POSTED: 10 Oct 2023

What Causes Ochronosis & How Can You Treat It?

Hyperpigmentation is relatively common and for the most part is treatable. The best treatments of course depend on the causes and severity. One type of pigment disorder that is however extremely difficult to treat is ochronosis. This is a distinctive looking skin condition that results in dark patches of skin that often causes distress to sufferers. In this article we review what exactly is ochronosis and what causes it. Discover the difference between endogenous and exogenous ochronosis. We also explore how to avoid it and effective treatments for ochronosis.

What is Ochronosis?

Ochronosis is a rare skin condition characterised by blue-black or grey-brown discolouration which can be disfiguring. When severe, it can cause concern and distress to those suffering from it. Ochronosis primarily affects connective tissues. There are two main types of ochronosis. These are endogenous (related to metabolic disorders) and exogenous ochronosis. The latter is more common and gets a lot of interest due to its link with hydroquinone. At the core of prevention and treatment is understanding the underlying cause of ochronosis.

Endogenous Ochronosis

The underlying cause of endogenous onchronois is a rare genetic metabolic disorder called alkaptonuria. In this genetic disorder, the body lacks an enzyme needed for the complete breakdown of two amino acids, tyrosine and phenylalanine. This leads to an accumulation of a substance called homogentisic acid in the body. Over time, this acid deposits in the connective tissues, especially cartilage. Exposure to air causes the acid to oxidise and form a dark pigment. This leads to the characteristic pigmentation.

The telltale sign of this endogenous ochronosis is a darkening of the urine when it is exposed to air. As individuals with alkaptonuria age, the accumulated pigment can become visible in the skin. It gives the skin a characteristic blue-black or grey-brown appearance.This is particularly noticeable around joints. The condition can also impact other body systems and lead to problems like arthritis. Although endogenous ochronosis is primarily managed by monitoring and treating symptoms, understanding its origin is vital. This allows early diagnosis and intervention to stop the condition from progressing.

Exogenous Ochronosis

Whilst endogenous ochronosis has genetic roots, exogenous ochronosis is caused by external factors. It arises primarily due to the prolonged and excessive application of certain skin products. The most common culprit is hydroquinone which is a chemical frequently found in skin-lightening and hyperpigmentation treatments. When hydroquinone is used beyond recommended durations or at high concentrations, it can have an adverse effect on the skin. Instead of evening out the skin tone and fading dark patches, it can paradoxical cause dark pigmentation. This hyperpigmentation is characterised by blue-black or grey-brown discolouration. It often occurs in patches and can be particularly prominent on the face. Worse still, ochronosis is particulary hard to treat and in some cases may not be reversible. This is one of the reasons that hydroquinone is a prescription only medicine in many countries.

Aside from hydroquinone, other agents like resorcinol, phenol and mercury have also been implicated in causing exogenous ochronosis. Hence recognising the potential triggers and understanding the way this condition develops is crucial for preventing it. Furthermore, timely diagnosis of exogenous ochronosis is vital for appropriate management.

How To Prevent Ochronosis

The only way to prevent endogenous ochronosis is early detection and management of alkaptonuria. This can disrupt the metabolic dysfunction that ultimately leads to it. Exogenous ochronosis is however largely preventable if you take precautions against the common causes and risk factors. Below is a summary of the key things that increase the risk of developing exogenous ochronosis.

Extended Use of Skin Lightening Agents

Long-term and frequent application of skin-lightening products, like hydroquinone a top risk. This is why you should not use hydroquinone without supervision of a doctor. Concentrations higher than 4% are especially problematic. As is consistent use for more than 5-6 months without a break.

High Concentrations of Active Agents

Products containing high concentrations of active agents like resorcinol, phenol and mercury can also cause exogenous ochronosis.

Taking Matters in to Your Own Hands

Using skin-lightening products without professional guidance or a doctor’s prescription can elevate the risk. This is especially true if the user isn’t aware of potential side effects or appropriate protocols.

Unregulated or Counterfeit Products

Hydroquinone and other causative products from dubious sources or outside the proper channels is dangerous. These products might contain undisclosed ingredients or higher-than-advertised concentrations of hydroquinone or other agents.

Sun Exposure

Continuous exposure to the sun without proper protection might exacerbate the skin’s response to hydroquinone and other skin treatments. This can accelerate the development of exogenous ochronosis in predisposed individuals.

Skin Trauma

Damaged skin or skin undergoing procedures like dermabrasion or chemical peels might absorb higher amounts of topical agents. This can potentially heightening the risk of ochronosis if you’re using hydroquinone or other active agents at the same time or shortly after.

