Lifa Disease: Frictional Dermal Melanosis over Bony Prominences (Clinicopathological Study)

doi:10.4236/jcdsa.2012.23036

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Journal of Cosmetics, Dermatological Sciences and Applications, 2012, 2, 196-200

http://dx.doi.org/10.4236/jcdsa.2012.23036 Published Online September 2012 (http://www.SciRP.org/journal/jcdsa)

Lifa Disease: Frictional Dermal Melanosis over Bony

Prominences (Clinicopathological Study)*

Khalifa E. Sharquie1#, Muhsin A. Al-Dhalimi2, Adil A. Noaimi3, Hussein A. Al-Sultany4

1Scientific Council of Dermatology & Venereology-Iraqi Board for Medical Specializations, Baghdad, Iraq; 2Department of Derma-

tology & Venereology, College of Medicine, University of Kufa, Najef, Iraq; 3Department of Dermatology & Venereology, College

of Medicine, University of Baghdad, Baghdad, Iraq; 4Department of Dermatology & Venereology, College of Medicine University of

Babylon, Babylon, Iraq.

Email: #[email protected]

Received April 20th, 2012; revised May 23rd, 2012; accepted June 10th, 2012

ABSTRACT

Background: Lifa disease (Frictional dermal melanosis over bony prominences) has been described in Iraq for the first

time in 1993, as a new distinctive pigmentary skin condition that followed chronic friction with a body washing agent

(lifa) during bathing. Objective: To assess this increasingly common problem where still many doctors unaware about

its presence especially in other Middle East countries. Patients and Methods: A case series descriptive study done in

Departments of Dermatology-Najaf and Baghdad Teaching Hospitals, between March 2007 - October 2008. Full history

and clinical examination were done for all patients including Wood’s light examination. Biopsies were taken from 21

patients and sent for hematoxylin-eosin and Congo red stains. Results: Fifty-two (49 females and 3 males) patients with

typical clinical features of lifa disease were studied. The mean age of presentation was 27.92 ± 7.58 years. All patients

were slim with prominent bones and low body mass index, used lifa vigorously during bathing. Pigmentation was dis-

tributed bilaterally and symmetrically over bony prominences. The most common affected sites were: clavicular areas

(67.3%) and upper back (42%). Wood’s light and histopathological examinations revealed dermal melanosis. No amy-

loid deposit was detected by using Congo red stain in any patient. Conclusions: Lifa disease is a common distinctive

pigmentary disfiguring problem especially among females. The histopathology showed dermal melanosis, and might be

confused with other pigmentary problems like macular amyloidosis.

Keywords: Frictional Dermal Melanosis; Lifa Disease; Macular Amyloidosis

1. Introduction

Pigmentary skin disorders are a major problem among

Iraqi and other Asian countries as they had a bad cosmetic

appearance and considered as a disfiguring diseases [1,

2].

Dermal melanosis is one of the important pigmentary

problems, most commonly observed in inflammatory

skin disorders, particularly in dermatoses that involve da-

mage to the epidermal basal cells and/or to the dermo-

epidermal junction. Post-inflammatory dermal melanosis

may occur following trauma (as friction and rubbing) or

other inflammatory diseases as lichen planus [3].

Lifa disease (frictional dermal melanosis over bony pro-

minences), seem to be a common problem especially in

Iraq and other countries in the Asia and Middle East as

Japan, Korea, India, Jordan [4-10]. The disease most

probably appears as a result of using rough washing agent

like lifa in Iraq [4-6] and Jordon, scrub pad in Mexico [7],

and nylon towel in Japan [8] and this problem could be

easily mixed up with macular amyloidosis which is also

prevalent in these countries [11-15]. In Iraq this problem

was first reported in 1993 by Sharquie. The main features

of this disease were the affection of slim females mainly,

by pigmentation that occurs bilaterally and symmetri-

cally over the bony prominences like clavicular areas,

upper back, upper arms, and shins [4].

The aim of this study is to evaluate this common prob-

lem where still many dermatologists are unaware about its

presence especially in other Middle East countries.

2. Patients and Methods

This case series, descriptive study was carried out in the

Departments of Dermatology in Najaf, and Baghdad Teach-

ing Hospitals, during March 2007 - October 2008. Fifty-

two patients were enrolled in this study.

*This study was an independent study and not funded by any of the

drug companies.

#Corresponding author.

Lifa Disease: Frictional Dermal Melanosis over Bony Prominences (Clinicopathological Study) 197

All patients had clinical features of lifa disease that

characterized by rippled, spotty, or confluent macular hy-

per-pigmentation over the superficial bony prominences

with bilateral and symmetrical distribution.

