienced hands. Possible complications are inesthetical scars formation, dischromias and development of herpetic eczema. It is important to highlight that, even after depigmentation is totally accomplished, there is a risk of pigmentation returning, mainly in those patients who do not protect themselves properly from ultraviolet radiation. However, there are no contraindications for therapeutical reuse.
1. Freedberg IM, Eisen AZ, Wolff Ket al. Fitzpatrick's dermatology in general medicine. In: Mosher DB, Fitzpatrick TB, Ortonne JP, Hori Y, eds. Hypomelanosis and hypermelanoses, 5th ed. New York: McGraw-Hill, 1999: p. 945-60. [ Links ]
2. Zanini M, Wulkan C, Machado Filho CDS. Vitiligo: há ou não melanócitos? Med Cut Ibe Lat Am. 2002; 30: 152-3. [ Links ]
3. Oakley AM. Rapid repigmentation after depigmentation therapy: vitiligo treated with monobenzyl ether of hydroquinone. Australas J Dermatol. 1996;37:96-8. [ Links ]
4. Catona A; Lanzer D. Monobenzone, Superfade, vitiligo and confetti-like depigmentation. Med J Aust. 1987;146:320-1. [ Links ]
5. Brody HJ. Chemical peeling and resurfacing. 2nd ed. Missouri: Mosby, 1997: p.137-53. [ Links ]
6. Moy LS, Kotler R, Lesser T. The histologic evaluation of pulsed carbon dioxide laser resurfacing versus phenol chemical peels in vivo. Dermatol Surg. 1999;25:597-600. [ Links ]
7. Stuzin JM, Baker TJ, Gordon HL. Treatment of photoaging: Facial chemical peeling (phenol and trichloroacetic acid) and dermabrasion. Clin Plast Surg. 1993; 20:9-25. [ Links ]
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Received in February
Approved by the Consultive Council and accepted for publication on August 20, 2004.
* Work done at Dermatology Discipline at Faculdade de Medicina do ABC - Santo André, São Paulo, SP, Brazil.