Pre-existing Skin Conditions

People with certain skin conditions, which might compromise the skin barrier, can be more susceptible to the adverse effects of hydroquinone and other agents. This can make them more prone to develop exogenous ochronosis.

In addition to being aware of these risk factors, please approach active skincare (especially pigment suppressing treatments) with caution. Always seek guidance from a doctor or medical provider who is experienced in dermatology. They will ensure that you only use safe and effective protocols to treat your skin concerns. Never buy products like hydroquinone from the internet or non legitimate sources. Always patch test any new skincare products and regularly update your doctor with your progress to ensure that you are responding well to treatment.

Why is Ochronosis Hard to Treat?

Ochronosis, particularly exogenous ochronosis, is very hard to treat. There are a number of reasons why this is the case but usually it is due to a combination of reasons.

Deep Pigment Deposits

The blue-black or grey-brown pigmentation associated with ochronosis is due to deposits of pigment deep within the dermal layer of the skin. This makes it more challenging to target than superficial pigmentation disorders.

Chronic Nature

By the time ochronosis is diagnosed, the condition has often been present for a long period. Chronic conditions usually pose more substantial treatment challenges. This is because the skin has undergone more prolonged and sometimes irreversible changes.

Absence of Standardised Treatments

Another problem is that there isn’t a universally accepted or consistently effective treatment protocol for exogenous ochronosis. There is huge variability in treatment success rates between different people. Thus its hard to predict what would be the best treatment for someone. This makes it challenging to find a ‘one-size-fits-all’ remedy.

Limited Choice of Treatments

Treatments that are highly effective for hyperpigmentation, such as bleaching agents or aggressive laser treatments, can worsen ochronosis. This can cause even more pronounced discolouration. As such, the choice of treatment options is limited.

Lack of Research

Given its relative rarity and the number of potential contributing factors, there’s limited extensive research on ochronosis. This means there are fewer evidence-based treatment options compared with other skin conditions.

Complex Causative Factors

Exogenous ochronosis can be induced by a variety of substances. This includes hydroquinone, phenol, resorcinol and even certain antimalarials. As such, treatment approaches might need to be tailored based on the specific cause. This adds another layer of complexity.

Psychological Impact

The location of the discolouration, often on the face, can have a profound psychological impact on affected individuals. This might mean they are desperate to see pronounced results urgently. However, for all the reasons above, treatment is often slow and requires commitment. This can lead to frustration when results are slow or treatments are ineffective and lead to giving up.

Ochronosis Treatment

With ochronosis, prevention is always better than cure. If however you are noticing dark patches of discolouration on your skin, the first thing you should do is stop using any of the agents above. Then urgently see a dermatologist or other doctor experienced in skin pigmentation problems. They will ensure that it is actually ochronosis. Whilst ochronosis treatment can be challenging, there are a few things that can help:

  • Topical Treatments: products containing retinoids or antioxidant-rich formulations can be helpful. They promote skin turnover and over time can fade pigmentation. This approach will take time to work but is gentler on the skin than more invasive treatments.
  • Chemical Peels: when administered by a professional, certain chemical peels can lighten the skin. Depending on the peel this can reach deeper deposited pigment and eventually reduce the hyperpigmentation. Usually multiple courses over a period of time are needed.
  • Laser Treatments: some laser therapies can target and break down the pigment. Like chemical peels, success varies between person to person. Also depending on the type of laser, multiple sessions over a period of time are often required.

Given the complexities of ochronosis, it’s vital that you consult with an experienced doctor who can guide you throughout your treatment journey. You will need to manage your expectations and be prepared for potentially prolonged treatment with varied results.

Ochronosis can be prevented and even treated with the right knowledge and approach. Firstly, always prioritise skin health over quick fixes. Be careful about understanding what goes onto your skin and always consult with a medical professional for advanced treatments and skin problems. Whilst its easier to prevent ochronosis, there are treatments that can help. However, its important to be aware that treatment can take time. Also results can be variable and you may need a combination of several treatments.

We fiercely believe that skincare is always personal. Through our virtual clinic we offer safe and effective prescription-strength treatments like Tretinoin for conditions like acnehyperpigmentation and skin ageing. Book a virtual consultation with one of our doctors today and take your first step towards great skin.


Authored by:

Dr Amel Ibrahim
Aesthetic Doctor & Medical Director
Founder City Skin Clinic
Member of the Royal College of Surgeons of England
Associate Member of British Association of Body Sculpting GMC Registered - 7049611

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