The patients were questioned regarding the: Age, sex,

site of the lesions, age of onset and duration, presence of

itching, presence of friction, duration and type of friction

and agents used with special concern about usage of lifa

(lifa in Iraq is made from fibers which is either of plant

or plastic in origin (Figure 1)) during body bathing, his-

tory of administration of drugs, and history of topical

application of medications or other chemicals. Also they

were questioned about any associated skin or systemic

diseases and family history of similar skin pigmentation

in close relatives of the patients.

Careful physical examination was carried out to iden-

tify the site of the lesions, color, pattern of pigmentation,

and distribution and symmetry of the lesions. Wood’s

lamp examination was performed for every patient and the

enhancement of pigmentation was determined. The weight

and the height of the patients were measured, and then body

mass index (BMI) was calculated for all patients.

Laboratory studies including complete blood count

(CBC), renal and liver function tests were undertaken for

each patient. Skin biopsies were taken from 21 patients,

from the worst affected sites. Two staining methods were

performed to each biopsy specimen, the ordinary hema-

toxylin-eosin and Congo red stains.

All patients were photographed by a digital camera in

the same place with fixed illumination and distance by

using a digital camera (Sony: Cyber shoot with resolu-

tion 7 mega pixels).

Ethical approval was performed by the scientific com-

mittee of the Scientific Council of Dermatology and Ve-

nereology-Iraqi Board for Medical Specializations, and

informed consents were obtained from all participants in

the study. We used the EPI INFO system version 3.5.1

Figure 1. Lifa washing agent.

for the statistical analysis of the results.

3. Results

Fifty-two patients were included in this study. Their ages

at presentation ranged from 16 - 45 years with a mean ±

SD of 27.92 ± 7.58 years. The disease duration varies

between 0.5 - 12 years with a mean ± SD of 4.65 ± 3.33

years. The age of onset of the disease ranged from 15 -

38 years with a mean ± SD of 23.19 ± 6.31 years. The

disease started between 15 - 29 years in 43 (82.6%) pa-

tients with a mean ± SD of 20.95 ± 4.24 years. There

were 49 (94%) female patients and 3 (6%) male patients

with a female: male ratio of 16:1.

The main presenting feature in all patients was the bad

cosmetic disfiguring pigmentation. Itching was found in

38 (73%) patients.

All patients were slim with prominent bones and low

BMI < 20 kg/m2. The BMI of the patients ranged from

17.5 - 19.8 kg/m2 with a mean ± SD of 18.21 ± 0.66, 37

(71.2%) of the patients were underweight (BMI < 18.5)

and the remainder 15 (28.8%) patients were within the

lower normal level (18.5 - 19.9).

All patients gave history of using lifa vigorously dur-

ing body bathing for long period before the appearance

of the hyper-pigmentation.

No history of any associated skin and systemic dis-

eases was given by any patient. There was no history of

administration of drugs, or history of topical application

of medication or other chemicals. Family history of

similar skin pigmentation among close relatives of the

patients was positive in 9 (17.3%) patients.

The patients were presented with dark brown pigmen-

tation, which was bilaterally and symmetrically distrib-

uted over the superficial bony prominences (Figure 2).

The most commonly affected sites were: clavicular areas

in 35 (67.3%) patients, upper back 22 (42%), lateral as-

pect of the arms 19 (36.5%), shins 16 (30.7%) and A-

dam’s apple 14 (26.9%) patients (Table 1).

The morphology and pattern of hyper-pigmentation

were variable according to the site of involvement. The

most common pattern was the rippled or reticulated form

that was seen in 36 (69.2%) patients especially on the

clavicular areas, and neck (Figures 2 and 3). The hyper-

pigmented macules may coalesce to form large patches

with small macules that could be seen at its periphery.

This pattern of hyper-pigmentation was seen in 23

(44.2%) patients especially on the upper back. Spotty

(mottled) hyper-pigmented patches were seen in 19

(36.5%) patients on the lateral aspect of the arms, shoul-

der and upper back. Different combinations of these pat-

terns have been detected in many patients.

According to Fitzpatrick classification for skin types,

21 (40.3%) patients were of skin type III, and 31 (59.6%)

Lifa Disease: Frictional Dermal Melanosis over Bony Prominences (Clinicopathological Study)

198

Table 1. Predilection sites in lifa disease.

Patients

% No.

Sites

86.5% 45 1—Chest:

67.3% 35 Clavicle

9.6% 5 Upper chest

5.8% 3 Sternum

3.8% 2 Ribs

48% 25 2—Back:

42% 22 Upper back

3.8% 2 Whole back

1.9% 1 Midline of back

46% 24 3—Upper limbs:

36.5% 19 Lateral aspect of arms

9.6% 5 Lateral aspect of forearms

42% 22 4—Neck:

26.9% 14 Adam’s apple

3.8% 2 Back of neck

7.7% 4 Sides of neck

3.8% 2 Whole neck

7% 10 5—Lower limbs:

30.7% 16 Shins

1.9% 1 Thigh

3.8% 2 6—Mandible:

Figure 2. Bilateral and symmetrical distribution of rippled

hyperpigmentation over the ribs.

(a)

(b)

Figure 3. Bilateral and symmetrical distribution of rippled

hyper-pigmentation over the clavicular areas.

patients were of skin type IV.

Wood’s light examination in all patients showed no

contrast enhancement, which indicated that this pigmen-

tation is mainly dermal melanosis. The laboratory studies

for all patients were normal.

The histopathology of biopsies from 21 patients show-

ed:

1) Slight hyperkeratotic changes in a basket-weave

configuration in 8 (38%) patients (Figure 3);

2) The stratum granulosum was of normal thickness in

all patients;

3) Acanthosis was detected in 3 (14%) patients;

4) Diffuse continuous basilar hyper-pigmentation was

seen in 16 (76%) patients (Figure 3);

5) Striking degree of pigmentary incontinence with

presence of melanin containing macrophages (melano-

phages) in the upper dermis was found in all patients

(Figure 4);

6) Superficial perivascular lymphohistiocytic inflam-

matory infiltrate was seen in 7 (33%) patients;

Lifa Disease: Frictional Dermal Melanosis over Bony Prominences (Clinicopathological Study) 199

Figure 4. Pigmentary incontinence confined to the papillary

dermis (HE, ×400).

7) No amyloid deposits were seen in any patient, with

negative Congo red stain using polarized light in all

cases.

4. Discussion

Lifa disease has been described in many countries in-

cluding Iraq. It is often very disfiguring pigmentary dis-

ease especially among females [4-8].

The present study had shown that lifa disease was

problem of young people with a mean age of onset of

23.19 ± 6.31 years. The disease duration varied between

0.5 - 12 years with a mean ± SD of 4.65 ± 3.33 years.

The patients gave history of using the lifa vigorously

during bathing for long time before the appearance of the

hyper-pigmentation. This gave a dirty appearance to the

patient, followed by more vigorous rubbing friction

which leads to aggravation and worsening of the condi-

tion.

Females were predominantly affected (94%), with a

female/male ratio of 16:1. These results were similar to

the findings of previous studies [4-8]. This female pre-

dominance is probably because females take longer time

during bathing and bath more frequently, and so more

friction and more pigmentation. Also the musculature

built of males probably prevents the squeezing and dam-

age of the skin by the overlying washing agent.

This study showed that the pigmentation was dark

brown and distributed bilaterally and symmetrically. The

most common affected sites were the clavicular areas in

67.3%, upper back in 42%, lateral aspect of the arms in

36.5%, shins in 30.7% and Adam's apple in 26.9% of

cases. The most common pattern of pigmentation was the

rippled pattern especially over the clavicular areas fol-

lowed by confluent macular and spotty (mottled) pattern.

These findings were similar to that from previously pub-

lished studies [4,5].

The pigmentation was dermal as revealed by wood

light and histopathological examination, and this is simi-

larly reported [4-8].

The disease affects mainly slim people with low BMI.

The disease is often chronic, but could be self limited if

the patient stops the use of lifa for long time [10] and

especially if the patient becomes obese. It is obvious that

obesity is a protective factor against the development of

lifa disease, as the fat in the subcutaneous tissue works as

a cushion like and prevents the damage of the basal cell

layer by lifa. When the patient is slim the epidermis es-

pecially basal layer would be squeezed between the

washing agent and the underling bone as a part of mech-

anobiology of the melanocytes which lead to pigmentary

incontinence [4].

Histopathology of the disease had been studied but the

cases were few in other reports [4,6,7]. The present work

included a histopathological examination in 21 patients

using hematoxylin and eosin stain and Congo red stain.

The main finding was mainly dermal melanosis in the

form of melanophages in the papillary dermis; while

amyloid deposition was not seen in any case and this is

different from Sharquie’s study that found amyloid de-

posits in 10% [4]. This raises a problem how we can dif-

ferentiate between lifa disease and macular amyloidosis

that has many common sharing features including:

1) Macular amyloidosis is a common condition among

Asian and Middle East people, including Iraqis espe-

cially females [11-15];

2) The features of pigmentation are similar in both

macular amyloidosis and Lifa disease. Sometimes we

may have a combination of both of them in the same pa-

tient [14,15];

3) The histopathology of both conditions consists of

dermal melanosis [14,15];

4) Amyloid deposition could be seen in both diseases

but more commonly in macular amyloidosis. Even in the

latter, the amyloid deposition might be so small that ex-

amination of repeated biopsies and multiple sections is

necessary for its detection [14].

In conclusion, lifa disease is a common pigmentary

disfiguring problem especially among young slim fe-

males, where the histopathology is mainly dermal melano-

sis. It could be mixed up with other pigmentary diseases.

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